Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Goshen Healthcare Community during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions sustained a skin tear after being grabbed by another resident known for unpredictable and impulsive behaviors. Staff interviews confirmed that the injured resident often approached others, and supervision protocols requiring the aggressive resident to be kept at a safe distance were not followed, resulting in the incident. Facility policy required interventions to prevent abuse, but these were not effectively implemented.
The facility failed to use PPE for residents on droplet and enhanced barrier precautions and failed to report a respiratory outbreak involving 13 residents. A staff member entered one resident’s room without PPE while outbreak precautions were still in place, and the DON and an LPN performed a dressing change for another resident with a stage II pressure ulcer using gloves only, despite enhanced barrier precautions being posted. The infection preventionist confirmed the outbreak was not reported and that the facility’s enhanced barrier precautions were not being performed to the national standard.
Failure to monitor antibiotic use was identified after the IP stated that antibiotics were reviewed at the end of the month instead of when ordered, and that the facility had not implemented an ASP. The policy showed the IP was responsible for tracking antibiotic orders for completeness and checking whether cultures or other tests were obtained before antibiotics were ordered.
Failure to Provide Bed-Hold Notice: A resident was transferred to the ER, and although the transfer/discharge notice indicated bed-hold information, there was no evidence that a written bed-hold policy was provided to the resident or resident representative. The DON stated the resident or representative should have received a packet with the policy and that telephone notification should have been documented, but the chart only contained the first page copied by the nurse.
A resident with memory impairment, CVA, Alzheimer's dementia, and significant mobility limitations was transferred to the bathroom using a sit-to-stand lift and left alone while still attached to the lift. The CNA left the resident on the toilet without staff supervision, then returned minutes later to complete care and remove the sling. The DON stated residents should not be left in the bathroom attached to a mechanical lift without staff present.
A facility failed to follow a pharmacist’s MRR recommendation for one resident’s trazodone dose. The pharmacist recommended decreasing the antidepressant from 50 mg to 25 mg qhs, and the physician and DON approved the change, but the MAR still showed the higher dose remained in place until later. The DON stated she did not know why the change was not implemented and confirmed it should have been done earlier.
The facility did not follow its abuse prevention policy by failing to report suspected abuse allegations to the administrator and State Survey Agency within required timeframes in multiple cases. Delays also occurred in submitting final investigative reports for incidents involving staff, visitors, and residents. These reporting failures were confirmed by the administrator and DON.
A night shift LPN administered medications that were not prescribed to two residents to induce sleep during difficult nights. This action was discovered after a CNA reported concerns, and the LPN later admitted to the conduct during an internal investigation.
An LPN administered unapproved medications, including Tylenol, melatonin, and Benadryl, to two residents with dementia in a secured memory care unit, resulting in sedation and early bedtimes. These medications were not ordered by a physician and were given for staff convenience, in violation of facility policy prohibiting Benadryl. The incident was not initially recognized as chemical restraint by administration, and documentation of follow-up actions was lacking.
The facility did not complete or maintain required documentation during an investigation into an LPN allegedly administering unprescribed medications to residents in a secure unit. Eight residents were potentially affected, but their records lacked documentation of the allegation and notifications to their representatives or PCPs. Urine drug test results were not retained, and consultations with the medical director and consultant pharmacist were not documented. The incident was not treated as chemical restraint, and QAPI meeting minutes were unavailable.
The facility's main kitchen had sanitation and food storage deficiencies. An unsecured plastic piece and white powdery substance on the ice machine posed contamination risks. The walk-in refrigerator contained improperly labeled and expired food items, which were still available for resident consumption. The dietary manager confirmed the issues but was unsure of the ice machine's cleaning schedule.
The facility did not verify the CNA abuse registry for a CNA who was rehired after a six-month gap in employment. Although the registry was checked before the CNA's initial employment, it was not rechecked upon rehire, as confirmed by the business office manager and CEO.
The facility failed to identify and monitor target symptoms for residents using psychotropic medications. Three residents with cognitive impairments and various diagnoses were prescribed medications like Abilify, buspirone, and Seroquel without specific target symptoms being identified or monitored. The Director of Nursing confirmed this oversight, which was contrary to the facility's policy on psychotropic medication use.
A facility failed to ensure accurate advance directives for a resident, resulting in a conflict between the WyoPOLST indicating CPR and physician orders showing DNR. This discrepancy was confirmed through medical record reviews and staff interviews, revealing a failure to update the POLST upon the resident's return.
A resident with memory impairment and dementia did not receive oral care as per their care plan, which required assistance after each meal. Observations showed staff failed to provide oral hygiene on multiple occasions, and documentation was inconsistent with the care plan. The infection preventionist and DON confirmed the need for oral care within 30 minutes post-meal.
The facility failed to follow proper infection control techniques during perineal care for two residents, leading to potential cross-contamination. In one case, a resident with Alzheimer's dementia was assisted by two CNAs, and one CNA did not remove contaminated gloves before handling clean items. In another case, a resident with non-Alzheimer's dementia was assisted by CNAs, and one CNA failed to change gloves while performing care, contaminating clean items. The infection preventionist and DON confirmed the need for glove changes and hand hygiene, as outlined in the facility's policy.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A resident with moderate cognitive impairment and a history of dementia, coronary artery disease, heart failure, and hypertension sustained a skin tear to the right elbow after being grabbed by another resident. The incident occurred when the first resident tapped the second resident on the shoulder, prompting the second resident to grab the first resident's arm. Staff interviews confirmed the sequence of events, with a CNA observing the arm being squeezed and an LPN noting that the first resident often approached others in this manner. The resident who sustained the injury was not fearful and had limited recollection of the incident. The second resident involved had a care plan indicating frequent, unpredictable, and impulsive behaviors, including a risk of slapping or punching others. The care plan required adjusted supervision to prevent aggression, and staff were expected to keep this resident greater than arm's length from others. However, on the day of the incident, this supervision did not occur, and the resident was observed unsupervised in the hallway for an extended period. The facility's abuse prevention policy defined abuse to include hitting, slapping, scratching, and pinching, and required interventions to protect residents, which were not effectively implemented in this case.
Failure to Use PPE and Report Respiratory Outbreak
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not ensure PPE was used for residents on precautions and did not report an infectious disease outbreak involving 13 residents. On 7/21/25, the entrance doors displayed a sign indicating the facility was experiencing an outbreak, and the administrator stated several residents had a respiratory illness. Review of the state licensing agency incident database showed no evidence that the outbreak had been reported, and the infection preventionist later confirmed that 13 residents had experienced respiratory symptoms and that the outbreak was not reported to the licensing agency. The facility also failed to ensure PPE use for two residents on precautions. Resident #8 had a droplet precautions sign on the door and PPE stored outside the room, but an unidentified staff member entered the room to deliver a meal tray without donning PPE. The infection preventionist confirmed the outbreak precautions had not been lifted and that staff should have worn PPE in the room until 7/23/25. Resident #63 had a BIMS score of 13 out of 15, diagnoses including urinary incontinence, and a stage II pressure ulcer; the DON and an LPN entered to perform a dressing change wearing gloves only, despite a sign indicating enhanced barrier precautions. The DON confirmed no gown was worn, and stated enhanced barrier precautions were a new practice that had not been fully implemented; the infection preventionist also confirmed the precautions were not being performed to the national standard.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to ensure a system to monitor antibiotic usage. During an interview, the infection preventionist stated that physicians ordered antibiotics while lab results were pending and then changed the antibiotic when results were obtained, and that antibiotics were reviewed at the end of the month rather than when they were ordered. He confirmed that the facility had not implemented an antibiotic stewardship program. Review of the facility's Antibiotic Stewardship Program policy dated 2016 showed that the infection preventionist was responsible for infection surveillance and MDRO tracking and could collect and review data such as antibiotic prescription order completeness, including dose, route, frequency, duration, and indication, as well as whether appropriate tests such as cultures were obtained before ordering antibiotics.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a bed-hold policy for resident #10 when the resident was transferred to the Hospital ER. The Notice of Transfer or discharge dated 7/2/25 showed the bed-hold policy box was marked, but there was no evidence that a written bed-hold notice was given to the resident or the resident representative. During interview on 7/24/25 at 9:40 AM, the DON stated the resident or representative should have received a packet including a copy of the bed-hold policy and that there should have been documentation showing the resident's representative was notified by telephone when the resident was discharged to the ER. The DON also stated the policy had been sent with the resident to the ER and only the first page had been copied by the nurse and placed in the chart, and confirmed there was no evidence the resident or family received the notice. Review of the facility policy titled Discharge Plan and Summary, last revised March 2025, showed written documentation will be given to the resident or resident representative about payment needed to hold a bed when readmission or return is expected.
Inadequate Supervision During Bathroom Transfer
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with short-term and long-term memory impairment, a history of cerebrovascular accident and Alzheimer's dementia, upper extremity impairment on one side, lower extremity impairment on both sides, and dependence on staff for transfers. During observation, a CNA used a sit-to-stand lift to transfer the resident from a wheelchair into the bathroom, removed the resident's pants and brief, lowered the resident onto the toilet, locked the lift brakes, and then left the bathroom while the resident remained attached to the lift without staff supervision. The CNA returned several minutes later, asked if the resident was done, provided care, transferred the resident back to the wheelchair, and removed the sling. The DON stated that a resident should not be left in the bathroom attached to a mechanical lift without staff present and that the lift sling should be removed while residents were using the bathroom.
Failure to Implement Pharmacist MRR Recommendation for Trazodone
Penalty
Summary
The facility failed to follow the pharmacist’s medication regimen review recommendations for one resident, identified in the report as resident #55. A GDR dated 6/6/25 showed the pharmacist recommended decreasing trazodone from 50 mg to 25 mg, and the recommendation was signed by the physician on 6/13/25 and by the DON on 6/19/25. However, a subsequent MRR dated 7/7/25 still noted that the recommendation to decrease trazodone to 25 mg qhs had been approved, but there was still an order for 50 mg daily in the chart. The resident’s MAR showed the trazodone dose was not decreased until 7/10/25. During interview on 7/24/25, the DON stated she did not know why the change was not implemented and confirmed it should have been performed on 6/19/25. The facility policy and procedure for Medication Regimen Review stated the facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR.
Failure to Timely Report Suspected Abuse and Submit Investigative Reports
Penalty
Summary
The facility failed to follow its abuse prevention policy and procedures regarding the timely reporting of suspected abuse, neglect, or theft. Specifically, in four out of ten reviewed abuse allegations, the facility did not report incidents to the administrator and the State Survey Agency within the required timeframes. For example, in one case, an allegation of staff-to-resident abuse was not reported to the administrator until nearly two days after the incident, and the State Survey Agency was not notified until four days after the event. In another instance, staff were aware of an abuse allegation but delayed notifying the administrator and subsequently delayed reporting to the State Survey Agency. Additionally, the facility did not submit final investigative reports to the State Survey Agency within the required five business days for certain cases, including allegations of visitor-to-resident and resident-to-resident abuse. These delays were confirmed during interviews with the administrator and the DON, who acknowledged that the required reporting timeframes were not met for the identified abuse allegations.
Unprescribed Medication Administration by LPN
Penalty
Summary
A concern was raised by a CNA that a night shift LPN may have been administering medications to residents that were not prescribed to them. Upon investigation, it was confirmed that the LPN had given two residents medications without a prescription in order to make them sleep during particularly difficult nights. The LPN admitted to this action during an interview and subsequently resigned. The incident was reported to the Wyoming Board of Nursing, and the LPN's license was later terminated. The facility census at the time was 69 residents, including 19 in a secure unit. The report is based on a review of facility investigations, state agency incident reports, staff interviews, and verification with the Wyoming Board of Nursing.
Unapproved Medication Administration Resulting in Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and the use of medications that may restrain a resident's ability to function. An LPN was reported by a CNA for administering medications to residents on the Alzheimer's unit that were not ordered for them. The CNA observed that after receiving these medications, three residents appeared sedated and were put to bed early. The LPN was overheard making statements about giving residents extra medication, raising concerns about intentional chemical restraint for staff convenience. Further investigation revealed that a bottle of Tylenol in the medication cart contained three Benadryl tablets mixed in with the acetaminophen, despite a strict facility policy prohibiting Benadryl for the patient population. The LPN later admitted to giving at least two residents combinations of Tylenol, melatonin, and Benadryl without physician orders, stating this was done when the unit became difficult to manage. The LPN could not recall all the residents who had received these medications, and it was determined that the practice had been ongoing for over a month. All residents involved had dementia and were housed in a secured memory care unit. Staff reported that some residents were unusually tired or unresponsive after receiving medications from the LPN. The facility's administrator did not initially treat the incident as an allegation of chemical restraint, and there was no documentation of follow-up actions such as urine drug testing. The facility's abuse prevention policy defines chemical restraint as the use of drugs for discipline or convenience, which was consistent with the actions observed.
Failure to Document Abuse Investigation and Notifications
Penalty
Summary
The facility failed to complete and maintain required documentation during the investigation of an allegation that an LPN administered unprescribed medications to residents in the secure unit. Although the facility immediately suspended the LPN and began an investigation, documentation was lacking in several key areas. Eight residents were identified as potentially affected, but their medical records did not contain documentation of the allegation or notification to their representatives or primary care providers. Additionally, while urine drug testing was performed on the residents, there was no evidence that the test results were retained. Consultation with the medical director and consultant pharmacist was reported, but there was no documentation of these consultations in the investigation report. The NHA stated that representatives and primary care providers were notified for two residents to whom the LPN confessed to administering unprescribed medications, but this was not documented in the residents' medical records. The NHA also convened an ad hoc QAPI meeting to discuss the allegation, but minutes from this meeting were not available. The facility did not treat the incident as an allegation of chemical restraint, as it was considered an isolated incident involving one nurse rather than a systemic issue. The facility's abuse prevention policy requires thorough documentation of investigations, which was not followed in this case.
Sanitation and Food Storage Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its main kitchen, as observed during a survey. The ice machine had a plastic piece that was not secured, and a white powdery substance was built up around the exterior above the door. This substance moved when the ice machine door was opened and closed, posing a risk of contamination to the ice. Additionally, the walk-in refrigerator contained several food items without proper date labeling, including tomatoes, bell peppers, beef base, chicken base, chili, and hardboiled eggs. Some of these items were past their expiration or use-by dates, yet they remained available for resident consumption. The dietary manager confirmed that expired items or those past their use-by date should be discarded and acknowledged the facility's awareness of the damaged part of the ice machine. However, she was unsure of the cleaning schedule for the ice machine. The facility's practices were not in compliance with the 2022 U.S. Public Health Food Code, which requires food-contact surfaces and equipment to be clean and free of debris, and mandates proper date marking for ready-to-eat, time/temperature control for safety food held for more than 24 hours.
Failure to Verify CNA Abuse Registry Upon Rehire
Penalty
Summary
The facility failed to verify the CNA abuse registry for one of the certified nursing assistants (CNA) prior to resident contact. The personnel record review revealed that the CNA had initially been employed, quit, and was rehired after six months. Although the abuse registry was checked before the CNA's initial employment, there was no evidence of verification upon rehire. An interview with the business office manager and CEO confirmed that the facility did not recheck the abuse registry when the CNA was rehired.
Failure to Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for residents using psychotropic medications. For three residents, the care plans and medication administration records lacked evidence of resident-specific or medication-specific target symptoms. Resident #14, with moderate cognitive impairment and diagnoses including non-Alzheimer's dementia and depression, was prescribed Abilify, buspirone, and sertraline. However, the care plan did not specify target symptoms for these medications, and there was no monitoring of their effectiveness from January to April 2023. Similarly, resident #20, with memory impairment and diagnoses including Alzheimer's disease and adjustment disorder, was prescribed citalopram, divalproex sodium, and Seroquel. The care plan did not identify specific target symptoms for these medications, and no monitoring was conducted. Resident #32, with non-Alzheimer's dementia and anxiety disorder, was prescribed buspirone, Celexa, and clonazepam, but again, no target symptoms were identified or monitored. The Director of Nursing confirmed the lack of identification and monitoring of target symptoms. The facility's policy on psychotropic medication use, last revised in 2016, emphasized the need for clinical indications and monitoring for efficacy, risks, benefits, and adverse consequences, which was not adhered to in these cases.
Inaccurate Advance Directives for Resident
Penalty
Summary
The facility failed to ensure that the advance directives for a resident were accurate, leading to a discrepancy between the resident's WyoPOLST and the physician orders. The WyoPOLST indicated that the resident elected Cardiopulmonary Resuscitation (CPR), while the physician orders showed a Do Not Resuscitate (DNR) status. This inconsistency was confirmed through a review of the medical records and interviews with staff, including an LPN and the health information coordinator. The LPN acknowledged the discrepancy, noting that the POLST had not been updated since the resident's return to the facility. The health information coordinator also confirmed the conflict between the POLST and the physician orders, highlighting a failure to honor the resident's rights to have accurate advance directives.
Failure to Provide Oral Care Per Care Plan
Penalty
Summary
The facility failed to ensure that a resident with memory impairment and multiple diagnoses, including rheumatoid arthritis and non-Alzheimer's dementia, received oral care as per their care plan. The resident required partial to moderate assistance for oral hygiene, and the care plan specified that oral care should be provided after each meal with one-person assistance. However, observations revealed that staff did not offer or perform oral hygiene after meals on multiple occasions. Specifically, on two separate days, staff were observed assisting the resident after meals without providing oral care. Additionally, documentation of oral care tasks from several days showed inconsistencies and did not align with the care plan's requirement for oral care after each meal. An interview with the infection preventionist and DON confirmed that the resident should receive oral care within 30 minutes following each meal, indicating a failure to adhere to the established care plan.
Infection Control Breach During Perineal Care
Penalty
Summary
The facility failed to implement appropriate infection control techniques during perineal care for two residents, leading to potential cross-contamination. In the first observation, a resident with Alzheimer's dementia and other conditions, who was totally dependent on staff for personal hygiene, was assisted by two CNAs. After providing perineal care, CNA #2 did not remove her contaminated gloves before applying a clean brief, pulling up the resident's pants, and touching the resident's shirt, which violated infection control protocols. In the second observation, another resident with non-Alzheimer's dementia and rheumatoid arthritis, requiring substantial assistance with personal hygiene, was assisted by CNA #1 and CNA #2. CNA #1 failed to change her contaminated gloves while performing perineal care, repeatedly using the same gloves to obtain wipes, handle a perineal spray bottle, and touch the resident's clothing. This improper glove use was confirmed by the infection preventionist and DON, who stated that gloves should be changed before touching clean areas and removed before handling resident clothing. The facility's policy on perineal care also emphasized the need to remove gloves and perform hand hygiene before proceeding with dressing or undressing the resident.
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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 Torrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mitchell Care Center | 22.5 mi | ★★★★★ | 10 | 0 |
| Monument Healthcare And Nursing Center | 30.6 mi | ★★★★★ | 13 | 0 |
| Northfield Retirement Communities Care Center | 31.5 mi | ★★★★★ | 2 | 0 |
| Heritage Estates | 32 mi | ★★★★★ | 0 | 0 |
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