Goshen Healthcare Community
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, facility investigation review, and policy review, the facility failed to protect the residents right to be free from physical abuse by another resident for 1 of 3 sample residents (#1) reviewed for abuse. The findings were: 1. Review of the quarterly MDS assessment dated [DATE REDACTED] showed resident #1 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, and had diagnoses which included dementia, coronary artery disease, heart failure, and hypertension. The following concerns were identified:a. Review of the facility incident report dated 8/14/25 and timed 4:45 PM showed resident #1 tapped resident #2 on the shoulder. Resident #2 then grabbed resident #1's arm resulting in a skin tear to his/her right elbow. b. Interview with the MDS coordinator on 10/1/25 at 6:13 PM confirmed resident #1 had a skin tear following the incident; was not fearful, and did not recall if the incident had occurred.c. Interview with Resident #1 on 10/2/25 at 8:50 AM confirmed s/he had some memory of the incident and was not fearful. d. Interview with CNA #1 on 10/2/25 at 10:05 AM revealed she observed resident #2 squeezing resident #1's arm during the incident. e. Interview with LPN #1 on 10/2/25 at 11:22 AM confirmed the incident occurred. She further revealed that resident #1 often approached other residents in this same manner. f. Interview with the NHA on 10/2/25 at 10:10 AM revealed staff were expected to keep resident #2 greater than arm's length away from other resident's, which did not occur that day. 2. Review of resident #2's care plan dated 5/13/25 showed s/he had frequent, unpredictable, and impulsive behaviors and may slap or punch other residents. A goal and intervention in
the care plan included adjusting supervision as needed to avoid aggression toward other residents. a.
Observation on 10/1/25 at 12:50 PM showed resident #2 was unsupervised in the hall outside of his/her room from 12:50 PM to 1:20PM. 3. Review of the policy titled Abuse Prevention Plan last revised 10/2024 showed .1. All residents will be protected from abuse and interventions would be implemented . Abuse was defined as A.2.Hitting, slapping, scratching, and pinching .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Goshen Healthcare Community in Torrington, WY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Torrington, WY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Goshen Healthcare Community or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.