Restoracy of Goshen, The

In the surveyor’s words

From the most serious findings on record at Restoracy of Goshen, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686May 14, 2021

  Based on interview and record review, the facility failed to ensure thorough assessments, interventions and treatments were implemented timely for 1 resident identified as being high risk for developing pressure ulcers who developed two Stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum and additional pressure ulcers to both heels, resulting in the resident having wound pain and fears of wound pain with toileting, depression, and requiring hospitalization for wound care and a severe UTI (Resident W). The immediate jeopardy began on 1/3/21 when Resident W was noted to have shallow open areas on her buttocks, and the facility failed to notify the physician, assess, monitor, and obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF684Jun 6, 2023

  Based on record review and interview, the facility failed to to identify multiple nitroglycerin patches during an admission skin assessment for 1 of 3 residents reviewed for hospitalization , and follow a Physician's order to obtain daily lab work for a resident receiving Coumadin therapy for 1 of 4 residents reviewed for anticoagulation therapy. (Residents C & Y) Findings include: 1. A record review of Resident Y was completed on 6/1/2023 at 10:19 A.M. Diagnoses included, but were not limited to: atrial fibrillation, pneumonia, and hypothyroidism. Resident Y admitted to the facility on [DATE]. A Nursing Comprehensive Evaluation was completed on 2/14/2023 at 3:29 P.M. The assessment indicated that a skin assessment was completed with skin conditions present. […]

• Actual harm, isolatedF883Jun 6, 2023

  Based on record review and interview, the facility failed to provide a pneumococcal vaccination timely for a resident whose Power of Attorney had indicated consent upon admission, subsequently the resident was assessed at a local hospital and diagnosed with multi-focal pneumonia. This affected 1 of 6 residents reviewed for immunizations. (Resident B) Finding includes: A record review of Resident B was completed on 5/31/2023 at 1:33 P.M. Diagnoses included, but were not limited to: pneumonia, dementia, and acute bronchitis. An Admission (5-day) Minimum Data Set (MDS) Assessment on 4/28/2023, indicated the pneumococcal vaccination was up to date. Resident B admitted to the facility on [DATE] with a recent history of COVID-19. […]

• Actual harm, isolatedF690May 14, 2021

  Based on interview and record review, the facility failed to develop a care plan and provide care and services for 1 resident with a history of UTI's, newly placed indwelling urinary catheter, and frequent bowel incontinence. The deficient practice resulted in the resident having urinary tract pain, recurrent UTI's and hospitalization for a drug resistant UTI. (Resident W) Findings include: On 5/12/21 at 11:52 A.M., the closed record for Resident W was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, dated 12/21/20, indicated the resident required extensive assistance from 2 staff members for bed mobility and toileting. […]

• No harm, potential for more than minimal, widespreadF732Nov 30, 2023

  Based on observation and interview, the facility failed to provide the posting of nursing staff hours in 4 of 4 homes reviewed for nurse staffing information. Finding includes: During a tour of the Strawberry Lane, Blueberry Lane, Penny Lane, and Green [NAME] homes on 11/30/2023 from 9:21 A.M. to 10:43 A.M., a posting of the total number of staff and actual hours worked of nursing staff could not be located. During an interview on 11/30/2023 at 1:05 P.M., CAN 2 indicated that the homes do not have postings of the number of staff and actual hours worked. At 2:18 P.M., the Administrator indicated that the facility scheduler and the Director of Nursing were responsible to ensure the posting of the number of staff and actual hours worked were completed. […]