Goshen Assisted Living LLC

A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/7/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/7/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey with complaint #CO40323 was completed on 8/7/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to ensure that each resident care plan included special health or behavioral management needs that support the member (resident) affecting affecting three of four sample residents (#1-#3). (Cross reference B1710)Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24, completed by the assistant administrator (AA). The intake assessment read the resident was an elopement risk. An admission assessment dated 6/15/24, completed by the AA, The assessment read .. Based on interviews and record review, the facility (residence) failed to ensure an assessment was conducted prior to admission and at least annually, and documented the member (resident' s) behavioral and social needs, affecting three of three residents who had a history of behaviors (#1-#3). (Cross reference B1770)Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24, which was the residence' s pre-admission assessment, was completed by the assistant administrator. The intake assessment read the resident w.. Based on observation and interview, the facility (residence) failed to store medications under proper conditions, affecting one of one sample member (resident) on refrigerated medications (#2). Findings include:1. ObservationsOn 8/7/25 at 8:07 a.m., an environmental tour revealed a "staff only" sign was on a door that led to the garage where there was a refrigerator filled with food which was also the medication refrigerator. The refrigerated medications included as follows:A box of Lantus 100 unit injectionsA box of risperidone 200 mg injectionsA clear bag with a single dose of Humulog 100 unit and Lantus 100 unit injections. However, the clear bag was not labeled with the resident' s .. Based on observations, record review and interview, the facility (residence) failed to maintain a home-like quality and feel for members (residents) at all times, affecting 12 current residents. Findings include:The residence' s undated resident agreement read in part: "(The residence) agrees to make available... a physically safe and sanitary environment."On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour of the residence revealed the following:The residence grounds were covered in cigarette butts. The downstairs common area bathroom had a hole of approximately one foot, in the drywall above the shower. Additionally, the shower wall had six missing tiles t.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000.8.7414 Medication AdministrationA. Provider Agencies shall provide sufficient support to Members in the use of prescription and non- prescription medications. Members shall be presumed capable of self-administration unless they are determined otherwise. The type and level of medication administration support provided shall be determined by the results of an assessment performed by a qualified person. Medications shall be a..

A relicensure survey with complaint #CO40322 was completed on 8/7/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure written minutes of resident meetings were maintained and readily available for review, affecting 12 current residents. Findings include:On 8/7/25 at 7:57 a.m., meeting minutes for the last three resident council meetings were requested. Meeting minutes were requested again.. Based on interview and record reviews the residence failed to complete a comprehensive assessment that included all required information, affecting three of four sample residents (#1-#3). (Cross reference U1110, U1150 and U2230)Findings include:Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schi.. Based on interviews and record review, the residence failed to ensure each resident care plan promoted resident safety and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting three of four sample residents (#1-#3). (Cross reference U1010, U1142 and U2230)Findings include:1.. Based on interviews and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issues affecting three of four sample residents (#1-#3). (Cross reference U1010, U1142 and U1150).Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses i.. Based on observation and interview, the residence failed to keep the residence handrails in good repair, affecting 12 current residents.Findings include:On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour of the residence revealed the handrails on the ramp at the front of the residence had peeling paint and splintering wood. O.. Based on observation and interviews, the residence failed to provide paper towels or hand drying devices in each common bathroom, affecting 12 current residents. Findings include:On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour revealed all three common area bathrooms at the residence failed to make available pa.. Based on observation, record review and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 12 current residents.Findings include:The residence' s undated resident ag.. Based on observations and interviews, the residence failed to ensure all refrigerated medications were clearly labeled with the resident' s name and prescribing information, and were stored in a refrigerator that did not contain food, affecting one of one sample residents on refrigerated medications (#2).Findings include:1. ObservationsOn 8/7/25 at .. Based on record review and interview, the residence failed to complete a comprehensive pre-admission assessment of residents and ensure those persons' needs can be met fully by the existing staff, affecting three of three residents who had a history of behaviors (#1-#3). (Cross reference U1150, U1142 and U2230)Findings include: 1. Resident #2 was ad.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1 Chapter 7.7.13 Each personnel file shall include, but not be limited to, written documentation regardin..

A recertification survey was completed on 2/15/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting three of four sample residents (participants) (#4, #7, #8).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence policyThe residence' s Medication Administration policy, read in part, "This community complies with all applicable federal and state statutes and regulations, including but not limited to Chapter 7 and Chapter 24 ... This community complies with all federal and state laws and regulations relating to procurement, storage, administration, and disposal of controlled substances."b. Resident #8 was admitted to the residence on 5/12/22 with diagnoses including schizophrenia, major depressive disorder. MelatoninA written practitioner' s order, dated 6/14/22, directed the residence to administer Melatonin five mg once daily every evening at bed time. However, the January and February 2023 medication administration record (MAR) read the residence did not administer the medication from 1/1-1/31, 2/1-2/13/23 as the medication was not available for a total of 45 missed doses FluticasoneA written practitioner' s order, dated 5/23/22, directed the residence to instill fluticasone 50 mcg one spray in each nostril daily. However, the January and February 2023 MAR read the medication was not administered as the medication was not available 1/1-1/31, 2/1-2/13/23 for a total of 45 missed doses. On 2/14/23 at approximately 12:20 p.m., Staff #3 stated Resident #8' s fluticasone and melatonin were not available.On 2/14/23 at 12:30 p.m., the administrator stated Resident #8 did not receive the above medications because they were not available. He sated Staff #3 did not docum..