Inspection Reports for
The Restoracy of Goshen

The facility was found deficient in multiple areas including medication administration, timely treatment and monitoring of pressure ulcers, obtaining and following up on laboratory tests, timely notification of lab results and physician orders, and adherence to infection prevention protocols including enhanced barrier precautions.

Complaint IN00440031 was substantiated with deficiencies related to failure to notify family/POA of medication changes. Complaint IN00439575 was substantiated with deficiencies related to care plan implementation for transfers. Complaint IN00439243 was not substantiated with any deficiencies.

The facility was found deficient in notifying a resident's family/POA of medication discontinuation, implementing a care plan for self-care deficits and fall risk, and ensuring staff supervision during meals for residents requiring assistance. Some complaints were substantiated with deficiencies cited, while one complaint had no deficiencies related to the allegations.

The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness plan deficiencies, emergency lighting testing, fire alarm system labeling, fire drills, smoking regulations, electrical receptacle testing, interior wall finishes, and egress door accessibility.

Complaint IN00435388 resulted in Federal/State deficiencies related to the allegations cited at F677. Complaint IN00436069 had no deficiencies related to the allegations.

The facility was found deficient in multiple areas including posting of correct ombudsman information, timely care plan updates, provision of personal hygiene care, wound care and medication administration, catheter orders, respiratory equipment storage, and antibiotic stewardship.

Complaint IN00429796 was substantiated with deficiencies cited at F580 and F684 related to notification and quality of care. Complaint IN00426664 had no deficiencies cited.

The facility failed to timely notify the resident's physician, responsible party, and Director of Nursing of a fall with injury for one resident (Resident B). Additionally, the facility failed to provide adequate care and treatment related to lack of assessment and neurological checks after the fall. Policies require immediate notification and post-fall evaluations, which were not followed.

Complaint IN00422005 was substantiated with deficiencies cited at F584 (environmental cleanliness) and F732 (nurse staffing postings).

The facility failed to provide a clean environment in 23 of 37 resident rooms, with issues such as debris, dust clumps, gouged and marred drywall, and unpainted plaster. Additionally, the facility failed to post nursing staff hours in all four homes reviewed.

Complaint IN00416481 was investigated and deficiencies related to the allegations were cited. Resident E reported ongoing housekeeping issues including unemptied trash and infrequent mopping. Family observed soiled bedpans left in the room. Staff interviews revealed lack of cleaning schedules and insufficient time to complete housekeeping tasks. The Executive Director confirmed no employed housekeepers and reliance on resident care providers for cleaning.

The facility failed to provide a clean environment in 11 of 39 resident rooms reviewed, with observations of debris, dirt, gouges in walls, and unsanitary conditions in multiple rooms. Resident and family complaints about inadequate cleaning were substantiated by observations and staff interviews.

The facility was found not in compliance with Life Safety Code requirements including failure to conduct quarterly fire drills for one quarter, failure to conduct annual inspection and testing of fire door assemblies, failure to document 36-month emergency generator testing, failure to maintain weekly generator inspection records, and failure to maintain fire alarm system in proper operating condition.

This inspection included investigations of Complaints IN0000407309, IN00407184, IN00403836, IN00400374, IN00409061, and IN00402210. Deficiencies related to complaints IN00409061 and IN00402210 were cited.

The facility was found deficient in several areas including failure to obtain physician orders for CPR, failure to include residents or representatives in care plan meetings, failure to provide resident-centered activities, failure to identify nitroglycerin patches and follow anticoagulation lab orders, failure to assess gastrostomy tube placement prior to feeding, improper respiratory care orders and equipment storage, failure to follow pureed food recipes, unsanitary food storage and handling practices, inadequate glucometer sanitation, and failure to timely provide pneumococcal vaccination.