Inspection Report Summary
The most recent inspection on June 27, 2025, found Laurels of Goshen in compliance with applicable regulations and no deficiencies were cited. Prior inspections showed a pattern of deficiencies primarily related to medication administration, wound care, infection control, care plan implementation, and environmental cleanliness. Several complaint investigations were substantiated with deficiencies, including issues with notification of medication changes, fall care, and housekeeping, while others were found to be unsubstantiated. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The overall trend suggests improvement, with the most recent inspection showing compliance following a period of mixed findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was conducted as a Paper Compliance to the Recertification and State Licensure Survey completed on June 2, 2025.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance to the Recertification and State Licensure Survey.
Inspection Report
Renewal
Census: 45
Capacity: 45
Deficiencies: 5
Date: Jun 2, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on May 28, 29, 30, 2025 and June 2, 2025.
Findings
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.
Deficiencies (5)
Failed to ensure staff administering medication met professional standards regarding ensuring a resident consumed medication during medication pass.
Failed to notify the physician and obtain treatment orders timely for an unstageable pressure ulcer.
Failed to follow physician orders by not obtaining ordered laboratory tests for a resident.
Failed to ensure lab results were obtained in a timely manner and antibiotic treatment for a UTI was initiated timely.
Failed to follow enhanced barrier precautions for a resident with a pressure ulcer.
Report Facts
Census SNF/NF beds: 45
Census residents present: 45
Medicare residents: 2
Medicaid residents: 31
Other payor residents: 12
Deficiency count: 5
Audit frequency: 3
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Cardoso | Executive Director | Signed the report and provided policy information |
| QMA 5 | Observed medication administration deficiency involving Resident 26 | |
| Director of Nursing | Director of Nursing | Provided interviews and information regarding deficiencies and corrective actions |
| CNA 7 | Observed not following enhanced barrier precautions for Resident 19 | |
| LPN 6 | Licensed Practical Nurse | Observed not following enhanced barrier precautions for Resident 19 |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00448903 and IN00448680.
Complaint Details
Complaint IN00448903 - No deficiencies related to the allegations are cited. Complaint IN00448680 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00448903 and IN00448680 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 39
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 7
Inspection Report
Re-Inspection
Census: 47
Capacity: 48
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/11/24.
Findings
At this PSR survey, Laurels of Goshen was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered except for concealed crawl spaces and had smoke detectors hard wired to the fire alarm system in all resident sleeping rooms and open areas.
Report Facts
Facility capacity: 48
Census: 47
Survey date: Aug 12, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00440031 and IN00439575.
Complaint Details
The visit was related to complaints IN00440031 and IN00439575. The facility was found to be in compliance with the complaint investigation requirements.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 3
Date: Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00440031, IN00439575, and IN00439243) regarding alleged deficiencies at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to ensure a resident's family member/Power of Attorney was notified when a medication was discontinued for 1 of 3 residents reviewed for medication changes.
Failed to ensure a care plan regarding self-care deficits and fall risk was implemented for 1 of 3 residents reviewed for staff assisted transfers.
Failed to ensure staff members were present when 3 residents were observed at the dining room table, eating and drinking who required supervision with meals.
Report Facts
Census: 46
Total Capacity: 46
Residents requiring supervision at meal: 3
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Underly | Laboratory Director or Provider/Supplier Representative | Signed the report |
Inspection Report
Routine
Census: 47
Capacity: 48
Deficiencies: 13
Date: Jul 11, 2024
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
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.
Deficiencies (13)
Failed to maintain an emergency preparedness plan based on a documented facility and community-based risk assessment and include strategies for addressing emergency events.
Failed to ensure emergency preparedness communication plan includes required contact information.
Failed to conduct annual training for the Emergency Preparedness Program and demonstrate staff knowledge.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to ensure battery backup emergency lights were tested annually for 90 minutes with proper documentation.
Failed to provide complete interior finish with flame spread rating of Class A or B in basement areas.
Failed to maintain fire alarm system circuit breaker box labeling and marking.
Failed to conduct fire drills on each shift for 2 of 4 quarters.
Failed to maintain designated smoking area in accordance with regulations; smoking area located within 15 feet of vented natural gas meter.
Failed to ensure non-hospital grade electrical receptacles in resident rooms were tested annually.
Failed to ensure means of egress through courtyard exit gate was readily accessible without requiring an employee key-fob.
Failed to ensure therapy patient treatment areas were not open to the corridor as required.
Failed to ensure multi-plug adaptors were not used as a substitute for fixed wiring in resident rooms.
Report Facts
Certified beds: 48
Current census: 47
Deficiencies cited: 14
Battery backup emergency lights: 6
Resident rooms with non-hospital grade receptacles: 48
Fire drills missing: 2
Resident rooms with multi-plug adaptors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness, fire alarm system, emergency lighting, fire drills, electrical receptacles, and egress door issues. | |
| Administrator | Interviewed and involved in findings review and exit conference. | |
| Facility Administrator | Responsible for sustaining compliance and overseeing corrective actions. | |
| Director of Maintenance | Received education and responsible for corrective actions related to emergency preparedness and fire safety. | |
| Director of Therapy | Communicated therapy equipment use restrictions related to corridor access. |
Inspection Report
Annual Inspection
Census: 46
Capacity: 46
Deficiencies: 7
Date: Jun 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00436069 and IN00435388.
Complaint Details
Complaint IN00435388 resulted in Federal/State deficiencies related to the allegations cited at F677. Complaint IN00436069 had no deficiencies related to the allegations.
Findings
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.
Deficiencies (7)
Facility failed to ensure the current ombudsman's name was listed on Resident Rights posters in 4 houses.
Failed to ensure a Care Plan was updated timely for 1 of 3 residents reviewed.
Failed to provide nail and hand hygiene and grooming assistance to a resident unable to complete care for themselves.
Failed to obtain orders for wounds, change wound dressings as ordered, ensure recommended treatments for edema, identify bruising, and prevent medication errors.
Failed to obtain a physician's order for an indwelling urinary (Foley) catheter for 1 of 2 residents reviewed for catheters.
Failed to ensure respiratory equipment was stored properly for 1 of 2 residents reviewed for respiratory care.
Failed to ensure the appropriate antibiotic was prescribed at the appropriate time and duration for a skin infection for 1 of 4 residents reviewed for antibiotic stewardship.
Report Facts
Survey dates: 5
Census: 46
Total capacity: 46
Residents with Medicare: 4
Residents with Medicaid: 21
Residents with Other payor: 21
Deficiencies cited: 7
Medication errors: 9
Antibiotic duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | HFA (Health Facility Administrator) | Facility Administrator who requested paper compliance for plan of correction |
| Chad Underly | Administrator | Signed the inspection report |
| CNA 5 | Reported Resident B should have been shaved and nails trimmed on shower day | |
| LPN 6 | Licensed Practical Nurse | Described Resident 35's elbow wounds and confirmed receipt of orders |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The inspection was conducted as a Paper Compliance to the Recertification and State Licensure Survey, including the investigation of Complaint IN00435388.
Complaint Details
Complaint IN00435388 was investigated and found to be corrected.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Recertification and State Licensure Survey and the investigation of Complaint IN00435388.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00429796.
Complaint Details
Complaint IN00429796 was investigated and found to be in compliance as of March 14, 2024.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429796 and IN00426664. Complaint IN00429796 resulted in federal/state deficiencies related to notification and quality of care, while complaint IN00426664 had no deficiencies cited.
Complaint Details
Complaint IN00429796 was substantiated with deficiencies cited at F580 and F684 related to notification and quality of care. Complaint IN00426664 had no deficiencies cited.
Findings
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.
Deficiencies (2)
Failure to notify resident's physician, responsible party, and Director of Nursing timely of a fall with injury.
Failure to provide adequate care and treatment related to lack of assessment and neurological checks after a resident fell and sustained a head injury.
Report Facts
Census: 45
Total Capacity: 45
Residents Medicare: 2
Residents Medicaid: 18
Residents Other: 25
Date of Fall Incident: Mar 1, 2024
Date of Survey: Mar 13, 2024
Date of Plan of Correction Completion: Apr 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Signed report and contact for plan of correction |
| LPN 12 | Licensed Practical Nurse | Notified responsible party of fall and applied wound care; involved in assessment |
| LPN 8 | Licensed Practical Nurse | Notified off-site health service but failed to notify physician, responsible party, and Director of Nursing |
| RN 9 | Registered Nurse | Evaluated resident after fall with LPN 8 |
| LPN 7 | Licensed Practical Nurse | Assisted with assessment and wound care after fall |
| Director of Nursing | Director of Nursing | Notified late of fall incident; responsible for oversight of notification and care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00422005 completed on November 30, 2023.
Complaint Details
Complaint IN00422005 was investigated and found to be in compliance as of the review date January 9, 2024.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422005 regarding deficiencies related to environmental cleanliness and nurse staffing postings.
Complaint Details
Complaint IN00422005 was substantiated with deficiencies cited at F584 (environmental cleanliness) and F732 (nurse staffing postings).
Findings
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.
Deficiencies (2)
Failed to provide a safe, clean, comfortable, and homelike environment; 23 of 37 rooms had debris, dust clumps, gouged drywall, and unpainted plaster.
Failed to post nursing staff total number and actual hours worked in a prominent place in all four homes.
Report Facts
Resident rooms with environmental deficiencies: 23
Total residents present: 37
Medicare residents: 3
Medicaid residents: 16
Other payor residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Named in relation to the plan of correction and interview regarding findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00416481 completed on September 22, 2023.
Complaint Details
Complaint IN00416481 was investigated and the facility was found to be in compliance.
Findings
Laurels of Goshen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00416481 regarding allegations of deficiencies related to the facility's environment and housekeeping.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide a safe, clean, comfortable, and homelike environment; 11 rooms had debris on floors, sinks, gouges and scuffs on walls, and unsanitary bathroom conditions.
Report Facts
Number of rooms with environmental deficiencies: 11
Total census: 39
Total capacity: 39
Medicare census: 3
Medicaid census: 18
Other payor census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Named in plan of correction and administrative contact |
| QMA 2 | Interviewed regarding cleaning responsibilities and challenges | |
| CNA 3 | Interviewed regarding cleaning responsibilities and shift tasks | |
| Executive Director | Interviewed regarding housekeeping policies and cleaning practices | |
| Director of Nursing | Mentioned as responsible for addressing family complaints and cleaning schedules |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Date: Aug 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414233.
Complaint Details
Complaint IN00414233 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00414233 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 4
Medicaid census: 20
Other payor census: 16
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-06-06, including a PSR to the Investigation of Complaints IN00409061 and IN00402210.
Complaint Details
Complaint IN00409061 and Complaint IN00402210 were investigated and found corrected during this visit.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00409061 and IN00402210. Both complaints were corrected.
Report Facts
Census: 43
Medicare Census: 9
Medicaid Census: 21
Other Census: 13
Inspection Report
Life Safety
Census: 42
Capacity: 48
Deficiencies: 5
Date: Jul 6, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code.
Findings
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.
Deficiencies (5)
Failed to conduct quarterly fire drills for 1 of 4 quarters in Building 01, 02, 03, and 04.
Failed to ensure annual inspection and testing of 8 of 8 fire door assemblies in Buildings 01, 02, 03, and 04.
Failed to document 36-month period emergency generator testing for 4 of 4 emergency generators in Buildings 01, 02, 03, and 04.
Failed to ensure a written record of weekly inspections for the generator was maintained for 4 of 52 weeks in Buildings 01, 02, 03, and 04.
Failed to ensure 1 of 1 fire alarm systems was continuously in proper operating condition in Building 03.
Report Facts
Certified beds: 48
Census: 42
Fire door assemblies: 8
Emergency generators: 4
Weekly generator inspections missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Named in relation to exit conference and plan of correction |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/06/23 was completed on 07/28/23.
Findings
The Laurels of Goshen was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 42
Capacity: 42
Deficiencies: 10
Date: Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple Complaints.
Complaint Details
This inspection included investigations of Complaints IN0000407309, IN00407184, IN00403836, IN00400374, IN00409061, and IN00402210. Deficiencies related to complaints IN00409061 and IN00402210 were cited.
Findings
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.
Deficiencies (10)
Failed to obtain physician's order for CPR as indicated by resident's POA upon admission.
Failed to include resident or representative in care plan meetings.
Failed to provide resident-centered activities that incorporate residents' interests and hobbies.
Failed to identify multiple nitroglycerin patches during admission skin assessment and follow physician's order for daily lab work for anticoagulation therapy.
Failed to ensure placement of gastrostomy tube was assessed prior to administration of tube feeding.
Failed to ensure physician orders for oxygen therapy were obtained and respiratory equipment was stored properly.
Failed to ensure menu was followed for pureed food preparation.
Failed to ensure food was stored, prepared and served in a sanitary manner in four kitchens.
Failed to comply with infection control measures for glucometer sanitation.
Failed to provide pneumococcal vaccination timely for a resident whose POA consented upon admission.
Report Facts
Survey dates: May 30, 31, June 1, 2, 5, & 6, 2023
Census: 42
Total Capacity: 42
Medicare residents: 8
Medicaid residents: 22
Deficiency counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Signed report |
| LPN 6 | Interviewed regarding CPR orders and oxygen therapy | |
| LPN 10 | Observed performing blood sugar monitoring and glucometer sanitation | |
| RN 3 | Observed administering tube feeding without checking gastrostomy tube placement | |
| Cook 11 | Observed preparing pureed food and food handling | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including CPR orders, anticoagulation, oxygen therapy, and pneumococcal vaccination |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385669.
Complaint Details
Complaint IN00385669 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 41
Total Capacity: 41
Medicare Census: 8
Medicaid Census: 25
Other Payor Census: 8
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