Majestic Care of Goshen
2400 College Ave, Goshen, IN 46528 · Elkhart County · (574) 533-0351
186 certified beds, about 128 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2001
Special Focus Facility candidate CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 155689 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on January 23, 2025, inspectors cited 11 health deficiencies (the Indiana average is 7.2, the national average 9.2).
Of 84 health citations since January 2023, 4 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 2 fines totaling $16,036 in the last three years; the largest was $8,018, and the latest is dated March 2, 2024.
Nurses and nurse aides worked 3.17 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
56.1% of nursing staff left within the year CMS measured (Indiana average 45.9%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1601/23
110/23
101/24
2903/24
108/24
408/24
309/24
311/24
1101/25
109/25
301/26
202/26
406/26
106/26
407/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 84 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
64D
10E
5F
Potential for minimal harm
0A
0B
1C
July 24, 2026Complaint inspection · 4 citations
- J Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure post fall assessments and monitoring had been completed for 1 of 6 residents reviewed for falls. (Resident B) This deficient practice resulted in Resident B serious injuries due to having a delay in treatment related to a broken occipital bone and subarachnoid hemorrhages in April and a delay of treatment related to a broken humerus bone in June. In addition to the Immediate Jeopardy, the facility failed to ensure 2 of 6 residents reviewed for falls received thorough post fall assessments and monitoring which resulted in the potential for harm, that is not immediate jeopardy. (Resident J and H)The Immediate jeopardy that began on 4/6/2026 when Resident B had an unwitnessed fall and staff failed to complete thorough post fall assessments. [...]
- F Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the physical environment remained free of vermin and pests and failed to promptly eradicate an ongoing insect infestation. This deficient practice affected the main kitchen and dry storage areas and had the potential to affect all 121 residents who resided in the facility and received food from the kitchen. See F0812 for additional information regarding storing and serving food in a safe and sanitary manner.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and serve food under sanitary conditions in to prevent the growth of potential foodborne pathogens and reduce the risk of cross-contamination. Specifically, the facility failed to enforce proper infection control techniques during meal service, failed to maintain appropriate cold storage capacity by over-stacking units, failed to track and remove expired food items, failed to ensure effective chemical sanitization levels, and failed to maintain kitchen floors and areas underneath appliances in a clean, dry, and sanitary manner. This deficient practice had the potential to affect all 121 residents who consumed meals prepared by the facility kitchen. See F0925 for additional findings related to pest control.
- E Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of cooking grease and maintain refuse storage in a sanitary manner in 1 of 1 kitchen and refuse storage area.
June 12, 2026Complaint inspection · 1 citation
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a sanitary kitchen for 1 of 1 main kitchen observed for sanitation. This deficient practice had the potential to affect 120 of 120 residents who consumed food from the kitchen.
June 2, 2026Complaint inspection · 4 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure 2 of 3 residents reviewed for abuse were free from verbal abuse and physical injury when a Certified Nursing Assistant (CNA) was verbally abusive to one resident (Resident R), and physically abusive as evidenced by grabbed another resident's wrist during a transfer which resulted in bruising and skin tears to the resident's arm, (Resident P). Using the reasonable person concept, the abuse likely led to emotional distress related to intimidation and anxiety for both residents (Resident R and P) and actual physical injuries for Resident P.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's physician and responsible party were notified when the resident experienced seizure activity and when antiseizure medications had not been administered in accordance with physician orders for 1 of 3 residents reviewed for notification of change of condition, (Resident N).
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, observation, and record review, the facility failed to fully implement their abuse policy regarding timely reporting, timely resident assessments, and immediate removal of an alleged perpetrator, when a Certified Nursing Assistant (CNA) was alleged to be verbally abusive to a resident (Resident R) and verbally and physically abusive to another, (Resident P), for 2 of 3 residents reviewed for abuse. (Resident R and P)
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure antiseizure medications were available and administered in accordance with physician orders for 1 of 3 residents reviewed for medication administration, (Resident N). This deficient practice resulted in the resident displaying seizure activity.
February 3, 2026Complaint inspection · 2 citations
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, observation, and record review, the facility failed to implement their policy related to reporting, two allegations of abuse in a timely manner for 1 of 3 residents reviewed for allegations of abuse, (Resident C).
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, observation, and record review, the facility failed to implement their policy related to investigating, an allegation of abuse for 1 of 3 residents reviewed for allegations of abuse, (Resident C).
January 7, 2026Complaint inspection · 3 citations
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure showers were completed for 2 of 4 residents reviewed for activities of daily living. (Residents C & B)
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for 1 of 3 residents reviewed for medication administration and failed to ensure an appointment for a specialized physician had been scheduled for 1 of 3 residents reviewed for resident rights. (Residents C & E)
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review, the facility failed to ensure urinary output was monitored for 1 of 3 residents reviewed for urinary catheters. (Resident B)
September 10, 2025Complaint inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to ensure catheter care was completed as ordered for 3 of 3 residents reviewed (Resident B, Resident C, Resident D).
January 23, 2025Standard inspection, Complaint inspection · 11 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review and interview, the facility failed to store and prepare food under sanitary conditions related to foods not sealed appropriately, outdated foods, and dirty kitchen equipment for 1 of 1 kitchen observed. This issue had the potential to affect all 101 residents who resided in the facility and received food from this kitchen.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were followed related to glove use and handwashing for 3 of 3 residents reviewed for perineal/catheter care and for 1 of 1 residents reviewed for nephrostomy care and during 1 of 3 medication administration passes. In addition, the facility failed to follow their policy regarding Enhanced Barrier Precautions (EBP) to ensure residents with wounds and catheters were placed in isolation for 3 of 5 residents reviewed for EBP isolation. Finally, the facility failed to report an illness outbreak to the State Department of Health. These deficient practices potentially affected 101 of 101 residents in the facility. (Residents 18, E, 98, G, 96, 314 & H)
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician was notified of abnormal blood sugar levels and insulin refusals for 2 of 2 residents reviewed for insulin (Resident 4 & 96) and of new skin issues for 1 of 6 residents reviewed for skin (Resident 5).
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to ensure corrective action adequately addressed a response to resident council grievances of call light and shower concerns and readily provided grievance forms for residents to utilize anonymously. This practice had the potential to affect 101 of 101 residents.
- D Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and interview, the facility failed to ensure 1 of 2 resident's Level One PASARR (Preadmission Screening and Resident Review) assessment was completed accurately and failed to ensure an updated Level 1 review was completed for 1 of 27 residents reviewed for MDS assessments . (Resident 18)
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preventative measures were implemented timely to prevent pressure ulcer development for 1 of 3 residents reviewed for facility-acquired pressure ulcers (Resident 96).
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide nephrostomy dressing changes for 1 of 4 residents reviewed for catheter care. (Resident G)
- D Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure follow up speciality appointments and referrals (gynecological/oncology/hematology/vascular surgeon/nephrology) were made for 2 of 2 residents reviewed for physician orders. (Residents G & 64)
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for 2 of 5 residents reviewed for unnecessary medications (Residents 18 & 101).
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were kept in a locked cart when unattended, were dated and labeled, medication carts were without loose pills and failed to store treatment creams separate from oral medications during medication storage review for 2 of 3 storage units. (200 hall middle medication cart and 100 hall medication cart)
- D Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility failed to complete laboratory testing as ordered by the physician for 1 of 1 residents reviewed for laboratory services. (96)
November 14, 2024Complaint inspection · 3 citations
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing opportunities and oral care were provided for 2 of 3 residents, who required assistance and who were dependent on staff for Activities of Daily Living (ADL). (Residents B and G)
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent falls, for 1 of 3 residents reviewed for falls. (Resident C)
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure urinary catheters were emptied for 2 of 3 residents and urine output had been documented for 3 of 3 residents reviewed for urinary catheter use. (Residents B, E and G)
September 12, 2024Complaint inspection · 3 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensured bowel protocol was followed 1 of 3 residents reviewed for bowel movements, (Resident B).
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure 1 of 3 residents reviewed for pressure wounds, received timely care and treatment to prevent the development of a pressure wound, (Resident B).
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided and a pain assessment was completed upon admission for 1 of 3 residents reviewed for pain, (Resident B).
August 16, 2024Complaint inspection · 4 citations
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rights were honored when bathing preferences were not accommodated for 1 of 6 residents reviewed for Resident Rights, (Residents C)
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive and person centered care plan was developed for urostomy care for 1 of 3 residents reviewed for urostomy care, (Resident C).
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers/bathing opportunities as scheduled for for 6 of 6 residents reviewed for Resident Rights, (Residents B, C, D, J, K, and M).
- D Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure urostomy orders, care, and monitoring orders were in place for the care of 1 of 3 residents reviewed for urostomy care, (Resident C).
August 1, 2024Complaint inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to complete follow up assessments for changes in condition related to urinary tract infections for 3 of 3 residents reviewed for urinary tract infections. (Residents B, D, and E)
March 2, 2024Standard inspection, Complaint inspection · 29 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect a resident's right to be free from verbal abuse from another resident, which resulted in emotional distress, and physical abuse by a staff member, for 3 of 4 residents reviewed for abuse. (Residents 68, 218 & 43)
- G Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review, and observation, the facility failed to identify and manage an acute change in condition of worsening respiratory symptoms, irregular blood sugar levels, and abnormal laboratory results not addressed. The deficient practice resulted in a delayed hospital evaluation, and hospitalization for pneumonia, acute kidney injury on chronic kidney disease, and cardiac disease (Resident 96). The facility failed to notify the physician of blood sugars outside of ordered parameters (Resident 109), to assess and treat a scabbed skin area (Resident 27), and to identify and notify the physician of bruising and swelling in a resident who received an anticoagulant medication (Resident 64) for 4 of 5 residents reviewed for quality of care.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. (Main Kitchen) This had the potential to affect 113 residents who received food from the kitchen.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comfortable water temperatures were provided for showers and/or peri care, even after grievances had been filed, for 2 of 3 units observed. (Cedar and Birch units)
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review, and , the facility failed to ensure food was served at a palatable temperature on 2 of 3 nursing units. (Cedar & Dogwood units)
- E Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased observation, record review, and interview, the facility failed to ensure the menu for therapeutic diets was prepared and offered. This deficient practice had the potential to affect residents receiving therapeutic diets from the kitchen.
- E Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure walls and floors were maintained in a sanitary and comfortable condition for 2 of 3 nursing units observed. (Cedar and Birch units)
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review, and interview, the facility staff failed to report alleged abuse allegations immediately to the administrator for 3 of 4 residents reviewed for abuse. (Residents 43, 218 and 68)
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, record review, and interview, the facility failed to investigate allegations of abuse for 3 of 4 residents reviewed for abuse prevention. (Residents 43, 218 and 68)
- D Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview and record review, the facility failed to provide required resident information to the receiving facility for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10)
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interviews and record reviews, the facility failed to provide the required transfer and discharge form to the resident or resident representative for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10)
- D Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interviews and record reviews the facility failed to provide the required bed hold form to the resident or resident representative for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10)
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed, related to PASARR (Pre-admission Screening and Resident Review) coded incorrectly, for 1 of 27 MDS assessments reviewed. (Resident 7)
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an individualized comprehensive care plan was developed for 2 of 2 residents reviewed for bowel and bladder incontinence (Residents D and 90) and failed to ensure fall care plans were followed for 1 of 4 residents reviewed for falls. (Resident 267)
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to include or invite residents' family members or responsible parties to participate in Care Plan conferences and failed to revise Care Plans timely for 5 of 5 residents reviewed for care planning. (Residents 95, C, 30, 64 and 27).
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 5 of 5 dependent residents reviewed for Activities of Daily Living received needed assistance related to AM care, showers, and shaving. (Residents E, D, B, C, & G)
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an individualized activity program for 1 of 2 residents reviewed for activities. (Resident 27)
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 of 3 residents reviewed for vision needs received timely assistance to address visual impairment needs. (Resident 64)
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate interventions were in place to ensure an area for a resident with a previous pressure ulcer remained closed and/or healed, for 1 of 4 residents reviewed for pressure ulcers. (Resident 17)
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 of 2 residents reviewed for bladder incontinence received timely care to prevent and treat a urinary tract infection. (Resident D)
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 of 1 residents observed for hydration was offered sufficient fluids to maintain proper hydration and health. (Resident 27)
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide sanitary nebulizer equipment for 1 of 2 residents reviewed for respiratory care. (Resident 68)
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to provide ongoing assessment for a 1 of 1 resident reviewed for dialysis. (Resident 109)
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to monitor for the use of a thyroid medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 17)
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, that facility failed to limit as needed (PRN) psychotropic medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 18)
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 of 2 residents reviewed for dental services received timely assistance. (Resident 90)
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow infection control standards during incontinence care, for 2 of 7 residents reviewed for activities of daily living. (Residents D and 27) The facility also failed to ensure transmission based precautions were implemented appropriately for 1 of 3 residents reviewed for infections. (Resident 11)
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 5 residents reviewed for immunizations/vaccine administration, had received them. (Residents 4, 95 and 51)
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staff posting was current for 1 of 7 survey days observed. This had the potential to affect all residents in the facility.
January 4, 2024Complaint inspection · 1 citation
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of misappropriation of property was reported to the State Survey Agency (SSA) in a timely manner for 1 of 3 residents reviewed for misappropriation of property, (Resident B).
October 23, 2023Complaint inspection · 1 citation
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported timely, in 1 of 3 residents reviewed for allegations of abuse. (Resident D)
January 18, 2023Standard inspection · 16 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a sanitary refrigerator and food storage for the residents' nutrition needs in 3 of 3 pantries observed. (Halls 100, 200, 300)
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive, person centered, care plans were in place and accurate for 4 of 4 residents review for care plans. (Residents G, H, 72, 280).
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to provide care plan meetings for 6 of 6 residents reviewed for care plan meetings.( Residents 16, 46, 47, 71, 22, & H)
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure showers were provided timely for 7 of 8 residents reviewed for Adl care (Activities of Daily Living). (Residents 16, 46, 44, D, L, 180)
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to provide a correct physician order for the resident's resuscitation wishes for 1 of 2 residents reviewed for advanced directives. (Resident 69)
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to prevent mental anguish to 1 of 3 residents reviewed for abuse. (Resident 16)
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report the follow-up to a reportable timely for 1 of 3 residents whose reportable's were reviewed. ( Resident 18)
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, record review, and interview, the facility failed to complete an activity comprehensive assessment for 1 of 3 residents reviewed for activities comprehensive assessments. (Resident 280) During an initial interview on 1/10/2023 at 11:51 A.M., Resident 280 indicated she stayed in her room all day, including meals, and would like to participate in activities.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of choice for 1 of 3 residents reviewed for activities. (Resident 280)
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to collaborate with hospice regarding the development of a comprehensive hospice care plan related to communication of resident changes i.e.: pain, nutrition, skin and end of life for 1 of 3 residents reviewed for hospice. (Resident 180)
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure catheter care was completed appropriately for 2 of 3 residents reviewed for catheter care. (Resident 28 and Resident L)
- D Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to change PICC (peripherally inserted central catheter) line dressings for 1 of 1 resident reviewed for intravenous antibiotic therapy ( Resident 101) During an observation on 1/10/2023 at 2:26 P.M., Resident 101's PICC line dressing had a PICC line kit dated tape adhered to the clear Tegaderm with the date of 12/4/2022. The Tegaderm was observed to be rolled on the edges and not adhered around the PICC lines. A clinical record review of Resident 101 was completed on 1/13/2023 at 9:13 A.M. Diagnoses included, but were not limited to: congestive heart failure, atrial fibrillation, chronic kidney disease, and osteomyelitis. A Significant Change MDS (Minimum Data Assessment) Assessment on 12/15/2022 indicated Resident 101 was cognitively intact. [...]
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on Observation, record review and interview, the facility failed to maintain oxygen equipment and non-invasive respiratory mechanical devices in a sanitary manner for 2 of 4 residents reviewed for oxygen use. (Resident 44 and 279)
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident did not receive unnecessary antibiotics for 1 of 6 residents reviewed for urinary tract infections. (Resident 279)
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to complete a gradual dose reduction for a resident receiving psychotopic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 46)
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications/treatments were kept in locked carts when unattended, failed to ensure medication storage areas were free from loose medications; failed to have medications labeled; failed to date medications when opened; and failed to destroy medications that were discontinued /refused or the resident had been discharged and no longer being used during medication storage reviews for 1 of 2 medication rooms observed and 3 of 5 medication carts observed. (Dogwood Medication carts, Birch Medication carts and med room, and Cedar treatment cart.)
Fire safety inspections
66 fire safety citations on file: 2 on July 1, 2026, 21 on January 23, 2025, 9 on March 2, 2024, 34 on January 18, 2023.
Every fire safety citation66 citations
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Have approved installation, maintenance and testing program for fire alarm systems.
- F Address patient/client population and determine types of services needed.
- F Address subsistence needs for staff and patients.
- F Establish procedures for tracking staff and patients during an emergency.
- F List the names and contact information of those in the facility.
- F Provide emergency officials' contact information.
- F Establish staff and initial training requirements.
- F Conduct testing and exercise requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Meet other general requirements that are deficient.
- F Have properly installed electrical wiring and gas equipment.
- F Provide a written emergency evacuation plan.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have proper medical gas storage and administration areas.
- E Provide properly protected cooking facilities.
- E Install corridor and hallway doors that block smoke.
- E Ensure proper usage of power strips and extension cords.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Use approved construction type or materials.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Have properly installed electrical wiring and gas equipment.
- D Ensure proper usage of power strips and extension cords.
- F Develop and maintain an Emergency Preparedness Program (EP).
- F Conduct risk assessment and an All-Hazards approach.
- F Develop Emergency Preparedness policies and procedures.
- F Establish procedures for tracking staff and patients during an emergency.
- F Establish policies and procedures for sheltering.
- F Establish policies and procedures for volunteers.
- F Establish roles under a Waiver declared by secretary.
- F Develop a communication plan.
- F Conduct testing and exercise requirements.
- F Implement emergency and standby power systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- E Provide properly protected cooking facilities.
- E Install an approved automatic sprinkler system.
- E Properly install and monitor supervisory attachments on automatic sprinkler systems.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- E Ensure proper usage of power strips and extension cords.
- E Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- D Install corridor and hallway doors that block smoke.
- C Provide emergency officials' contact information.
- C Provide primary/alternate means for communication.
- C Establish methods for sharing information.
- C Provide a means of sharing information on occupancy/needs.
- C Provide family notifications of emergency plan.
- C Establish emergency prep training and testing.
- C Establish staff and initial training requirements.
- C Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- C Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- C Provide a written emergency evacuation plan.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| March 2, 2024 | Fine | $8,018 |
| March 2, 2024 | Fine | $8,018 |
| March 2, 2024 | Payment Denial | 14 days from April 2, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Indiana | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.17 | 3.69 | 3.86 |
| Registered nurses | 0.47 | 0.67 | 0.69 |
| All nursing staff on weekends | 2.57 | 3.25 | 3.42 |
| Nurse aides | 1.91 | ||
| Licensed practical nurses | 0.80 | ||
| Nursing staff turnover (share who left in a year) | 56.1% | 45.9% | 45.8% |
| Registered nurse turnover | 59.1% | 40.3% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.47 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.41 on weekdays and 2.57 on weekends, 25% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.25 in April to June 2025 to 3.17 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.17 | 0.47 | 3.41 | 2.57 | 0.8% | 0 of 90 | 128 |
| Oct to Dec 2025 | 3.11 | 0.51 | 3.34 | 2.52 | 0.5% | 0 of 92 | 120 |
| Jul to Sep 2025 | 3.28 | 0.66 | 3.52 | 2.66 | 0.1% | 0 of 92 | 113 |
| Apr to Jun 2025 | 3.25 | 0.61 | 3.46 | 2.72 | 0.0% | 0 of 91 | 110 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Indiana, Jan to Mar 2026 | 3.63 | 0.62 | 3.80 | 3.19 | 3.4% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Indiana | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 0.6 | 11.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.2 | 1.1 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.2 | 3.9 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 0.8 | 11.9 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 3.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.9 | 13.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.9 | 22.2 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.2 | 10.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 1.4 | 1.8 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 33 problems in this area, most recently on July 24, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 11 problems in this area, most recently on June 2, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 9 problems in this area, most recently on June 2, 2026: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 8 problems in this area, most recently on July 24, 2026: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.57 hours per resident per day, below the Indiana average of 3.25.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Greencroft Healthcare Goshen, 1.1 mi · 2 of 5 stars · 38 citations
- Waterford Crossing Goshen, 1.8 mi · 5 of 5 stars · 12 citations
- Restoracy of Goshen, the Goshen, 3.1 mi · 4 of 5 stars · 29 citations
- Elkhart Meadows Elkhart, 10.6 mi · 5 of 5 stars · 6 citations
- Valley View Healthcare Center Elkhart, 10.8 mi · 1 of 5 stars · 48 citations
- Waters of Syracuse Skilled Nursing Facility, the Syracuse, 10.8 mi · 1 of 5 stars · 34 citations
- Brickyard Healthcare - Elkhart Care Center Elkhart, 11.4 mi · 1 of 5 stars · 39 citations
- Waters of Wakarusa Skilled Nursing Facility, the Wakarusa, 11.8 mi · 1 of 5 stars · 32 citations
Indiana contacts for a concern about a nursing home
These are the official offices in Indiana. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Indiana Department of Health, Division of Long-Term Care, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Indiana Long-Term Care Ombudsman Program, 800-622-4484. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Indiana Department of Health, Nursing Home Report Cards, where Indiana publishes its own records on licensed homes.
Common questions
- What is Majestic Care of Goshen's Medicare star rating?
- CMS rates Majestic Care of Goshen 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Majestic Care of Goshen get at its last inspection?
- 11 health deficiencies at the standard inspection on January 23, 2025. The Indiana average is 7.2.
- Has Majestic Care of Goshen been fined?
- Yes. CMS lists 2 fines totaling $16,036 in the last three years.
- Does Majestic Care of Goshen accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Majestic Care of Goshen?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.