Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Waterford Crossing during CMS and state inspections, most recent first.
The facility failed to maintain required infection control surveillance documentation for all residents. A review of the Infection Control Binder showed that it only contained surveillance records for a three-month period, with no records from earlier months. The IPN reported that she had been discarding monthly infection control surveillance data at the start of each new month because she did not believe it needed to be retained. The RNC stated that surveillance documents should be kept from one annual survey to the next and acknowledged that the facility lacked a policy for maintaining infection control surveillance records.
The facility failed to offer and document pneumococcal vaccinations for two residents with multiple chronic conditions, including dementia, chronic pulmonary disease, hypertension, dysphagia, and major depression. Record review showed no evidence that either resident had been offered or received a pneumococcal vaccine within the past year. In interviews, the IPN stated vaccinations should be offered annually, and the RNC confirmed that these residents had not been offered or administered the vaccine and that the facility lacked a policy addressing pneumococcal vaccination.
A resident with cognitive intactness and specific medical conditions expressed a preference for daily showers on the day shift, but the facility failed to honor this preference after the resident was moved to a different room. The resident was instead scheduled for showers twice a week on the evening shift, contrary to her stated preference. Staff interviews confirmed the oversight, and the facility's policy on resident choice was not followed.
A facility failed to develop a care plan for a resident's vision needs, despite assessments indicating impaired vision and the resident's inability to read. Diagnoses included metabolic encephalopathy, major depressive disorder, and macular degeneration. Staff confirmed the absence of a care plan, which was required by the facility's policy.
A QMA failed to maintain professional standards by pre-pouring medications for multiple residents, contrary to the facility's policy. During an observation, the QMA was seen with souffle cups labeled with residents' names and containing medications, which he admitted should not have been preset. The facility's policy prohibits pre-pouring medications in advance or for more than one resident at a time.
The facility failed to label over-the-counter medications appropriately in one of the medication storage carts. During an observation, a nurse retrieved medication bottles that lacked necessary labels, including a bottle of 81 mg aspirin, multivitamins, and Acetaminophen 650 mg. The nurse acknowledged the labeling oversight. The facility's policy requires non-prescription medications to be labeled with the resident's name and other essential information.
A facility failed to implement enhanced barrier precautions for a resident receiving dialysis care. Despite orders and a care plan requiring PPE during high-contact activities, staff did not use gowns or gloves, and there was no precautionary signage. Observations showed a CNA providing care without PPE, and an RN confirmed precautions were only used for the dialysis fistula, contrary to policy.
Failure to Maintain Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain documentation of its infection control surveillance records, affecting all 73 residents. During a review of the Infection Control Binder (ICB), surveyors found that it contained infection control surveillance data only for January through March 2026, with no records for any months prior to January 2026. In an interview, the Infection Prevention Nurse stated she did not believe she was required to retain infection control surveillance information and had been discarding each month’s surveillance records at the beginning of the following month. She also noted that the last annual survey had occurred in December 2024. In a separate interview, the Region Nurse Consultant reported that monthly infection control surveillance documents should have been kept in the ICB from one annual survey until the next and confirmed that the facility did not have a policy for maintaining infection control surveillance information. No specific resident medical histories or conditions at the time of the deficiency were described in the report, only that 73 residents resided in the facility and were potentially affected by the lack of retained infection control surveillance documentation.
Failure to Offer and Document Pneumococcal Vaccinations and Absence of Related Policy
Penalty
Summary
The facility failed to provide pneumococcal immunizations and lacked related documentation and policy for two residents whose immunization records were reviewed. Resident 39, who had diagnoses including dementia, major depressive disorder, and chronic pulmonary disease, had no documentation in her record indicating she had been offered or administered the pneumococcal vaccination within the last year. Resident 40, with diagnoses including vascular dementia, hypertension, dysphagia, and major depression, also had no documentation in her record showing she had been offered or administered the pneumococcal vaccination within the last year. During an interview, the Infection Prevention Nurse stated that vaccinations should be offered yearly and indicated she would need to check whether these two residents had been offered or received the pneumococcal vaccine. In a separate interview, the Region Nurse Consultant confirmed that the two residents had not been offered or administered the pneumococcal vaccination, despite the expectation that they should have been, and further acknowledged that the facility did not have a policy related to pneumococcal vaccination.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's shower preference, which was a violation of the resident's right to self-determination and choice. Resident 13, who was cognitively intact and had diagnoses including anemia, end-stage renal disease, and celiac disease, expressed a preference for daily showers on the day shift. However, the resident was receiving showers twice a week on the evening shift. This discrepancy arose after Resident 13 was moved from one room to another within the facility, resulting in a change from the day shift to the evening shift for showers. Interviews with staff revealed that Resident 13 had previously received showers on the day shift in an assisted living setting before admission to the facility. The Staff Development Director acknowledged that residents were interviewed for their shower preferences upon admission, and these preferences were supposed to be documented on the shower schedule. However, due to the room change, Resident 13 was placed in an available shower slot on the evening shift, contrary to her stated preference. The facility's policy on resident choice emphasized the right of residents to make choices regarding their care and daily routine, which was not adhered to in this case.
Failure to Develop Care Plan for Vision Needs
Penalty
Summary
The facility failed to develop a care plan for a resident's vision needs, which was identified as a deficiency during a survey. The resident, who has diagnoses including metabolic encephalopathy, major depressive disorder, and macular degeneration, reported being unable to read the newspaper or the Bible due to impaired vision. Despite a Quarterly Minimum Data Set (MDS) assessment indicating moderate cognitive impairment and impaired vision, and an Annual MDS assessment triggering a care area assessment for visual impairment, no care plan was developed to address these needs. Interviews with facility staff, including the MDS Coordinator and the Social Service Director, confirmed that a care plan for the resident's vision needs was not created, although it should have been. The facility's policy on Comprehensive Care Plan Guidelines requires that care plans reflect the risk areas or disease processes impacting individual residents and remain accurate and current. However, in this case, the policy was not followed, resulting in the absence of a care plan for the resident's impaired vision.
Failure to Maintain Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that a Qualified Medication Aide (QMA) adhered to professional standards of quality during medication administration. During an observation, the QMA was seen removing a souffle medication cup from the top drawer of the medication cart, which had the name of a resident written on it and contained 14 different medications. Additionally, the drawer contained two more souffle cups with the names of other residents written on them. The QMA admitted during an interview that he should not have preset the medications. The facility's policy, titled 'Medication Administration-General Guidelines,' revised in November 2018, explicitly states that medications should not be pre-poured in advance of the medication pass or for more than one resident at a time.
Medication Labeling Deficiency in Medication Storage Cart
Penalty
Summary
The facility failed to ensure that over-the-counter medications were labeled appropriately for one of the two medication storage carts, specifically the 300 hall-back medication cart. During a medication administration observation, a registered nurse obtained medication bottles from the cart that lacked labels indicating the ordering physician, resident's name, or ordered dose. The medications included a bottle of 81 mg aspirin, multiple bottles of men's multivitamin capsules, a bottle of vitamin B12 - 5000 mg tablets, a bottle of multivitamins, and a bottle of Acetaminophen 650 mg. The registered nurse acknowledged that the medications observed without labels should have been labeled. The Director of Nursing provided the facility's policy titled 'Medication Ordering and Receiving from Pharmacy- Medication Labels,' dated November 2018, which indicated that resident-specific non-prescription medications not labeled by the pharmacy should be kept in the manufacturer's original container and identified with the resident's name. Facility personnel may write the resident's name on the container or label as long as the required information is not covered. The policy specifies that the resident's name, medication name, strength of medication, prescriber's name, and beyond use (or expiration) date of medication should be included.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to infection control practices regarding enhanced barrier precautions for a resident receiving dialysis care. The resident, who had diagnoses including anemia, end-stage renal disease, and dependence on renal dialysis, required enhanced barrier precautions during high-contact care activities. Despite a physician's order and a care plan indicating the need for staff to use gowns and gloves during such activities, observations revealed a lack of precautionary signage and personal protective equipment (PPE) outside the resident's room. The resident reported that staff did not wear PPE, including gowns, gloves, and masks, during direct care. Further observations showed a CNA providing care without PPE, and the CNA expressed a misunderstanding of the requirement for PPE during direct care. An RN confirmed that enhanced barrier precautions were only used for the resident's dialysis fistula, contrary to the facility's policy, which required such precautions during all high-contact care activities. The facility's policy, provided by the Director of Nursing, specified that enhanced barrier precautions should be in place for residents with indwelling medical devices during high-contact care activities, including ADL care, toileting, and showers.
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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 | 1.2 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Goshen | 1.8 mi | ★★★★★ | 6 | 0 |
| Restoracy Of Goshen, The | 2.8 mi | ★★★★★ | 1 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 9.6 mi | ★★★★★ | 22 | 0 |
| Waters Of Wakarusa Skilled Nursing Facility, The | 10.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.