Goshen Healthcare Community
Goshen Healthcare Community in Torrington, WY — inspection on October 2, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the quarterly MDS assessment dated [DATE] 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
Facility ID: