Inspection Reports for
Gosnell Health and Rehab
700 Moody Street, Gosnell, AR, 72315
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an accident involving Resident #199 during a van wheelchair lift transfer on 09/10/2024, which resulted in serious injury.
Complaint Details
The investigation was triggered by a complaint regarding an accident on 09/10/2024 involving Resident #199 who fell from a van wheelchair lift due to staff not following safety protocols. The complaint was substantiated with findings of staff failure to follow manufacturer guidelines and inadequate training. The involved CNA was suspended and later terminated.
Findings
The facility failed to prevent an accident causing serious injury to Resident #199 due to not following the manufacturer's guidelines for the wheelchair lift and inadequate staff training. The incident resulted in a left ankle fracture and suspected sacrum fracture. The facility implemented corrective actions including staff retraining, suspension and termination of involved staff, and enhanced monitoring.
Deficiencies (1)
Failure to prevent an accident during van wheelchair lift transfer due to not following manufacturer's guidelines and inadequate staff training, resulting in serious injury to Resident #199.
Report Facts
Residents potentially affected: 5
Date of incident: Sep 10, 2024
Date of survey completion: Sep 19, 2024
Training dates: Jan 16, 2024
Retraining completion date: Sep 13, 2024
Fall height: 24
Monitoring frequency: 3
Monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Involved in the incident; failed to follow manufacturer's guidelines and training; suspended and terminated. |
| CNA #7 | Certified Nurse Aide | Witnessed the fall and assisted with other resident transfers; completed retraining on 09/12/2024. |
| Director of Nursing | Director of Nursing | Interviewed regarding incident response and notification. |
| Maintenance Director | Maintenance Director | Demonstrated van lift operation and confirmed training dates. |
| Administrator | Administrator | Interviewed regarding incident and corrective actions. |
| Van and Mobility Mechanic | Van and Mobility Mechanic | Inspected transport vans post-incident and confirmed safety mechanisms. |
| CNA #6 | Certified Nurse Aide | Confirmed recent van transport training on 09/13/2024. |
Inspection Report
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including accurate assessments, foot care, and accident prevention following a serious injury incident.
Findings
The facility was found deficient in accurately coding resident assessments, providing appropriate foot care for diabetic residents, and preventing accidents during resident transport, resulting in an immediate jeopardy citation due to a serious injury from a van lift incident. Corrective actions and staff retraining were implemented.
Deficiencies (3)
Failed to accurately code a Minimum Data Set (MDS) for a contracture under Section GG for one resident.
Failed to ensure residents requiring assistance with foot care received necessary care, resulting in poor toenail hygiene for one resident.
Failed to prevent an accident causing serious injury during a van lift transfer due to not following manufacturer's guidelines and training for one resident.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Date of injury: Sep 10, 2024
Fall height: 24
Number of residents potentially affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Involved in van lift accident causing resident injury; failed to follow safety procedures; suspended and terminated |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding foot care deficiency for Resident #24 |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding contracture care for Resident #3 |
| Certified Nursing Assistant #7 | CNA | Witnessed van lift accident involving Resident #199 |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding contracture care and foot care deficiencies |
| Director of Nursing | DON | Interviewed regarding contracture assessment, foot care, and van lift incident response |
| Maintenance Director | Interviewed regarding van lift operation and training | |
| Administrator | Interviewed regarding van lift incident and corrective actions | |
| Van and Mobility Mechanic | Inspected transport vans following incident and confirmed safety mechanisms | |
| MDS Coordinator | Interviewed regarding inaccurate MDS coding for Resident #3 | |
| MDS Consultant | Interviewed regarding facility MDS policies | |
| Certified Nursing Assistant #6 | CNA | Confirmed recent van transport training |
Inspection Report
Routine
Census: 57
Deficiencies: 6
Date: Sep 29, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident fund notifications, resident safety, living environment cleanliness, respiratory care, medication management, and food safety in the nursing home.
Findings
The facility was found deficient in notifying Medicaid residents about Trust Fund balances nearing limits, failure to notify family after a choking incident, poor cleanliness and maintenance of resident rooms and common areas, inadequate respiratory care including improper oxygen use, failure to date insulin vials and remove expired medications, and unsafe food handling practices by dietary staff.
Deficiencies (6)
Failed to notify Medicaid recipient residents or their responsible parties when Trust Fund balances approached the Medicaid maximum limit.
Failed to notify resident's representative or Power of Attorney after a choking incident requiring Heimlich Maneuver.
Failed to maintain a safe, clean, comfortable, and homelike environment; multiple resident rooms, hallways, and shower rooms were dirty, had insect infestations, damaged fixtures, and unclean equipment.
Failed to provide safe and appropriate respiratory care; portable oxygen not used during transport and oxygen tanks not checked as ordered.
Failed to ensure insulin vials were dated when opened and expired medications were removed from the narcotic box.
Failed to ensure foods stored in refrigerator and freezer were covered and dietary staff washed hands before handling clean equipment or food items.
Report Facts
Residents affected: 3
Residents affected: 1
Resident rooms observed: 9
Residents affected: 8
Residents affected: 56
Total Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Named in Medicaid Trust Fund notification deficiency | |
| Administrator | Named in Medicaid Trust Fund notification deficiency and policy absence | |
| Activity Director/Certified Nursing Assistant (CNA) #1 | Performed Heimlich maneuver during choking incident | |
| Director of Nursing (DON) | Responded to choking incident notification questions and medication cart checks | |
| Licensed Practical Nurse (LPN) #1 | Checked oxygen for residents and provided information on oxygen use | |
| Licensed Practical Nurse (LPN) #3 | Provided information on medication cart checks | |
| Housekeeper #1 | Provided cleaning process information | |
| Dietary Employees (DE) #1, #2, #3, #4 | Named in food safety and handwashing deficiencies | |
| Dietary Supervisor | Provided facility policy on employee cleanliness and handwashing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 24, 2022
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure fall prevention interventions were promptly and consistently implemented to minimize fall-related injuries for residents at high risk of falls.
Complaint Details
The complaint investigation found that the facility failed to implement fall prevention interventions promptly and consistently for Resident #45, who fell on 5/31/22. The interventions were updated on 6/21/22 but not reflected in the closet care plan. The resident was at high risk for falls with a Morse Fall Scale score of 75.
Findings
The facility failed to implement timely and consistent fall prevention interventions for Resident #45, who had a recent fall and was identified as high risk. The closet care plan did not address fall risk, and post-fall interventions were delayed and inconsistently documented.
Deficiencies (1)
Failure to ensure fall prevention interventions were promptly and consistently implemented to minimize fall-related injuries for a high-risk resident.
Report Facts
Morse Fall Scale score: 75
Residents at high risk for falls: 20
Fall date: May 31, 2022
Fall monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed about Resident #45's care and fall risk | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about Resident #45's care, fall risk, and interventions | |
| Care Plan Coordinator | Interviewed about responsibility for care plans and fall risk interventions |
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