ROSWELL, GA - Federal inspectors imposed immediate jeopardy violations on Roswell Nursing & Rehab Center following the choking death of a resident who was left unsupervised with food for 32 minutes despite requiring one-on-one assistance during meals.
Fatal Supervision Failure
The inspection, completed February 20, 2025, revealed that a resident with a documented diagnosis of dysphagia (difficulty swallowing) died after choking on a sandwich. The resident, identified as R200 in the inspection report, was left alone with his dinner tray when a certified nursing assistant (CNA) ended his shift without ensuring proper meal supervision.
According to the inspection findings, the facility's policies required residents with swallowing difficulties to receive "one-on-one assistance while eating and drinking" with specific precautions including maintaining an upright position at 90 degrees during meals and alternating between liquids and solids slowly.
Video surveillance documented that a CNA brought the resident's food tray to his room at 6:43 pm but left the facility at 7:05 pm. Another CNA discovered the resident unresponsive at 7:15 pm. The medical examiner's report confirmed the resident choked on the sandwich, with investigators finding "a half-eaten slice of bread on the resident's pillow and a half-eaten slice of bread on the floor next to the resident's bed."
Medical Analysis of Dysphagia Risks
Dysphagia significantly increases choking and aspiration risks, particularly for residents with cerebral palsy, visual impairments, and cognitive limitations. The resident's medical history included functional quadriplegia, poor visual acuity from retinal detachment, and severe cognitive impairment requiring total dependence for activities of daily living.
Speech therapy evaluations had specifically identified the resident as demonstrating "the risk of choking/aspiration due to decreased visual acuity" and established clear precautions: "upright during oral intake, set up and orient resident to items on meal tray, supervision during meals."
When residents with dysphagia eat without supervision, food particles can become lodged in the airway without the ability to clear them independently. The medical orders specified that this resident required assistance alternating between liquids and solids slowly - a critical safety protocol designed to prevent exactly this type of fatal incident.
Staffing Communication Breakdown
The inspection revealed significant communication failures during shift changes. The day shift CNA informed the night nurse that he would not have time to feed the resident after distributing trays to other residents but could drop off the food tray before his 7:00 pm clock-out time.
During interviews, the day shift CNA stated: "You have to be patient feeding him and watch him... make sure he swallows before giving the resident the next bite. I would give R200 a bite and intermittently give him fluids to drink in between bites."
Despite this clear understanding of the resident's needs, the handoff to night shift staff failed to ensure continuity of care. The Director of Nursing acknowledged during interviews that she "did not understand why the MDS nurse failed to include the dysphagia diagnosis on the care plan."
Additional Safety Violations
Beyond the fatal incident, inspectors documented multiple other safety failures affecting resident welfare:
Transfer Injury: Another resident sustained a right femur fracture when a CNA attempted a two-person transfer alone, despite care plan requirements for mechanical lift assistance with two staff members present.
Severe Burns: A resident experienced second-degree burns to bilateral buttocks after spilling hot coffee, with burn wounds measuring up to 26.5 cm. Kitchen staff confirmed they did not monitor coffee temperature, and paramedics reported the IV gauge used on another resident was "normally used on infants" and caregivers "should have noticed that it was blown immediately."
IV Infiltration: Poor monitoring of intravenous therapy resulted in a resident experiencing pain and severe arm swelling requiring emergency room treatment. The nurse took blood pressure on the same arm as the IV site and failed to monitor the infusion every two hours as required.
Industry Standards and Required Protocols
Federal nursing home regulations require facilities to ensure residents maintain their highest level of functioning and receive appropriate supervision for activities of daily living. For residents with dysphagia, this means:
- Constant supervision during meals and snacks - Proper positioning at 90 degrees during eating - Alternating between liquids and solids - Immediate response to signs of choking or distress - Updated care plans reflecting current medical needs
The facility's own policies stated that "residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity" and emphasized "keeping interactions with other staff to a minimum while assisting residents with meals."
Systemic Administrative Failures
Inspectors cited the facility's administration for failing to provide protective oversight, noting that leadership changes and ownership transfers had compromised audit processes and safety protocols. The Director of Nursing acknowledged that "audit processes are not perfect right now in relation to the MDS assessments and care plans."
The immediate jeopardy designation indicates that violations posed an immediate threat to resident health and safety. Federal officials required the facility to implement comprehensive corrective actions including mandatory retraining for all nursing staff, enhanced supervision during meal service, and emergency quality improvement meetings.
Corrective Actions and Ongoing Monitoring
Following the immediate jeopardy citation, Roswell Nursing & Rehab Center implemented extensive corrective measures including retraining 115 nursing staff members on supervision requirements and meal assistance protocols. The facility established daily assignment sheets identifying residents requiring feeding assistance and implemented continuous oversight during shift changes.
Administrative leadership conducted emergency quality assurance meetings with the medical director and regional operations staff to review root causes and develop performance improvement plans. The facility committed to ensuring meal assistance continues uninterrupted regardless of shift changes or staffing challenges.
Federal inspectors validated the facility's corrective actions but noted the facility remained under enhanced monitoring to ensure sustained compliance with safety requirements. The inspection findings serve as a stark reminder of the critical importance of following established protocols for residents with complex medical needs requiring specialized care and constant supervision.
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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