The facility's Director of Nursing couldn't explain why a resident identified as R200, who had a dysphagia diagnosis and required specialized diet supervision, wasn't included in care plans designed to prevent choking incidents. When asked about quality oversight during a February inspection, the nursing director said audit processes "are not perfect right now" due to multiple ownership and leadership changes over the past year.
The immediate jeopardy citation was triggered after inspectors discovered systemic failures in meal supervision and care planning. An audit revealed that 30 of 45 residents diagnosed with dysphagia needed updates to their care plan interventions for feeding assistance. Initially, only 23 residents were assigned meal supervision, but this was revised to 45 residents after the inspection.
R200 required one-on-one assistance while eating to ensure proper pacing and prevent rapid consumption that could lead to choking, according to the Director of Rehabilitation. The MDS Nurse, Registered Nurse NNN, confirmed that R200's medical record listed oral pharyngeal impairment and required specialized diet and close supervision to prevent aspiration incidents, but said she "did not remember the specifics because it had been too long ago."
The nursing director also couldn't recall whether R200's dysphagia or related incidents were discussed in Quality Assurance Performance Improvement meetings. "I would have to review my QAPI notes," she told inspectors.
Beyond meal supervision failures, inspectors documented widespread infection control violations. Staff routinely failed to follow hand hygiene protocols during incontinence care for four of five residents observed, potentially spreading infections between contaminated and clean body sites.
CNA RR provided incontinence care for resident R91, who had cutaneous abscess of the chest wall and required assistance with activities of daily living. The aide removed soiled briefs, cleaned the resident's genital area, then applied barrier cream and a clean brief without washing hands or using sanitizer between the contaminated and clean tasks.
When questioned, CNA RR said "the only time the hands should be washed was before and after incontinent care," not understanding that hand hygiene was required when moving from dirty to clean areas during the same care episode. An LPN confirmed that staff should sanitize hands after cleansing residents and before applying barrier cream and clean briefs.
Similar violations occurred with three other residents. CNA MMM completed incontinence care for resident R9 without sanitizing hands between handling dirty and clean wipes or briefs. The same aide changed resident R83 after a bowel movement without changing gloves before putting on new briefs.
Most concerning, CNA MMM applied Vaseline to resident R16's genital area using the same contaminated gloves used during incontinence care. When confronted, the aide said: "I'm going to tell the truth and shame the devil. She didn't change gloves and sanitize between the dirty and clean briefs."
The Director of Nursing acknowledged that staff should change gloves between cleaning residents after bowel movements and applying fresh briefs, saying another training session would be conducted even though incontinence care education had occurred just a week earlier.
Communication failures extended beyond care protocols. On the Jasmine Unit, call light systems weren't functioning, leaving cognitively intact residents unable to summon help. Resident R160 told inspectors that call lights had been broken since the weekend, forcing her to "wait till someone walks down the hall and then yell for help."
Multiple rooms had non-functioning call devices. When inspectors tested the systems, Licensed Practical Nurse XX began distributing bells to residents as a temporary solution, but admitted she hadn't realized the call lights were broken until the inspection began.
The Maintenance Assistant, who accompanied inspectors during call light testing, said the facility checks functionality "once to twice a week," though the Maintenance Director later contradicted this, stating they test systems monthly since the new operating company took over.
Problems ranged from dead batteries to burned-out light bulbs, basic maintenance issues that left vulnerable residents without emergency communication for days.
The facility implemented multiple corrective actions to address the immediate jeopardy citation. A Root Cause Analysis identified staffing challenges in the kitchen and nursing departments, poor coordination between dietary and nursing staff, and inadequate meal delivery scheduling.
New dining times were established: breakfast from 7:30 to 8:30 am, lunch from 11:30 am to 12:30 pm, and dinner from 4:30 to 5:30 pm. Daily assignment sheets now identify residents requiring feeding assistance, NPO status, and supervision needs.
Nurse managers were assigned to provide daily supervision during meal service for residents with dysphagia, including non-verbal or visually impaired residents. The MDS nurses reviewed and updated care plans for all residents identified with swallowing disorders.
Staff received re-education on Activities of Daily Living policies and infection control protocols. CNAs interviewed after training confirmed understanding that meal trays must accompany staff into rooms and exit with them, ensuring residents receive proper assistance.
CNA OO told inspectors that staff "must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage." Unit Manager TT emphasized that "staff is required to have the resident's meal tray when they leave the rooms."
The State Survey Agency validated the facility's corrective actions and removed the immediate jeopardy citation after confirming implementation of new protocols and staff education.
However, the inspection revealed deeper systemic issues stemming from ownership transitions and leadership instability. The facility's acknowledgment that "audit processes are not perfect right now" suggests ongoing challenges in maintaining consistent quality oversight and resident safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roswell Center For Nursing and Healing LLC from 2025-02-20 including all violations, facility responses, and corrective action plans.
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