Roswell Center For Nursing And Healing Llc
ROSWELL CENTER FOR NURSING AND HEALING LLC in ROSWELL, GA — inspection on February 20, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
- Harm was identified on [DATE] when R46 sustained a fall resulting in a right femur fracture with possible
patella fracture; on [DATE], R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee; and on [DATE], R204 experienced pain and swelling from an infiltrated intravenous site, resulting in R204 being sent to the emergency room (ER) for treatment and observation.
Cross Refer
The facility failed to develop a comprehensive care plan for R200 related to a diagnosis of dysphagia and supervision with meals.
Cross Refer
During an interview on [DATE] at 12:05 pm, the Director of Rehabilitation remembered prescribing R200 one-on-one assistance while he was eating to make sure that he was eating at a proper pace so he and not eat too fast or drink.
During an interview on [DATE] at 12:19 pm, the MDS Nurse, Registered Nurse (RN) NNN, stated that they do not always enter therapy diagnosis with the medical diagnosis.
She confirmed that R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that R200 required a specialized diet and close supervision to prevent an incident of aspiration.
She stated that she did not remember the specifics because it had been too long ago.
During an interview with the facility DON on [DATE] at 5:50 pm she stated she could not remember if R200's dysphagia or incidents related to dysphagia were discussed in Quality Assurance Performance Improvement (QAPI) meetings.
The DON stated, I would have to review my QAPI notes.
During an interview on [DATE] at 3:21 pm, the DON confirmed R46 required two-person assistance.
The DON stated that that two people were required to transfer the resident and an in-service was also completed to ensure all staff understood that a mechanical lift required two staff to transfer a resident.
The DON confirmed that the CNA does not work at the facility anymore and that she was a contract employee.
The facility implemented the following actions to remove the IJ:
On [DATE], a Root Cause Analysis (RCA) of the Care plans for residents with a diagnosis of dysphagia and ADL care for dependent residents who require assistance with dining system breakdown was completed by the Regional Director of Operation (RDC), Regional Director of Clinical Operations (RDCO), Administrator, and DON.
Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc meeting.
The administrator hosted an Ad Hoc QAPI meeting on [DATE], with the Medical Director, DON, RDCO, and Director of Operations to review the center's ADL Care for Dependent Residents and Care Plan performance improvement measures outlined in this document.
The Regional Director of Operations (RDO), RDCO, Medical Director, Administrator, and DON reviewed residents receiving swallow therapy in the past thirty (30) days to identify residents with a diagnosis of dysphagia to ensure that care plans were updated as appropriate, on [DATE].
Findings were shared at the next scheduled QAPI Meeting.
115422
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115422 B.
Wing 02/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roswell Nursing & Rehab Center 1109 Green Street Roswell, GA 30075
Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE].
The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC).
This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals.
Finding included:
A facility policy titled, Activities of Daily Living (ADL) updated [DATE] indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable.
Care and services will be provided for the following activities of daily living: 4.
Eating to include meals and snacks .
A review of the facility policy titled Assistance with Meals issued in [DATE], revealed that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3.
Residents Requiring Full Assistance: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity .
Keeping interactions with other staff to a minimum while assisting residents with meals.
A review of the Admission Record in the Electronic Medical Record (EMR) revealed R200 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history of gastroesophageal reflux disease without esophagitis, urinary tract infection, cerebral palsy, congenital malformation syndromes predominantly involving limbs, functional quadriplegia, asthma, seizures, malaise, and mood disorder. A Speech Therapy Transitional Evaluation and Plan of Treatment Record revealed that R200 had poor visual acuity (right eye retinal detachment) and was non-verbal.
115422
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115422 B.
Wing 02/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roswell Nursing & Rehab Center 1109 Green Street Roswell, GA 30075