Gosnell Health and Rehab

In the surveyor’s words

From the most serious findings on record at Gosnell Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 19, 2024

  Based on interviews, record review, observations, and document review, the facility failed to prevent an accident that caused serious injury during a van with lift transfer due to not following the manufacturer's guidelines for the lift and training for 1 (Resident #199) of 1 resident reviewed for accidents. This deficient practice resulted in Resident #199 sustaining a left ankle fracture on 09/10/2024, and a suspected fracture to the sacrum. The findings are: On 09/17/24 at 11:09 AM, during an interview with [NAME] President of Operations regarding incident he confirmed Certified Nurse Aide #1 (CNA #1) assisted with unloading Resident #199. CNA #1 failed to confirm the lift gate was up and ready for the transfer which caused the fall. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2023

  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. […]

• No harm, potential for more than minimal, patternF584Sep 29, 2023

  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. […]

• No harm, potential for more than minimal, patternF695Sep 29, 2023

  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. […]

• No harm, potential for more than minimal, patternF761Apr 20, 2022

  Based on observation, record review and interview, the facility failed to ensure licensed nursing staff observed complete consumption of medications during medication administration to assure appropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect 52 residents who received medications as documented on a list of Alphabetical Residents provided by the Administrator on 04/18/2022 at 11:00 am. The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission assessment dated [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. […]