Roswell Center for Nursing and Healing LLC

Inspectors wroteBased on observations, staff interviews, and review of facility policy titled Instructions, the facility failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were maintained free of dust and debris in two rooms (rooms [ROOM NUMBERS]) of twenty-six resident rooms observed on the Sapphire Hallway. This deficient practice had the potential to affect air quality and resident comfort in those rooms.

Inspectors wroteBased on observations and staff interviews, the facility failed to audit and dispose of expired medications from one of four medication rooms and two of nine medication carts. This deficient practice had the potential to place the residents at risk for receiving expired medication. The facility census was 175.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that medications delivered by pharmacy were properly secured. This deficient practice had the potential to cause medication diversion, medication administration errors, and adverse effects.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received showers as scheduled and requested for one of three residents (Resident (R) 2) reviewed for ADLs out of 30 sample residents. This failure placed the residents at risk of a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive care plan for one of 45 residents (R200) related to a diagnosis of dysphagia (difficulty swallowing) and supervision with meals, resulting in R200's death by choking on a sandwich. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/3/2025, at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. An Acceptable Removal Plan was received on 2/5/2025. [...]

Inspectors wroteBased on interviews, record review, and the review of the facility policies titled Activities of Daily Living (ADL) and Assistance with Meals, the facility failed to provide supervision and assistance with Activities of Daily Living (ADL) care during meals for one of 45 residents (R) (R200) related to a diagnosis of dysphagia (difficulty swallowing). On 8/6/2024, this failure resulted in R200's death by choking on a sandwich. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/3/2025, at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. [...]

Inspectors wroteBased on interviews and record review, the facility's Administration failed to provide protective oversight of the facility ensuring that staff followed appropriate policies and procedures to prevent accidents and hazards resulting in Immediate Jeopardy for resident (R) R200 and Harm for R46, R206, and R204. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/3/2025 at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. An Acceptable Removal Plan was received on 2/5/2025. [...]

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Incidents and Accidents, the facility failed to provide adequate supervision to prevent accidents for two of four sampled residents (R) (R46 and R206) reviewed for accidents hazards. Harm was identified to have occurred (1) on 9/25/2023 when R46 sustained a fall resulting in a right femur fracture with possible patella fracture, and (2) on 6/4/2023 when R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Infusion Therapy, the facility failed to monitor one of 19 sampled residents (R) (R204) for complications related to intravenous (IV) therapy, resulting in infiltration of the IV. Harm was identified to have occurred on 8/27/2024 when this failure caused R204 to experience pain and swelling, resulting in R204 being sent to the emergency room (ER) for treatment and observation per family request.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from dirt and debris. In addition, the facility failed to ensure the sliding door was kept closed when not in use. The facility census was 189 residents.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled Handwashing/Hand Hygiene and Activities of Daily Living (ADLs), the facility failed to follow infection control protocols related to hand hygiene during ADL care for four of five residents (R) (R91, R9, R83, R16) reviewed for incontinent care.

Inspectors wroteBased on observations, interviews, and a review of the facility's policy titled, Call Lights: Accessibility and Timely Response, the facility failed to ensure that the call light communication system was functioning adequately on one of five units (Jasmine Unit) to allow residents to call for staff assistance.

Inspectors wroteBased on resident and staff interviews, and record review the facility failed to ensure the advanced directive was documented accurately throughout the Electronic Medical Record (EMR) for one of 43 residents (R) (R68) reviewed for advanced directives.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility policy titled, Activities, the facility failed to ensure an ongoing program of activities based on preferences for one of one resident (R) (R59) reviewed for activities. The resident was not provided with person-centered activities that would meet their individual needs and preferences.

Inspectors wroteBased on observations, interviews, record review, and a review of the facility policy titled, Menu Policy, the facility failed to offer one of 19 sampled residents (R) (R5) a diet that suits her pescatarian diet (a diet that includes plant-based foods and fish and other seafood) preferences.

Inspectors wroteBased on observation, interviews, and review of the undated facility policies titled Ice Machine Sanitation Policy and Dietary Cleaning Policy, the facility failed to maintain the dry storage room in the kitchen and the basement ice maker in a sanitary manner. The facility census was 196 residents.

Inspectors wroteBased on observations, interviews, record review, and review of policy titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in the Facility, the facility failed to (1) provide proper source control as evidenced by not providing receptacles for containing doffed personal protective equipment (PPE) for seven of nine residents (R)( R#113, R#75, R#165, R#91, R#69, R#169, and R#126) residents on transmission based precautions (TBP); (2) properly managing COVID-19 positive residents by cohorting with COVID-19 negative (but exposed) residents without proper symptom monitoring for seven of nine residents (R) (R#113, R#75, R#165, R#91, R#69, R#169, and R#126) in isolation for TBP; and (3) properly have a water management program that would monitor measures in place for preventing growth of Legionella and other opportunistic waterborne pathogens.

Inspectors wroteBased on observation, staff interviews, and review of the Housekeeper/Room Attendant Job Description, the facility failed to maintain clean resident rooms on three of four units (Magnolia Way Unit, [NAME] Place Unit, and Emerald Court Unit).

Inspectors wroteBased on clinical record review, staff interviews, review of the facility's policy Advanced Directives the facility failed to ensure that the Do Not Resuscitate document was signed by a concurring physician for one of 63 sampled residents (R) (R#55).

Inspectors wroteBased on observations, interviews, record reviews and policy reviews, the facility failed to implement interventions in place for oxygen use, COVID-19 symptom, and vital sign monitoring for one of 63 sampled residents (R) (R#99).

Inspectors wroteBased on interviews, observations, record reviews and policy titled Activities of Daily Living (ADLs), Supporting, the facility failed to provide activities of daily living assistance as evidenced by an adequate number of showers provided for one of 63 sampled residents (R) (R#50).

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to provide care and services related to contracture management and range of motion (ROM) for one one of 63 sampled residents (R) (R#110).

Inspectors wroteBased on resident and staff interviews, and an observation of the test meal tray, the facility failed to serve meals that were palatable and attractive for two of 63 sampled residents (R) (R#95 and R#244).

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain vaccination consent prior to administering COVID-19 vaccines on four of five residents (R) (R#18, R#36, R#62, and R#99) reviewed for vaccination status.