Restoracy of Goshen: Blood Pressure Drug Given Dangerously Low - IN
The resident, identified in inspection records only as Resident F, had been prescribed losartan 100 milligrams daily since December 2024. Losartan is an antihypertensive, meaning its purpose is to bring blood pressure down. Her care plan, in place since 2020 and updated as recently as May 2024, flagged her for hypertension and specifically called for monitoring the side effects of orthostatic hypotension, a condition in which blood pressure drops dangerously when a person changes position. No one had written parameters into the physician's order specifying when nurses should withhold the drug if her readings were already low.
Between July and August 2025, nurses checked Resident F's blood pressure four times, found readings that were low, and gave her the medication anyway. On July 1, her reading was 113/55. On July 31, it was 110/41. On August 11, it was 123/41. On August 23, it was 122/49. The diastolic number, the lower figure in a blood pressure reading, had dropped into the 40s three times and nearly into the 30s once. Nobody called the physician.
The nurse practitioner who oversees Resident F's care learned about those readings for the first time when inspectors interviewed her on August 27. She said she "would not be cool" with losartan being given at diastolic pressures in the 40s and 30s. She had not been told.
The Director of Nursing, interviewed the same afternoon, said she personally would have held the medication for a systolic reading below 130 or a diastolic below 90. Three of the four readings that triggered no action had diastolic numbers well beneath that threshold. But she also acknowledged that "every nurse was different regarding their nursing judgement." In the absence of written parameters, that is exactly what happened: each nurse made her own call, and each gave the drug.
When inspectors asked for a written policy on administering antihypertensive medications, the Executive Director said one did not exist. Staff, she said, should have followed the physician's orders. The physician's orders, however, contained no guidance on when to hold the medication. That gap is precisely the problem inspectors cited.
The care plan intervention that called for monitoring orthostatic hypotension side effects existed on paper for years. It did nothing to protect Resident F during those four medication passes, because the nurses administering the drug had no standard to apply and no instruction to pick up the phone.
Losartan at therapeutic doses, given when blood pressure is already low, carries real risk. A diastolic reading in the 40s signals that the heart is not generating adequate pressure during its resting phase between beats. Administering a medication designed to lower pressure further in that state can reduce blood flow to vital organs, increase the risk of falls, and cause syncope. For a resident with cognitive impairment, who cannot reliably report dizziness, lightheadedness, or the warning signs that precede a collapse, that risk falls entirely on the staff observing her.
The inspection was triggered by complaints, two separate intake reports filed months apart, and was completed August 27, 2025. The citation was classified as causing minimal harm or potential for actual harm, affecting a small number of residents. Federal inspectors tagged the violation as F0684, which covers the standard requiring that residents receive care in accordance with professional standards of practice.
The nurse practitioner who prescribed the medication, and who said she would not have approved giving it at those readings, was never given the chance to weigh in. The four decisions were made at the bedside, independently, without parameters, without a policy, and without a call.
Resident F's blood pressure on the last recorded date before the inspection was 122/49.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Restoracy of Goshen, The from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 3, 2026 · Our methodology
RESTORACY OF GOSHEN, THE in GOSHEN, IN was cited for violations during a health inspection on August 27, 2025.
The resident, identified in inspection records only as Resident F, had been prescribed losartan 100 milligrams daily since December 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.