The resident, identified in inspection records as R200, was found unresponsive in his bed at Roswell Center for Nursing and Healing on an evening in late 2024. Medical examiner photos showed half-eaten bread on his pillow and another piece on the floor next to his bed.
R200 was a nonverbal male with cerebral palsy, seizures, and functional quadriplegia who had been receiving daily speech therapy for dysphagia since his admission. His physician had ordered specific aspiration precautions: "Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly."
The speech therapist had documented that R200 required one-on-one assistance during meals to ensure proper pacing and prevent choking. Treatment notes from the days before his death stated he was "unable to self-feed" and required "one-on-one assistance with feeding."
But on the night he died, the system broke down completely.
Certified nursing assistant EE had been assigned to feed R200 during the day shift. He told inspectors he fed the resident breakfast around 8:00 am and lunch after 1:00 pm, both times providing the careful supervision R200 required. "You have to be patient feeding him and watch him," CNA EE explained. "Make sure he swallows before giving the resident the next bite."
When dinner service ran late that evening, CNA EE faced a choice. As an agency worker, he wasn't paid for overtime beyond his scheduled 7:00 pm end time. He notified the night nurse that he wouldn't have time to feed R200 but could drop off the resident's tray before leaving.
At 6:43 pm, surveillance footage captured CNA EE entering R200's room with the food tray. He left it there and clocked out at 7:05 pm.
The feeding assignment was transferred to CNA FF, who didn't arrive for the night shift until 6:45 pm. But she didn't enter R200's room until 7:15 pm — 32 minutes after the food had been delivered.
When she finally arrived, R200 was unresponsive.
The facility's Director of Nursing told inspectors she "did not understand why the MDS nurse failed to include the dysphagia diagnosis on the care plan." She blamed the oversight on multiple ownership and leadership changes, saying "audit processes are not perfect right now."
The speech therapist, who also served as Director of Rehabilitation, told inspectors she remembered prescribing one-on-one assistance during meals specifically to prevent choking incidents.
But the MDS nurse offered a different explanation. She said that if the doctor didn't include dysphagia in the diagnosis list, "it may have been that he didn't feel they had dysphasia anymore" — despite the active speech therapy orders and documented swallowing difficulties.
Federal inspectors declared the violation an immediate jeopardy to resident health and safety. The facility's failure to provide required supervision had directly resulted in a preventable death.
This was not an isolated incident at Roswell Center. Inspectors found a pattern of inadequate supervision that had harmed multiple residents.
In September 2023, a resident requiring two-person assistance for transfers was dropped by a single nursing assistant, resulting in a fractured femur and possible patella fracture. The resident had specifically told the aide that two staff members should be helping with the transfer, but the request was ignored.
The following June, another resident suffered second-degree burns to both buttocks and left hip after spilling hot coffee on himself. The burns measured up to 26.5 centimeters across. Kitchen staff had served coffee directly from the machine without monitoring its temperature, and the resident sat in the scalding liquid long enough to sustain severe tissue damage.
"I spilled the damn hot coffee and it hurts," the resident told staff when they finally discovered the burns covering three separate areas of his body. He was hospitalized for treatment and refused to return to the facility.
A paramedic who responded to the coffee burn incident told police he was "shocked by how much the arm had swollen" and said the IV gauge used was "the smallest possible, normally used on infants." He added that caregivers "should have noticed that it was blown immediately" and that it was "extremely out of the ordinary given that it would have taken several hours for the arm to swell to the level that it had."
In another case, a resident receiving IV therapy developed severe infiltration when the nurse failed to monitor the infusion properly. The resident's family called emergency services at 2:52 am after the facility ignored the resident's call light while she suffered pain and swelling from the blown IV.
The nurse had taken the resident's blood pressure on the same arm where the IV was inserted — a practice that can disrupt infusion and create clots. Despite facility policy requiring monitoring every two hours, there was no documentation that the nurse checked on the IV throughout her 12-hour shift.
When paramedics arrived, they found the resident's arm severely swollen from hours of unmonitored infiltration. She required emergency room treatment and pain medication.
The facility's problems extended beyond life-threatening incidents. Inspectors found that kitchen staff weren't monitoring coffee temperatures until the day before the inspection — months after the severe burn incident. The dietary manager admitted she had no system for checking beverage temperatures that could scald residents.
Even basic activities were mismanaged. One resident who loved reading and specifically requested books was repeatedly told they would be provided, but staff never followed through. The activities director admitted she "just visits and talks" during one-on-one time rather than providing meaningful engagement.
The garbage area outside the kitchen remained cluttered with debris despite facility policies requiring clean surroundings to prevent pest attraction.
Federal inspectors validated the facility's corrective actions in February 2025, including mandatory retraining for all nursing staff and new procedures for meal supervision. The immediate jeopardy designation was removed after the facility demonstrated that feeding assignments would continue uninterrupted during shift changes.
But for R200's family, the corrections came too late. The medical examiner's report was unambiguous: death by choking on a sandwich that should never have been left within his reach.
The resident who required careful, patient feeding — who needed staff to watch him swallow each bite and alternate liquids with solids — died alone with food he couldn't safely consume, in a facility that had been warned repeatedly about the consequences of inadequate supervision.
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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