Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gosnell Health And Rehab during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Incomplete Comprehensive Care Plan: A resident with multiple diagnoses, including DM, impaired mobility, a foley catheter, wounds, and dependence for many ADLs, had a care plan that did not include needed interventions for self-care deficits, wheelchair use and fall prevention, medication monitoring, black-box warnings, or wound care. CNAs relied on a closet care plan that lacked guidance for medications and wound care, and the MDS Nurse, DON, and Administrator confirmed the care plan was not comprehensive and did not contain the information needed to direct resident care.
A resident sustained serious injuries during a van transfer when a CNA failed to follow the manufacturer's guidelines for the wheelchair lift. The CNA did not ensure the lift gate was properly raised, resulting in the resident falling and suffering fractures. The CNA had not received recent training on the lift's operation, contributing to the incident.
A resident with a stroke diagnosis and left-sided weakness was observed with a left hand contracture, yet the MDS inaccurately marked no impairment for upper limited mobility. Staff interviews confirmed the contracture's presence since admission, but there was a lack of documented interventions. The MDS Coordinator and DON acknowledged the importance of accurate assessments for care planning, highlighting a deficiency in the facility's documentation and intervention processes.
A resident with dementia and diabetes did not receive necessary foot care, resulting in long, jagged toenails. Despite the care plan requiring regular nail maintenance, there was no order for diabetic nail care, and staff failed to address the issue over several days. Interviews revealed a lack of communication and responsibility among staff, with both a CNA and an LPN acknowledging the poor condition of the toenails and the potential for complications.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wheelchair was fully and properly secured with all required safety straps before transport in the facility van, resulting in the resident falling backwards in the van. The resident had physician orders for LTC admission and diagnoses including hemiplegia and hemiparesis affecting the right dominant side, as well as an acquired absence of the left leg below the knee. The resident’s MDS showed moderate cognitive impairment, functional limitations in lower extremity range of motion bilaterally, and use of a wheelchair for mobility. The care plan documented a self-care performance deficit requiring limited assistance by one staff for transfers and noted an actual fall earlier in the month, with an intervention for staff education on proper van transport. On the date of the incident, the resident was being transported in the facility van by a CNA who served as the van driver. According to the facility’s reportable and the CNA’s written witness statement, the CNA applied two back floor locks and one front floor lock to secure the wheelchair but did not secure all four required locks. During the drive, as the CNA approached a dip or hump in the road and applied the brakes, the resident’s wheelchair tilted backwards. The resident stated they were falling, and when the CNA stopped the van, she found the resident lying flat on their back on the van floor with the wheelchair also on the floor. Nursing documentation indicated the resident reported pain at the base of the skull, had a nodule on the back of the head, and declined transfer to the emergency room. Interviews and document reviews showed that the CNA had previously received in-service training and skills checkoffs on how to properly secure residents in the van and had signed best-practice forms stating that wheelchairs would be securely attached to the van body and kept centered during transport. The Administrator reported that the CNA admitted she did not use the correct number of straps to secure the wheelchair and that a hold-down device (tie-down/safety strap) had been removed from the smaller van to be used in a larger van and was not replaced. The Maintenance staff confirmed that a hold-down device for the back of the wheelchair was missing from the van used for the transport and that tie-downs were interchangeable between vans. Subsequent observation with other CNAs demonstrated that when all four locks and the seat belt were properly engaged, the wheelchair did not move, but loosening the front locks allowed the wheelchair to move, illustrating how incomplete securement could permit wheelchair movement during transport. The facility’s Safety and Supervision of Residents policy stated that the environment should be made as free from accident hazards as possible and that employees should be trained and demonstrate competency in identifying and preventing accident hazards. Despite this policy and prior in-services, the resident’s wheelchair was not fully secured with all required straps at the time of transport, and a necessary hold-down device was missing from the van, directly contributing to the resident’s fall inside the vehicle.
Incomplete Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident whose admission record showed multiple diagnoses, including nerve damage, muscle weakness, type 2 diabetes mellitus, difficulty walking, urinary tract infections, constipation, anemia, thyroid disorder, high cholesterol, sleep apnea, high blood pressure, irregular heartbeat, arthritis, chronic kidney disease, shortness of breath, fatigue, and stomach paralysis. The resident’s MDS indicated a BIMS score of 15, independent daily decision-making, wheelchair use, impairment to both legs, and dependence on staff for personal hygiene, toileting hygiene, showering, dressing, shoe application, and multiple mobility tasks. The resident’s physician orders included OT, PT, and speech therapy evaluations and treatment, foley catheter care, enhanced barrier precautions, and other ongoing treatments. The MAR and TAR showed the resident received medications for insomnia, diabetes, wound healing, a UTI, blood thinning, heart rate and rhythm control, stomach acid, nerve pain, urinary output monitoring from a foley catheter, pain medication, ointment to the buttocks every shift, wound care to the right buttocks, and foley catheter care at bedtime. However, the care plan reviewed on 03/24/2026 did not address the resident’s dependence on staff for self-care, impaired mobility and wheelchair use, fall prevention, prescribed medications and related monitoring, black-box warnings for the antidepressant and opioid, or impaired skin integrity and wound care. Staff interviews confirmed the care plan information was incomplete. CNAs stated they did not use the kiosk care plan and relied on the closet care plan, which they used to know how to care for the resident. The closet care plan referenced assistive devices, functional mobility, and pressure-reducing devices, but did not include guidance for medications, wound care, or monitoring related to diagnoses or medications. The MDS Nurse stated care plans should include medications, antibiotics, black-box warnings, falls, skin assessments, and treatments, and verified the resident’s care plan was not comprehensive. The DON and Administrator both stated care plans should include the information needed to properly care for a resident, and the facility policy required a comprehensive, person-centered care plan within seven days of the MDS completion and no more than 21 days after admission.
Failure to Follow Lift Guidelines Leads to Resident Injury
Penalty
Summary
The facility failed to prevent an accident involving a resident during a van transfer, resulting in serious injury. The incident occurred when a Certified Nurse Aide (CNA) did not follow the manufacturer's guidelines for operating the van's wheelchair lift. The CNA, who was responsible for unloading the resident, did not ensure that the lift gate was properly raised and secured before attempting the transfer. This oversight led to the resident falling from the van while still in the wheelchair, causing a left ankle fracture and a suspected sacrum fracture. Interviews and video footage revealed that the CNA was unable to see over the resident in the wheelchair to confirm the lift gate's position. The CNA mistakenly believed the gate was up after hearing a colleague say "okay," which she interpreted as a signal to proceed. The safety mechanism designed to alert staff when the gate is not properly positioned was reportedly malfunctioning, as it beeped regardless of the gate's position. The CNA had not received recent training on the lift's operation, having last attended a session over two years prior. The facility's investigation confirmed that the CNA had been present for a training session earlier in the year, but the CNA claimed not to have received recent training. The incident was captured on video, showing the CNA struggling to hold the wheelchair and the resident falling from the van. The facility's policies required staff to demonstrate proper loading and unloading techniques, but the CNA's failure to adhere to these protocols directly contributed to the accident.
Removal Plan
- The Administrator/designee immediately disabled the transport van from this incident from all further transports until investigation and review was completed.
- The transportation aide was not permitted to perform any further transports or transfers until corrective measures were completed and she was suspended from employment pending investigation process.
- The DON/Designee determined, through medical record review and transportation data, that five residents had the potential to be affected and assessed all residents identified to ensure no injuries related to transportation had occurred.
- The Administrator made alternate arrangements for all resident transports until completion of transportation aide in-services with return demonstration could be completed. The maintenance director assisted in ensuring this staff education was completed.
- Both facility vans were placed in no transport mode until a thorough van/equipment inspection could be completed.
- Administrator/designee will monitor loading and unloading of residents to facility vans for transport 3 times a week for 4 weeks minimally or until compliance is achieved. Findings will be documented on a monitoring log.
- Any negative findings will be corrected immediately, and Administrator/Designee notified.
- Administrator/designee will present all findings to the monthly QA committee for further review and recommendations.
- All staff members who will be driving the van will have a valid driver's license and approved driving record.
- All staff members who will be driving the van or assisting during transport will be trained per manufacturer's guidelines/operator training videos and facility checklist. This will include instruction on lift operation and use of a sure-lock restraint system.
- The van must be taken out of service until deemed safe to use by [named] Van & Mobility of named city. All incidents/accidents involving the van will immediately be reported to the administrator/DON or designee.
- Incidents/accidents involving the van will be investigated and an incident report completed.
- Transports from facility will be monitored by a trained staff member 3 x weekly for 4 weeks, or until compliance is achieved. The above plan will be presented to the QAA committee, and any negative findings will be corrected immediately and reported to the QAA committee.
- Maintenance Inspection: Regional maintenance consultant will review van maintenance plan with maintenance director immediately and quarterly thereafter.
- The van driver will perform a pre-transport documented inspection daily, prior to the first transport.
- The facility will maintain a current list of employees who have been trained to drive the van and assist with transportation along with supporting documentation regarding training.
- Any transport driver found not following the appropriate transport policies will be immediately taken off transportation duty and disciplined up to and including termination. The staff member involved in the incident was terminated after the facility's completed investigation.
- The facility implemented a plan for retraining all transport staff. The staff watched the manufacturer training video linked below: https://youtube.com/watch?v=vDLdUXcotEc&si=LgpoAUyOrtwuHRJV The transport staff completed training along with demonstration of the skills of loading and unloading a resident in a wheelchair. Training also included safety measures for safe transportation of residents. This training will be ongoing.
Inaccurate MDS Coding for Resident Contracture
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident with a contracture under Section GG. The resident, who had a diagnosis of stroke with left-sided weakness/paralysis, was observed by the surveyor to have a left hand contracture with no interventions in place. Despite the resident's inability to stretch the hand and acknowledgment of having the contracture for a while, the MDS inaccurately marked no impairment for upper limited mobility. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed the presence of the contracture since admission, but there was a lack of awareness and documentation of interventions for the contracture. The MDS Coordinator acknowledged the error in the assessment, emphasizing the importance of accurate coding for providing appropriate care and interventions. The Director of Nursing (DON) also highlighted that an accurate assessment is crucial for populating the care plan with necessary interventions to manage and treat the contracture. The MDS Consultant confirmed that the facility follows the RAI Manual for MDS assessments, and there are no separate policies in place. This deficiency in accurately assessing and documenting the resident's condition led to a lack of appropriate interventions to address the contracture.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot care for a resident with multiple health conditions, including dementia, diabetes, chronic kidney disease, and congestive heart failure. The resident required assistance with personal care, as indicated in their care plan, which specified checking, trimming, and cleaning nails on bath days and as needed. However, there was no order for diabetic nail care for the nursing staff, and the resident's toenails were observed to be long, jagged, and thick, with one toenail missing a middle part. Despite the resident expressing concern about their toenails, no care was provided over several days of observation. Interviews with facility staff revealed a lack of communication and responsibility regarding the resident's foot care. A CNA mentioned that the nails had not been reported because hospice usually bathed the resident, and the resident typically did not require much help. The CNA and an LPN both acknowledged the poor condition of the toenails and the potential for infection or sores. The LPN confirmed the absence of a current order for diabetic nail care, and the DON emphasized the importance of having such orders for diabetic residents to ensure proper care and prevent complications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gosnell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Square Healthcare Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Manila Healthcare Center | 11.9 mi | ★★★★★ | 9 | 0 |
| River Oaks Care Center | 12.5 mi | ★★★★★ | 0 | 0 |
| Harris Health And Rehab | 15 mi | ★★★★★ | 0 | 0 |
| Senath South Health Care Center | 15.9 mi | — | 0 | 0 |
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