Gosnell Health And Rehab

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident #5) of five residents reviewed for the resident's comprehensive assessment. Specifically, the facility failed to ensure Resident #5's comprehensive care plan included information that would require staff to provide care and monitor for resident safety. The findings include: A review of Resident #5's admission Record indicated the facility admitted the resident on 01/16/2026, with diagnoses which included nerve damage, muscle weakness, limitation of activities, type 2 diabetes mellitus, difficulty walking, inflammation of the spine, urinary tract infections, constipation, adjustment disorder, anemia, thyroid disorder, high cholesterol, sleep apnea, high blood pressure, irregular heartbeat, arthritis, chronic kidney disease, shortness of breath, fatigue, and stomach paralysis. A review of Resident #5's admission Minimum Data Set (MDS) with an Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and facility policy review, the facility failed to ensure safety straps were placed and secured to all four wheels of a resident's wheelchair before being transported in the facility van which resulted in the resident falling backwards from the wheelchair for one (Resident #65) of four residents reviewed for accidents. The findings include: A review of Resident #65's Physician's Orders dated 12/31/2024, revealed an order to admit to long-term care on 09/18/2024. Resident #65's Physician's Orders also revealed diagnoses which included hemiplegia (complete or near-complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) which affected the right dominant side, and an acquired absence of left leg below the knee. Resident #65's Physician's Orders further revealed a medication for pain was ordered on 09/18/2024, to be given as needed every six hours. A review of Resident #65's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/19/2024, revealed a Brief Interview for Mental Status score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to accurately code a Minimum Data Set (MDS) for a contracture under Section GG for one out of one sampled residents (Resident #3). These are the findings: A review of the Order Summary revealed Resident #3 had a diagnosis of stroke with left sided weakness/paralysis. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/2024 reveals that Resident #3 scored a 12 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of Section GG in the MDS reveals that for upper limited mobility was marked no impairment. On 09/16/2024 at 11:36 AM, the surveyor observed Resident #3 in bed with left hand contracture with no intervention in place. Surveyor observed that Resident #3 could not stretch the hand out, and they stated, that they have had the contracture for a while. On 09/16/2024 at 3:00 PM Surveyor observed Resident #3 up in wheelchair with left hand contracture and no interventions. On 09/19/2024 at 9:25 AM, during an interview Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for one resident of one sampled resident. (Resident #24). These are the findings: Review of an Order Summary Report revealed that Resident #24 had diagnoses of dementia, diabetes, chronic kidney disease, congestive heart failure, and need for assistance with personal care. There was no order for diabetic nail care for the nursing staff. Review of a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed that Resident #24 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of a Care Plan initiated on 03/26/2024 revealed that Resident #24 had an activity of daily living (ADL) deficit that stated to check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator and freezer were covered and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 56 residents who received meals from the kitchen (Total Census: 57), as documented on a list provided by the Dietary Supervisor on 09/26/23 at 3:01 PM. The findings are: 1.On 09/25/23 at 11:01 AM, the following observations were made on a shelf in the freezer: a. An opened box of polish sausage. The box was not covered or sealed. b. An opened box of sausage links. The box was not covered or sealed. c. An opened box of diced chicken. The box was not covered or sealed. d. An opened box of fish. The box was not covered or sealed. e. An opened box of briskets. The box was covered or sealed. 2. On 09/25/23 at 11:15 AM, two boxes of breadcrumbs were on a rack in the storage room with an expiration date of 7/20/23. 3. On 09/25/23 at 11:28 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's living space (9 of 37 rooms, the hallways (1 of 4), shower rooms (2 of 2) and equipment were clean and well maintained. The failed practice had the ability to affect all residents who live in the facility, who utilize the common areas and shower rooms according to the census and condition which was provided by the administrator on 9/25/23 at 1:30 PM. The findings are: Resident room [ROOM NUMBER] B: a. On 09/25/23 at 11:58 AM, observed a medication cup sitting on the windowsill. The cup was approximately 1/2 full of a white granulated substance. The Surveyor asked the resident if he was aware of what was in the cup. The resident stated, That started out as cream for my butt, but it's been there while. Three tiny spiders were in the area surrounding the cup and dead bugs extending down the length of the windowsill from side to side. b. On 09/26/23 at 9:30 AM, observed holes in the left wall. The dead insects and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure portable oxygen was used when transporting a resident who required continuous oxygen for 1 (Resident #10) and oxygen tanks were checked to ensure the resident was receiving oxygen as ordered by the Physician for 1 (Resident #18) of 2 (Residents #10 and #18) sampled resident who received oxygen. The findings are: 1. Resident #10 had diagnoses of Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia. a. On 09/27/23 at 2:05 pm, Resident #10 was seated in a wheelchair being pushed by staff down the hall from the therapy room. Resident #10 had her nasal cannula in her nose, but the nasal cannula tubing was not connected to an oxygen cylinder and a portable oxygen cylinder was not on the back of the wheelchair. The Surveyor followed the resident down the hall and into her room. The Occupational Therapist connected Resident #10's oxygen tubing to a stationary oxygen tank at the bedside. Resident #10 stated, I'm a little short of breath. The Surveyor asked the Occupational Therapist if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when the amount in their Trust Fund account was within $200 of the maximum Medicaid recipient cash assets for 3 (Residents #9, #18 and #30) of 12 (Residents #1, #8, #9, #18, #23, #24, #25, #26, #30, #32, #36 and #41) sampled residents who had Medicaid coverage and had Trust Funds managed by the facility. The findings are: 1. On 09/27/23 at 1:00 PM, the Surveyor received the resident Trust Fund balances from the Business Office Manager (BOM) and noted Resident #9 had a balance of $1877.93, Resident #18 had a balance of $1867.97, and Resident #30 had a balance of $1892.90. 2. On 09/27/23 at 2:48 PM, the Surveyor asked the BOM for the documentation regarding the Medicaid notification letters for Resident #9, Resident #18, and Resident #30. The BOM stated she had not sent out the notification letters. The Surveyor asked how do you let resident/family know that they are approaching the maximum amount allowed by Medicaid. The BOM stated, I send…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's representative or Power of Attorney (POA) was notified after a resident choked and the Heimlich Maneuver was performed for 1 (Resident #32) of 1 sampled resident. The findings are: 1. On 09/26/23 at 11:09 am, during Resident Council Meeting a resident stated, I just wanted to give kudos to [Name], the Activity Director, for helping the man [Resident #32] seated across the table from me in Bingo, who choked on the [Name] candy. She did the Heimlich and saved him. 2. On 09/27/23 at 1:49 pm, the Surveyor asked the Activity Director/Certified Nursing Assistant (CNA) #1, Can you tell me about an incident that happened during an activity this week? Activity Director/CNA #1 stated, Oh yes. On Monday afternoon after Bingo, I was passing out snacks when a resident at the table with Resident #32 reported to me that the resident seated beside him was choking. I told the transport driver to go get the nurse, but I didn't feel she came quick…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and record review, the facility failed to ensure insulin vials were dated when opened, and expired medications were removed from the narcotic box. This failed practice had the potential to affect 8 residents who received insulin off the medication cart for the 100 and 200 Halls, and (1) resident with an expired narcotic card. The findings are: 1. On 9/27/23 at 2:07 PM, the following observations were made in the Medication Room: a. The Medication Cart had one opened vial of Novolog Insulin with no open date on it. b. The Medication Cart had one card of Trazadone with an expiration date of 9/14/23 in the locked narcotic box. c. On 9/27/23 at 2:28 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how often do you check your medication cart for expired medications. LPN #3 stated, When I can. d. On 9/29/23 at 9:34 AM, the Surveyor asked the Director of Nursing (DON) how often do you check the carts for expired medications? The DON stated, Assistant Director of Nursing [ADON], and myself check it monthly. The night shift nurses check it randomly and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.