Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MAJESTIC CARE OF GOSHEN
GOSHEN, IN · 186 certified beds · Last Life Safety survey July 1, 2026
CMS Certification Number 155689 · first certified March 2001
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
66
Citations on file
Rolling three-year window
4
Life Safety surveys
In the same window
16
Tags cited more than once
Across separate surveys
21
Inspection & testing records
Of the citations on file
Position within IN
66 citations — more than 100% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
Improvingfewer citations at the latest survey than at its earlier surveys in the window.
The latest survey found 2 citations; the earlier surveys in the window averaged 21.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 8 months from now. This facility’s last Life Safety survey was July 2026. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
24 of the 66 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 66 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 66 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 18, 2023 | 34 |
| March 2, 2024 | 9 |
| January 23, 2025 | 21 |
| July 1, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-01-23 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-01-23 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-01-23 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-01-23 |
| E-0031 | Provide emergency officials' contact information. | 2 | 2025-01-23 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 2 | 2025-01-23 |
| K-0222 | 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. | 2 | 2024-03-02 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 2 | 2025-01-23 |
What the citations cover
- Emergency Preparedness Deficiencies 24
- Smoke Deficiencies 18
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Miscellaneous Deficiencies 6
- Other 11
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 24 |
| Smoke Deficiencies | 18 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Miscellaneous Deficiencies | 6 |
| Services Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 1, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has plan of correction (July 7, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has plan of correction (July 7, 2026) |
January 23, 2025 — 21 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 14, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 14, 2025) |
March 2, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 28, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 28, 2024) |
January 18, 2023 — 34 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 25, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 25, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 11, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 25, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (March 25, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.