Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Restoracy Of Goshen, The during CMS and state inspections, most recent first.
A QMA failed to remain with a resident during medication administration, leaving oral medications unattended at the bedside and not verifying consumption, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses developed an unstageable pressure ulcer that was identified by nursing staff, but the physician was not notified and no treatment order was obtained until 11 days later, contrary to facility policy requiring timely physician involvement in wound care.
A resident with multiple chronic conditions did not receive several physician-ordered lab tests, including prealbumin, hemoglobin A1C, and basic metabolic panels. These tests were not found in the lab portal or medical record, and the DON confirmed their absence. The nurse practitioner stated some orders were placed by accident, and the facility's policy requiring completion of ordered diagnostic tests was not followed.
A resident with dementia and a history of UTIs experienced a delay in both obtaining lab results and starting antibiotic treatment for a UTI. After a gynecological visit and testing, there was a lack of documented follow-up to obtain results, leading to a delay in receiving a positive E. coli result and starting prescribed antibiotics. The DON confirmed the absence of timely documentation and follow-up, as well as a delay in medication delivery.
Staff did not follow enhanced barrier precautions for a resident with an unstageable pressure ulcer, as required by facility policy. During high-contact care activities, such as incontinence care and wound dressing changes, only gloves were worn instead of both gloves and gowns. Interviews revealed that staff were either unaware of or did not adhere to the required precautions, despite clear orders and signage.
A facility failed to notify a resident's POA when Zoloft was discontinued, despite a care plan indicating no GDR attempts. The medication was stopped without clear documentation, and a family member raised a concern. The facility's policy required notification of treatment changes, which was not followed, resulting in a deficiency citation.
A facility failed to implement a care plan for a resident with self-care deficits and fall risk. The resident, who required two-person assistance for transfers due to Parkinson's Disease and cognitive impairment, was transferred by a CNA alone, contrary to the care plan. The CNA was unaware of the two-person requirement and noted that the resident's husband sometimes transferred her without staff assistance. The facility's care planning policy emphasizes person-centered plans based on comprehensive assessments.
The facility failed to supervise three residents during meals, leading to a deficiency in the food and nutrition service. A CNA left the dining area unattended, leaving residents with dementia and other conditions without necessary assistance. Facility policy requires staff presence during meals, which was not followed.
A facility failed to update a resident's care plan in a timely manner. The resident, with mild protein calorie malnutrition and impaired cognitive function, was not on hospice services, yet the care plan included outdated hospice interventions. The MDS Coordinator acknowledged the care plan had not been updated since the resident stopped hospice in August 2023.
The facility failed to provide proper wound care for a resident, as bandages were not changed according to orders, and moisturizer was not applied as required. Another resident with edema did not receive prescribed treatments, such as leg elevation and ace wraps, despite complaints of discomfort. Additionally, a resident received Carvedilol despite heart rates being below the prescribed threshold, indicating medication administration errors. These deficiencies highlight lapses in following care plans and physician orders.
A facility failed to obtain a physician's order for a Foley catheter for a resident with obstructive uropathy and diabetes mellitus type 2. The resident returned from hospitalization with the catheter, but the physician's note did not mention it. The resident had a history of self-catheterization due to a prostate problem. The facility's policy lacked a requirement for a physician's order for catheter use.
A facility failed to properly store a Bi-Pap mask for a resident with obstructive sleep apnea, asthma, and morbid obesity. The mask was observed on a bedside table instead of in a respiratory bag, as required. The facility's policy lacked specific storage instructions, contributing to the deficiency.
A resident with a skin infection was prescribed Keflex, but the facility failed to adjust the antibiotic treatment after culture results indicated a different organism susceptible to other antibiotics. The resident's medical history included chronic kidney disease and diabetes. Despite the culture results, there was no documentation of notifying the physician to alter the treatment, and the Keflex was held for clarification of a stop date. The Executive Director acknowledged the oversight in antibiotic stewardship.
The facility failed to update the Resident Rights' posters with the current ombudsman's name in all four houses, affecting 46 residents. Posters in Penny Lane, Blueberry Hill, [NAME], and Strawberry Fields displayed outdated information, with some being partially obscured. The administrator had no policy for updating this information, and the previous ombudsman had retired four years ago.
A resident with severe cognitive impairment fell out of bed, sustaining a head injury. The facility failed to notify the resident's physician, responsible party, and DON immediately, resulting in a significant delay in medical evaluation and care.
A resident with severe cognitive impairment fell out of bed and sustained a head injury, but the facility failed to perform immediate assessments and neurological checks as required by their fall protocol. The incident was not properly documented or addressed until the following morning shift.
Failure to Ensure Resident Consumed Medications During Administration
Penalty
Summary
A Qualified Medication Aide (QMA) was observed administering medications to a resident and failed to ensure the resident consumed the medications as required by facility policy. The QMA placed a souffle cup containing the resident's medications on the bedside table, left the room to obtain a pain pill, and upon returning, placed the additional medication next to the original cup. The QMA then exited the room without observing the resident take any of the medications. During an interview, the QMA acknowledged that she should have remained with the resident until all medications were taken, as specified in the facility's policy for administering oral medications.
Delayed Physician Notification and Treatment Orders for Pressure Ulcer
Penalty
Summary
A resident with diagnoses including dementia, seizures, and palliative care was observed to have a low air loss mattress and was receiving hospice care. The resident was noted to have severe cognitive impairment and required substantial to maximal assistance for bed mobility. On one occasion, nursing staff identified a four centimeter by three centimeter open pressure ulcer with exposed adipose tissue, drainage, and slough on the resident's right hip. The ulcer was cleansed and bandaged at that time. Despite the identification of the pressure ulcer, there was no documentation that the physician was notified or that a treatment order was obtained until 11 days after the initial discovery. The physician, power of attorney, and DON were eventually notified, and a treatment order was written and implemented. Facility policy required that the physician or wound specialist order pertinent wound treatments, but this was not followed in a timely manner for this resident.
Failure to Obtain Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to follow physician orders by not obtaining ordered laboratory tests for a resident with multiple diagnoses, including diabetes mellitus type 2, chronic kidney disease, COPD, and Parkinson's disease. Record review showed that several laboratory tests, such as prealbumin, hemoglobin A1C, and basic metabolic panels, were ordered by the physician on multiple occasions but were not found in the laboratory portal or the resident's medical record. These tests were intended to monitor the resident's nutritional status, blood sugar control, and kidney function, but there was no documentation that they were completed as ordered. Interviews with the Director of Nursing (DON) confirmed that the laboratory tests could not be located in the records or portal. The DON also reported that the nurse practitioner who placed the orders indicated some were made by accident. The facility had recently changed management, and the DON was unable to clarify why the lab orders were not completed at the time they were ordered. The facility's policy requires that physicians identify and order diagnostic and lab testing based on residents' needs, but this was not followed in this case.
Delay in Obtaining Lab Results and Initiating UTI Treatment
Penalty
Summary
The facility failed to obtain laboratory results and initiate antibiotic treatment for a urinary tract infection (UTI) in a timely manner for a resident with a history of UTIs, dementia, and type 2 diabetes. The resident, who was severely cognitively impaired and required assistance with toileting and bathing, had been seen by a gynecologist and had a vaginal swab and urine test completed to check for infection. Facility documentation indicated that staff were instructed to call back for test results, but after an initial unsuccessful attempt to contact the OB/GYN office, there was no documentation of further attempts between 5/16/2025 and 5/23/2025 to obtain the results. The urinalysis results, when finally obtained, showed a positive result for E. coli, and an antibiotic was ordered and delivered several days later. The first dose of the antibiotic was not administered until after the medication was received, resulting in a delay in treatment. The Director of Nursing acknowledged the lack of timely documentation and follow-up to obtain the test results, as well as the delay in medication delivery. The facility's policy required that completed culture reports be reviewed and orders obtained as soon as possible, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to follow its own infection prevention and control policy regarding enhanced barrier precautions for a resident with a pressure ulcer. Resident 19, who had diagnoses including dementia, seizures, and was receiving palliative and hospice care, was identified as having an unstageable pressure ulcer and was ordered to be on enhanced barrier precautions. Observations revealed that staff providing incontinence care and wound care to Resident 19 wore only gloves, without the required gowns, during high-contact care activities. Interviews with the CNA and LPN involved in the care indicated a lack of awareness or adherence to the enhanced barrier precautions policy, despite the presence of signage indicating such precautions were necessary. The facility's policy specified that both gloves and gowns should be used during high-contact activities such as changing briefs and wound care for residents with chronic wounds. The failure to use appropriate personal protective equipment during these activities constituted a breach of the facility's infection control protocols.
Failure to Notify POA of Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident's family member or Power of Attorney (POA) when a medication was discontinued. Resident B, who had diagnoses including Alzheimer's disease and depression, was receiving Zoloft (Sertraline) for depression. The resident's care plan indicated a preference from the POA for no Gradual Dose Reduction (GDR) attempts. Despite this, a pharmacy consultation report suggested a GDR evaluation, and the Medical Director accepted the recommendation without a clear directive to discontinue the medication. The Medication Administration Record (MAR) showed that Zoloft was discontinued, but there was no documentation of who made this decision or why. A Nurse Practitioner later noted the discontinuation and restarted the medication after determining the resident had previously failed a GDR of Sertraline. A family member raised a concern about the discontinuation without notification, and the facility's Administrator could not find any record of notifying the family or POA. The facility's policy required notification of changes in treatment, but this was not followed in this instance, leading to the deficiency citation.
Failure to Implement Care Plan for Resident with Self-Care Deficits and Fall Risk
Penalty
Summary
The facility failed to implement a care plan for a resident with self-care deficits and fall risk. On August 7, 2024, Resident D was observed being pushed in a wheelchair by her husband, Resident B, who attempted to transfer her to the bed by himself. CNA 2 intervened and transferred Resident D to the bed alone, despite the care plan indicating that Resident D required the assistance of two staff members for transfers. The care plan, revised on June 14, 2024, specified that Resident D had a self-care deficit related to Parkinson's Disease and impaired cognitive function, necessitating extensive assistance for transfers. Additionally, a care plan revised on July 17, 2024, highlighted Resident D's fall risk due to muscle weakness, dementia, and osteoarthritis, recommending a two-person assist for transfers. During an interview, CNA 2 stated that Resident D was a one to two-person assist for transfers, depending on her cooperation, and was unaware of the care plan's requirement for a two-person transfer. CNA 2 also mentioned that Resident D's husband sometimes transferred her by himself, despite signs in the room advising him to call staff for assistance. The Director of Nursing provided the facility's care planning policy, which emphasized the development and implementation of a person-centered plan of care based on comprehensive assessments. This deficiency was related to a complaint investigation.
Failure to Supervise Residents During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meal times for three residents who required assistance, leading to a deficiency in the food and nutrition service. On the morning of August 8, 2024, three residents were observed eating breakfast unsupervised at a dining room table. These residents, identified as Resident M, Resident J, and Resident K, were left without any staff present to assist or supervise them. CNA 3, who was responsible for their supervision, had exited the building to attend to an emergency in another area, leaving the residents unattended. Resident M, diagnosed with dementia and Parkinson's Disease, required supervision with eating and drinking as per his care plan. Resident J, with dementia and dysphagia, also needed assistance with meals due to difficulty swallowing. Resident K, suffering from dementia and severe protein-calorie malnutrition, required adaptive equipment and supervision during meals. The facility's policy mandates that at least one nursing staff member be present in the dining room during meal service to assist residents and handle emergencies, which was not adhered to in this instance.
Failure to Update Resident Care Plan Timely
Penalty
Summary
The facility failed to update the care plan for a resident in a timely manner, as required. The resident, who had diagnoses including mild protein calorie malnutrition and impaired cognitive function, was not receiving hospice services as of the time of the review. However, the care plan, last revised on May 8, 2024, still included interventions related to hospice care, despite the resident not being on hospice since August 2023. This discrepancy was identified during a record review and interview with the MDS Coordinator, who acknowledged that the care plan had not been updated to reflect the resident's current status. The resident's care plan, dated March 22, 2023, and revised on May 8, 2024, included goals and interventions related to hospice care, such as assessing coping strategies, maintaining a calm environment, and providing hospice information to family members. Despite the resident's significant weight loss and dietary interventions noted in a progress note dated June 7, 2024, the care plan still contained outdated hospice-related information. This oversight indicates a failure to ensure the care plan accurately reflected the resident's current care needs and services.
Deficiencies in Wound Care, Edema Treatment, and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident 35, who had wounds on her elbows. Observations revealed that the bandages on her elbows were dated 6/9 and had not been changed by 6/19, despite visible soilage. The resident's care plan and physician's orders required the application of moisturizer to the scabbed areas twice daily, but these orders were not followed. Interviews with the Executive Director and LPN confirmed that the dressing should have been changed and treatment orders applied. Resident 26, who suffered from edema, was not provided with the necessary care as per her treatment plan. Despite complaints of edema and discomfort, observations showed that her legs were not elevated, and ace wraps were not applied as ordered by the Nurse Practitioner. The resident confirmed she had not refused the treatment, contradicting the Executive Director's suggestion that she might have been refusing care. The facility did not provide a policy for following physician orders, which contributed to the oversight in care. Resident 18 experienced medication errors, as Carvedilol was administered despite heart rates being below the prescribed threshold of 50. The Medication Administration Record showed multiple instances where the medication was given with heart rates significantly lower than 50. Interviews with the Administrator, DON, and the resident highlighted inconsistencies in following the medication administration policy, which required checking vital signs before administering certain medications. The resident was unaware of whether the medication was being held as per the physician's orders.
Failure to Obtain Physician's Order for Foley Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary (Foley) catheter for a resident who was reviewed for catheter use. The resident, who had diagnoses including obstructive uropathy and diabetes mellitus type 2, was observed with a Foley catheter upon returning from a recent hospitalization. Despite being seen by a physician, the physician's note did not reference the use of the Foley catheter. The resident indicated that he had a prostate problem and had been self-catheterizing at home prior to admission. The facility's Executive Director acknowledged that a physician's order should have been obtained for the catheter and its care. Additionally, the facility's policy on indwelling urinary catheter care did not reference the need for a physician's order.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident requiring respiratory care. During multiple observations, a Bi-Pap mask, which is used for non-invasive ventilation therapy, was found improperly stored on top of a bedside table instead of in a designated respiratory bag. The resident, who was cognitively intact, had a history of obstructive sleep apnea, asthma, and morbid obesity, and was prescribed to use the Bi-Pap mask at night. Despite the physician's order and care plan indicating the need for the Bi-Pap mask, the facility's policy did not include specific instructions for its storage, leading to the observed deficiency.
Failure to Adjust Antibiotic Treatment Based on Culture Results
Penalty
Summary
The facility failed to ensure the appropriate antibiotic was prescribed at the appropriate time and for the appropriate duration for a resident with a skin infection. The resident, who was cognitively intact and had a history of chronic kidney disease, diabetes mellitus type 2, and morbid obesity, reported an abdominal infection and a boil on her left thigh. A physician's order was made to obtain a wound culture and start the resident on Keflex, an antibiotic, for seven days. However, the wound culture results, which were available after 48 hours, indicated the presence of a gram-negative bacteria that was susceptible to other antibiotics, not Keflex. Despite the culture results, there was no documentation that the physician or nurse practitioner was notified to alter the antibiotic treatment. The Keflex was held for clarification of a stop date, but the necessary change in antibiotic treatment was not made. The Executive Director later acknowledged that the Keflex should have been stopped after seven days and that the physician should have been informed of the culture results to determine if a change in antibiotic was necessary. The facility's policy on antibiotic stewardship emphasized the importance of selecting the optimal antimicrobial drug regimen, dose, duration, and route of administration, which was not adhered to in this case.
Outdated Ombudsman Information on Resident Rights' Posters
Penalty
Summary
The facility failed to ensure that the current ombudsman's name was listed on the Resident Rights' posters in all four houses: Strawberry Fields, Blueberry Hill, [NAME], and Penny Lane. This deficiency was observed during a survey conducted on June 20 and 21, 2024. In Penny Lane, the poster opposite the Director of Nursing's office displayed the wrong local ombudsman's name, and there was no State Ombudsman information posted. Similarly, in Blueberry Hill and [NAME] houses, the posters also had incorrect ombudsman information. In Strawberry Fields, the poster was partially obscured by a dry erase board and also contained outdated information. The administrator admitted to having no policy regarding the display of ombudsman information, and the previous local ombudsman, whose details were still on the posters, had retired approximately four years ago.
Failure to Timely Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify a resident's physician, responsible party, and the Director of Nursing (DON) in a timely manner following a fall with injury. Resident B, who had severe cognitive impairment and required extensive assistance with daily living, fell out of bed and sustained a laceration above her right eye and swelling to the bridge of her nose. The incident occurred at 11:40 P.M., but the responsible party was not notified until the following day at 11:00 A.M. by LPN 12, who also obtained an order to send the resident to the hospital for evaluation. The DON was also not informed until the next day, which delayed the appropriate response to the head injury. LPN 8 and RN 9 were notified of the fall by CNA 3 but failed to notify the resident's personal physician, responsible party, or the DON immediately after the incident. The facility's policies required immediate notification of the responsible party and attending physician in the event of an incident or accident, especially if a potential head injury was present. The failure to follow these protocols resulted in a significant delay in addressing the resident's injury and ensuring appropriate medical evaluation and care.
Failure to Provide Adequate Care After Resident Fall
Penalty
Summary
The facility failed to provide adequate care and treatment for Resident B after she fell out of bed and sustained a head injury. Resident B, who had severe cognitive impairment and required extensive assistance with daily living, fell out of bed and hit her head, causing a laceration above her right eye and swelling to the bridge of her nose. Despite the facility's fall protocol requiring immediate assessment and neurological checks, there was no documentation of any physical assessment or neurological checks completed for Resident B immediately after her fall. Interviews with staff revealed that although the resident was found with a significant head injury, no assessments or neurological checks were performed through the night, and the wound was not cleaned or treated until the following morning shift. The Director of Nursing confirmed that neurological checks should have been initiated immediately after the fall, but they were not documented by the night shift nurse. The incident was first reported to Resident B's responsible party the morning after the fall, and the resident was eventually sent to the hospital for evaluation. The facility's fall assessment policy, which mandates that a licensed nurse evaluate the resident for injury and complete necessary documentation and neurological checks if a head injury is suspected, was not followed. This deficiency was identified during a review of the incident and interviews with the involved staff, highlighting a significant lapse in the facility's adherence to its own protocols for fall management and resident care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Goshen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greencroft Healthcare | 2.1 mi | ★★★★★ | 4 | 0 |
| Waterford Crossing | 2.8 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Goshen | 3.1 mi | ★★★★★ | 6 | 0 |
| Valley View Healthcare Center | 8.3 mi | ★★★★★ | 2 | 1 |
| Elkhart Meadows | 8.3 mi | ★★★★★ | 4 | 0 |
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