ROSWELL, GA - Federal inspectors have identified serious care failures at Roswell Nursing & Rehab Center that posed immediate danger to residents, including inadequate supervision for residents with swallowing disorders and widespread infection control violations during personal care.
Immediate Jeopardy Citation for Dysphagia Care Failures
The most severe violation at the 1109 Green Street facility resulted in an "immediate jeopardy" citation - the highest level of violation indicating conditions that could cause serious injury or death. Inspectors found the facility failed to properly identify and care for residents with dysphagia, a swallowing disorder that significantly increases the risk of choking and aspiration pneumonia.
The investigation revealed that 30 of 45 residents diagnosed with dysphagia required updates to their care plan interventions for feeding assistance. Initially, only 23 residents were assigned meal supervision, but this number was revised to 45 residents following the facility's internal audit prompted by the inspection.
The Director of Nursing admitted during interviews that she "did not understand why the Minimum Data Set (MDS) nurse did not include the dysphagia diagnosis" in at least one resident's chart and care plan. When questioned about quality oversight, she acknowledged that "the facility has had many transfers of ownership and leadership in the last year and audit processes are not perfect right now."
Medical Significance: Dysphagia affects up to 15% of nursing home residents and can lead to aspiration pneumonia, malnutrition, dehydration, and death if not properly managed. Residents with swallowing disorders require specialized diets, positioning during meals, and trained staff supervision to prevent food or liquid from entering the lungs. The failure to identify these residents in care plans means staff may not receive critical information about dietary restrictions and supervision requirements.
The MDS nurse acknowledged that one resident's medical record showed "a diagnosis of oral pharyngeal impairment (dysphagia)" and that the resident "required a specialized diet and close supervision to prevent an incident of aspiration," but stated she "did not remember the specifics because it had been too long ago."
Systemic Infection Control Failures
Inspectors documented widespread violations of hand hygiene protocols during intimate personal care for four of five residents observed during incontinence care. These violations occurred despite facility policies requiring hand sanitization "before moving from a contaminated body site to a clean body site during resident care."
During multiple observations, certified nursing assistants (CNAs) failed to wash hands or use sanitizer between handling soiled materials and applying clean briefs or barrier creams. In one instance, a CNA "provided incontinent care, removed the soiled brief, and cleaned [the resident's] peri area" but "neglected to wash hands or use hand sanitizer before applying the barrier cream and clean brief."
When questioned, one CNA stated she "did not wash or sanitize her hands after cleansing [the resident] and before applying barrier cream and a clean brief." Another CNA told inspectors: "I'm going to tell the truth and shame the devil. She didn't change gloves and sanitize between the dirty and clean briefs."
Medical Significance: Proper hand hygiene during personal care is fundamental to preventing healthcare-associated infections, including urinary tract infections, wound infections, and antibiotic-resistant organisms. Nursing home residents have compromised immune systems and multiple chronic conditions that make them particularly vulnerable to infections. The failure to follow basic infection control protocols during intimate care procedures creates significant risk for spreading harmful bacteria and viruses between residents.
The observed violations occurred despite residents having care plans specifically addressing infection risks. One resident's plan noted increased risk for urinary tract infection "due to incontinence of the bladder and bowel," while another was identified as being "at risk for skin breakdown related to decreased mobility and incontinence."
Communication System Failures Compromise Safety
Inspectors found that none of the call lights functioned properly on the Jasmine Unit, leaving residents unable to summon help during emergencies. One cognitively intact resident reported that "the call light had been out of order since the weekend" and explained that to get staff assistance, she "would wait till someone walks down the hall and then yell for help."
Multiple room call devices were observed to be non-functional, with maintenance staff attributing problems to dead batteries and burned-out light bulbs. The Licensed Practical Nurse on the unit was observed distributing handheld bells to residents as a temporary solution, but admitted she was unaware the call system wasn't working "until the surveyor was going to each room to check the lights."
Medical Significance: Call light systems serve as vital safety equipment in nursing facilities, allowing residents to request immediate assistance for medical emergencies, falls, or urgent care needs. The complete failure of this communication system on an entire unit creates dangerous conditions where residents experiencing cardiac events, strokes, falls, or other emergencies cannot quickly alert staff. For residents with mobility limitations or cognitive impairments, the call system may be their only reliable method of communication with caregivers.
The maintenance director revealed that testing frequency had been reduced from weekly to monthly under new facility ownership, suggesting inadequate equipment monitoring procedures.
Facility Response and Corrective Actions
Following the immediate jeopardy citation, the facility implemented extensive corrective measures including a comprehensive root cause analysis, staff re-education programs, and enhanced oversight procedures. The facility completed audits of all residents with dysphagia diagnoses and updated care plans accordingly.
New meal delivery schedules were established with breakfast from 7:30-8:30 AM, lunch from 11:30 AM-12:30 PM, and dinner from 4:30-5:30 PM to improve coordination between dietary and nursing staff. The facility also assigned nurse managers to provide daily supervision during meal service for residents with swallowing disorders.
Additional Issues Identified
Beyond the major violations, inspectors documented several other concerns including inadequate mechanical lift procedures and coordination issues between dietary and nursing staff that contributed to delayed meal service. The facility's quality assurance processes were found to be inadequate for identifying and addressing systemic care issues.
The inspection revealed challenges related to recent ownership transitions and staffing issues that impacted the facility's ability to maintain consistent care standards and oversight procedures.
Federal regulations require nursing facilities to maintain comprehensive quality assurance programs and ensure staff receive adequate training on safety protocols. The violations at Roswell Nursing & Rehab Center demonstrate the critical importance of rigorous oversight and staff education in protecting vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roswell Nursing & Rehab Center from 2025-02-20 including all violations, facility responses, and corrective action plans.
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