Roswell Nursing & Rehab Center

F-F656

3. Harm was identified on [DATE REDACTED] when Resident R46 sustained a fall resulting in a right femur fracture with possible patella fracture; on [DATE REDACTED], Resident R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee; and on [DATE REDACTED], Resident R204 experienced pain and swelling from an infiltrated intravenous site, resulting in Resident R204 being sent to the emergency room (ER) for treatment and observation.

Cross Refer

F-F677

2. The facility failed to develop a comprehensive care plan for Resident R200 related to a diagnosis of dysphagia and supervision with meals.

Cross Refer

F-F694

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview and record review with the facility Director of Nursing (DON) on [DATE REDACTED] at 9:30 am she did not understand why the Minimum Data Set (MDS) nurse did not include the dysphagia diagnosis in the Level of Harm - Immediate Resident R200's chart and care plan. When asked about who is responsible for auditing the MDS and care plans for jeopardy to resident health or accuracy, the DON stated the facility has had many transfers of ownership and leadership in the last year safety and audit processes are not perfect right now, but they are working on it.

Residents Affected - Few During an interview on [DATE REDACTED] at 9:50 am, the DON confirmed that her expectations were that nurses were supposed to be rounding at least every couple of hours when a resident has a continuous IV.

During an interview on [DATE REDACTED] at 12:05 pm, the Director of Rehabilitation remembered prescribing Resident 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 REDACTED] 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 Resident R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that Resident 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 REDACTED] at 5:50 pm she stated she could not remember if Resident 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 REDACTED] at 3:21 pm, the DON confirmed Resident 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 REDACTED], 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 REDACTED], 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 REDACTED]. Findings were shared at the next scheduled QAPI Meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The Administrator identified Improvement Activities and Performance Improvement Projects (PIP) based on trends and identified potential opportunities upon completion of the care plan and swallowing therapy audit Level of Harm - Immediate reviewed on [DATE REDACTED]. PIP plans and RCA documents were maintained as part of the QAPI process. jeopardy to resident health or safety A review of the residents receiving swallow therapy audit was reviewed by the IDT members on [DATE REDACTED], to validate care plans were updated appropriately to identify the level of dining assistance required. Residents Affected - Few

The MDS Nurse (s) reviewed and updated care plans on residents identified with a diagnosis of dysphagia as of [DATE REDACTED]. Recommendations were reviewed at the next scheduled regular QAPI meeting.

The RDCO provided re-education on [DATE REDACTED] to the Administrator and DON on the policies and procedures related to ADL Care for Dependent Residents and Comprehensive Care Plans.

The DON will assign Nurse Managers daily to each unit to provide supervision during meal service for those residents diagnosed with dysphagia, including those who are non-verbal or visually impaired.

The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee in February 2025.

All corrective actions were completed on [DATE REDACTED] and the IJ was removed on [DATE REDACTED].

The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:

A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE REDACTED] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE REDACTED], the assignments were revised on [DATE REDACTED] to 45 residents assigned meal supervision as an intervention for their individualized risk.

A review of the IJ Removal Plan showed that there were QAPI Meeting Minutes that occurred on [DATE REDACTED].

The signature includes the Administrator, DON, RDO, RDCO, Dietary, Social Services, and the Medical Director. The topic included an annual survey and IJ citations that were issued. Also, performance improvement plans were included.

There were two new diagnoses of dysphagia identified in the last 30-day review of the diagnosis report after

the facility audited the residents diagnosed with dysphagia on [DATE REDACTED] and updates to their care plans were updated as appropriate. Dated ([DATE REDACTED] and [DATE REDACTED])

A review of the RCA PIP template that was started on [DATE REDACTED] was completed. The Root Cause and Contributing Factors included staffing challenges in the kitchen and nursing staff to prepare and deliver meals on time; updating the get-up list for nursing staff to collaborate; poor coordination and communication between dietary staff and nursing staff related to meal readiness, delivery, and resident needs; inadequate coordination of get-ups times with meal delivery schedules; meal service workflow, review serving line efficiency in the kitchen. The plan further included the root cause, the corrective action, the responsible individual/group, and the completion deadline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE REDACTED] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were Level of Harm - Immediate 23 residents assigned meal supervision on [DATE REDACTED], the assignments were revised on [DATE REDACTED] to 45 residents jeopardy to resident health or assigned meal supervision as an intervention for their individualized risk. safety

A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE REDACTED] Residents Affected - Few discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE REDACTED], the assignments were revised on [DATE REDACTED] to 45 residents assigned meal supervision as an intervention for their individualized risk.

A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE REDACTED] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE REDACTED], the assignments were revised on [DATE REDACTED] to 45 residents assigned meal supervision as an intervention for their individualized risk.

A review of the facility's education/in-service record revealed the following: The presenters of in-service were

the Clinical leadership that was composed of the (DON, Unit Manager (UMs), and RDCO). The date of the education was [DATE REDACTED].

The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADLs, specifically dining to ensure availability of assistance, as appropriate.

The Administrator and DON will review assignment sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment.

A review of the Facility's daily assignment sheets included the following: The staff that is scheduled, residents that are identified as 'need to feed; Residents that are NPO, Snack times; Pass Ice; residents with scheduled showers, residents who are on the get-up list and residents who have appointments/visit time his section identified the residents by room and bed number that need to be fed. NPO residents are identified.

Interviews were conducted with staff to ensure that staff were in-serviced and were knowledgeable of where to retrieve assignments on a daily basis, but to additionally ensure that staff understood requirements for supervision, one-on-one assistance and tray set-up for residents.

During an interview on [DATE REDACTED] at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage.

During an interview on [DATE REDACTED] at 12:09 pm UM/ Licensed Practical Nurse (LPN) TT stated that a staff is required to have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand.

During an interview on [DATE REDACTED] at 12:34 pm, CNA WW stated one of the re-educations was to ensure the trays go in the resident room when they are ready to leave, and the tray goes out with the CNA when they leave the resident rooms

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 A new Dining Time for Meal Delivered to Units was implemented during the week of [DATE REDACTED]. New dining times for breakfast range from 7:30 am to 8:30 am; lunch from 11:30 am to 12:30 pm and dinner from 4:30 Level of Harm - Immediate pm to 5:30 pm. Meal carts have been monitored since the new implementation and are ongoing and noted to jeopardy to resident health or have improvements. safety All corrective actions were completed on [DATE REDACTED] and the IJ was removed on [DATE REDACTED]. Residents Affected - Few 49479

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49479 potential for actual harm Based on observations, staff interviews, record reviews, and review of the facility's policies titled Residents Affected - Some Handwashing/Hand Hygiene and Activities of Daily Living (ADLs), the facility failed to follow infection control protocols related to hand hygiene during ADL care for four of five residents (R) (Resident R91, Resident R9, Resident R83, Resident R16) reviewed for incontinent care.

Findings included:

A review of the facility's undated policy titled, Handwashing/Hand Hygiene, dated section Policy Interpretation and Implementation under number 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Number 7. Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: H. Before moving from a contaminated body site to

a clean body site during resident care.

A review of the policy titled, Activities of Daily Living (ADLs), revised August 2023 revealed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, groom, and personal and oral hygiene.

1. A review of the Electronic Medical Record (EMR) revealed that Resident R91 was admitted into the facility on [DATE REDACTED] with diagnoses of but not limited to cutaneous abscess of the chest wall, anoxic brain damage, and chronic obstructive pulmonary disease. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R91 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. The MDS also indicated Resident R91 had impairment to bilateral lower extremities and required assistance with ADLs.

During an interview on 2/10/2025 at 10:40 am, Licensed Practical Nurse (LPN) LPN III revealed two Certified Nursing Assistants (CNAs) CNA RR and CNA KKK would provide incontinent care for Resident R91.

During an observation on 2/10/2025 at 10:59 am, incontinence care for Resident R91 revealed CNA RR provided incontinent care for Resident R91 while CNA KKK positioned Resident R91 in place. CNA RR completed the incontinent care without washing hands or using hand sanitizer between dirty and clean. CNA RR provided incontinent care, removed the soiled brief, and cleaned Resident R91's peri area. CNA RR neglected to wash hands or use hand sanitizer before applying the barrier cream and clean brief to Resident R91.

During an interview on 2/10/2025 at 11:08 am, LPN III revealed the CNAs should have washed or sanitized their hands after cleansing Resident R91 and before applying barrier cream and the clean brief.

During an interview on 2/10/2025 at 11:10 am, CNA RR revealed the only time the hands should be washed was before and after incontinent care. CNA RR stated she did not wash or sanitize her hands after cleansing Resident R91 and before applying barrier cream and a clean brief.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A record review of Resident R91's care plan revealed that Resident R91 was at risk for skin breakdown related to decreased mobility and incontinence. The care plan interventions included but were not limited to providing residents Level of Harm - Minimal harm or with incontinence care after incontinence episodes, and applying moisture barrier as needed (PRN). Resident R91's potential for actual harm care plan also revealed that Resident R91 was at risk for urinary tract infection (UTI) due to incontinence of the bladder and bowel. The interventions included but were not limited to increased fluid intake and observation Residents Affected - Some of the color and characteristics of urine.

2. A review of the EMR revealed Resident R9 was originally admitted to the facility on [DATE REDACTED] with multiple diagnoses including cerebral infarction due to thrombosis of left anterior cerebral, hypertension, gastroesophageal reflux disease, cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side and dementia. A review of the Quarterly MDS assessment dated [DATE REDACTED] revealed that Resident R68 had a BIMS score of 99, indicating Resident R9 is severely cognitively impaired.

During an observation on 2/17/2025 at 4:44 am, CNA MMM entered Resident R9's room to provide incontinent care. CNA MMM completed the incontinent care without washing hands or using hand sanitizer between handling dirty and clean wipes and between handling dirty and clean briefs. Additionally, CNA MMM neglected to wash hands or use hand sanitizer before applying the barrier cream and clean brief to Resident R9.

3. A review of the EMR revealed Resident R83 was originally admitted to the facility on [DATE REDACTED] with multiple diagnoses including end-stage renal disease, anemia, heart failure, hypertension, Gastro-Esophageal Reflux Disease, sleep apnea, muscle weakness, and bilateral primary osteoarthritis of the knee. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R83 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident R83 is cognitively intact.

In an observation on 2/17/2025 from 5:04 am to 5:20 am, CNA MMM completed the incontinent for Resident R83. Resident R83 had a bowel movement, and the CNA MMM did not change the gloves after wiping the resident and putting

on new clean briefs.

4. A review of the EMR revealed Resident R16 was originally admitted to the facility on [DATE REDACTED] with multiple diagnoses including, Type II diabetes with hyperglycemia, End stage renal disease, hypertension, insomnia, sleep apnea, chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, and left and right above knee amputee. A review of the Annual MDS assessment dated [DATE REDACTED] revealed that Resident R16 had a BIMS score of 15, indicating Resident R16 is cognitively intact.

An observation on 2/17/2025 at 6:25 am, CNA MMM enters Resident R16's room to provide incontinent care. CNA MMM provided incontinent care and applied Vaseline to Resident R16's peri area with the same contaminated gloves.

During an Interview on 2/17/2025 at 7:05 am CNA MMM revealed she was not washing or sanitizing her hands in between taking off the dirty briefs and putting on the new one. CNA stated, I'm going to tell the truth and shame the devil. She didn't change gloves and sanitize between the dirty and clean briefs.

During an Interview on 2/17/2025 at 8:25 am, the Director of Nursing (DON) revealed the staff should be changing gloves in between changing a resident's diaper. A new set of gloves should be worn after the resident is wiped down after having a bowel movement. The last In-service about incontinent care was done

a week ago. The DON stated another Inservice will be done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 49687

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49687 potential for actual harm Based on observations, interviews, and a review of the facility's policy titled, Call Lights: Accessibility and Residents Affected - Some Timely Response, the facility failed to ensure that the call light communication system was functioning adequately on one of five units (Jasmine Unit) to allow residents to call for staff assistance.

Findings included:

A review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised [DATE REDACTED] Under Policy Explanation and Compliance number 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring residents access to the call light. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

A review of the Electronic Medical Record (EMR) revealed Resident R160 was originally admitted to the facility on [DATE REDACTED] with multiple diagnoses including lymphedema, essential (primary) hypertension, poly osteoarthritis, hyperlipidemia, morbid obesity, and chronic sinusitis. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R160 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident R160 was cognitively intact.

During an interview on [DATE REDACTED] at 11:20 am, Resident R160 revealed that none of the call lights work on the [NAME] Unit. Resident R160 continued that the call light had been out of order since the weekend. Resident R160 was asked how she would get help from staff since the call lights were not functioning, Resident R160 revealed that she would wait till someone walks down the hall and then yell for help. Resident R160 was asked to press the call light, but the call light did not light up.

During observations on the [NAME] Unit, the following was observed:

Observation on [DATE REDACTED] at 11:45 am, room [ROOM NUMBER]A's call device was not working.

Observation on [DATE REDACTED] at 11:46 am, room [ROOM NUMBER]B's call light was not working.

Observation on [DATE REDACTED] at 12:50 pm, Licensed Practical Nurse (LPN) XX was observed passing out bells and placing them in various rooms on the [NAME] unit as the call light functionality testing ensued.

Observation on [DATE REDACTED] at 12:55 pm, room [ROOM NUMBER]A's call light was not functioning.

Observation on [DATE REDACTED] at 1:49 pm, room [ROOM NUMBER]A's call device was not working.

Observation on [DATE REDACTED] at 12:31 pm, room [ROOM NUMBER]A's call light was not working.

During an interview on [DATE REDACTED] at 12:31 pm, the Maintenance Assistant revealed, It needed a new battery.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Observation on [DATE REDACTED] at 12:33 pm, room [ROOM NUMBER]B's Call light was not working.

Level of Harm - Minimal harm or In an Interview on [DATE REDACTED] at 12:33 pm, the Maintenance Assistant revealed, This may need a new light bulb. potential for actual harm

Observation on [DATE REDACTED] at 12:37 pm, room [ROOM NUMBER]B's call light was not working Residents Affected - Some

Observation on Room [DATE REDACTED] at 12:37 pm, room [ROOM NUMBER]C's call light was still not working

In an Interview on [DATE REDACTED] at 12:38 pm, the Maintenance Assistant revealed that these call lights may need a light bulb change.

Observation on [DATE REDACTED] at 3:05 pm, room [ROOM NUMBER]B's call light was not working.

Observation on [DATE REDACTED] at 3:28 pm, the Maintenance Assistant was outside room [ROOM NUMBER]B's, working on the call light.

During an interview on [DATE REDACTED] at 1:05 pm, LPN XX revealed she saw that the call lights were not working so

she decided to go get the bells for the residents. When asked if LPN XX was aware the call devices were not working, LPN XX stated no. She confirmed that it wasn't until the surveyor was going to each room to check

the lights that she noticed they were not working.

On [DATE REDACTED] at 12:29 PM, the Maintenance Assistant accompanied the surveyor to the [NAME] Unit to test the call devices' functionality. During an interview on [DATE REDACTED] at 12:29 pm, the Maintenance Assistant revealed

they check the call light functionality once to twice a week. The Maintenance Assistant continued that sometimes it just needs to be a new light bulb, or the call light needs to be reset.

During an interview on [DATE REDACTED] at 3:55 pm, the Maintenance Director (MD) stated since the new operating company, they don't test the call lights weekly they test them once a month.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 115422

F-F835 - Administration. jeopardy to resident health or The POCs and related performance improvement plans were initiated for abatement. The root causes and safety contributing factors were discussed. A review of the sign-in sheet for QAPI revealed that the Medical Director attended via phone. Residents Affected - Few All corrective actions were determined to be completed on [DATE REDACTED] and the IJ was removed on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47794 jeopardy to resident health or safety Based on interviews, record review, and the review of the facility policies titled Activities of Daily Living (ADL) and Assistance with Meals, the facility failed to provide supervision and assistance with Activities of Daily Residents Affected - Few Living (ADL) care during meals for one of 45 residents (R) (Resident R200) related to a diagnosis of dysphagia (difficulty swallowing). On [DATE REDACTED], this failure resulted in Resident R200's death by choking on a sandwich.

On [DATE REDACTED], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE REDACTED], at 10:25 am. The noncompliance related to the IJ was identified to have existed on [DATE REDACTED].

An Acceptable Removal Plan was received on [DATE REDACTED]. 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 REDACTED]. 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 REDACTED] 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 REDACTED], 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 Resident R200 was a [AGE] year-old male admitted to the facility on [DATE REDACTED] 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 Resident R200 had poor visual acuity (right eye retinal detachment) and was non-verbal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A review of the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of [DATE REDACTED], revealed Resident R200 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the Level of Harm - Immediate resident was severely impaired and required total dependence with ADL care. A review of the Speech jeopardy to resident health or Therapy Transitional Evaluation and Plan of Treatment dated [DATE REDACTED] revealed that Resident R200 received treatment safety for dysphagia and oropharyngeal phase by the facility Speech and Language Pathologist (SLP). It was revealed that Resident R200's prior level of function (PLOF) (prior to onset), Patient was previously consuming 75 - Residents Affected - Few 100% of low residue diet (LRD) of regular texture solids with thin liquids, in a home environment with caregiver supervision, with history of one episode of choking on a chicken bone, per caregiver report. Baseline ([DATE REDACTED]), Patient currently demonstrating oral/pharyngeal swallowing ability within functional limits for consumption of regular texture diet with thin liquids; however, the patient demonstrates the risk of choking/aspiration due to decreased visual acuity and per os (PO) (by mouth) efficiency. The assessment indicated precautions/ contraindications are as follows: nonverbal, falls, left foot wound, communicate via vocalizations/gestures/facial expressions; poor visual acuity; follow aspiration/choking precautions - upright

during PO intake, set up and orient resident to items on meal tray, supervision during meals. The most recent MDS assessment dated [DATE REDACTED] indicated that the resident required Setup or clean-up assistance with eating. Section K Swallowing Disorder indicated in C. Coughing or choking during meals or when swallowing medications. No.

Speech Therapy (ST) notes outlined that Resident R200 received Daily ST with a start date of [DATE REDACTED] through [DATE REDACTED].

A review of Resident R200's 'ST Daily Treatment Note', dated [DATE REDACTED] revealed Resident R200 was unable to self-feed today's noon meal. The Physical Therapy review notes dated [DATE REDACTED] revealed: PT required one-on-one assistance with feeding today due to the nature of the breakfast meal.

A review of the physician orders with the last review date of [DATE REDACTED] revealed that Resident R200 was full-code, and had special instructions of up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly . The Physician orders further included: Rehab ST orders: skilled therapy for five times a week x 12 weeks for dysphagia (start date [DATE REDACTED] end date [DATE REDACTED]). Aspiration Precautions Maintained: Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly every shift with the start date of [DATE REDACTED]. Regular diet regular texture and regular consistency with a start date of [DATE REDACTED].

During an interview on [DATE REDACTED] at 7:49 pm, Certified Nursing Assistant (CNA) EE stated he was assigned to feed Resident R200 during the 7:00 am to 7:00 pm shift on [DATE REDACTED]. CNA EE stated he fed Resident R200 breakfast around 8:00 am. He stated that lunch arrived late, and he fed Resident R200 after 1:00 pm. CNA EE stated the dinner service was running late as well that evening. The dinner trays came to his hall between 6:40 pm and 7:00 pm. He stated as an Agency CNA, they were not paid for working past the scheduled time. CNA EE stated, Resident R200 can't feed himself because of his condition. It's like he cannot grip a spoon to feed himself with it, so he needed to be fed by staff. CNA EE stated a female CNA (Couldn't remember her name) would help him with positioning Resident R200 to 90 degrees for feeding. CNA EE 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 Resident R200 a bite and intermittently give him fluids to drink in between bites. CNA EE stated he notified the night nurse that he would not have time to feed Resident R200 after distributing trays to other residents on the floor, but he could drop off Resident R200's tray in his room before his clock-out time of 7:00 pm. CNA EE left the facility in the resident's room at 7:05 pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A review of posted dining times for meals delivered to Resident R200's hall revealed that breakfast was served at 7:40 am, lunch was served at 11:40 am, and dinner was served at 4:40 pm. Level of Harm - Immediate jeopardy to resident health or A review of the timesheet for [DATE REDACTED] revealed that CNA HH clocked in at 6:45 pm for her 7:00 pm through safety 7:00 am shift.

Residents Affected - Few During an interview on [DATE REDACTED] at 8:25 pm, CNA HH reported that she was assigned to care for Resident R200 via assignment sheet and was assigned to feed Resident R200 at the shift change meeting.

A review of the video surveillance footage and documentation of the video footage the facility provided dated [DATE REDACTED] revealed CNA EE entered Resident R200's room with his food tray at 6:43 pm. The feeding assistance assignment was reassigned to CNA FF at 6:45 pm. Surveillance footage revealed that CNA FF entered Resident R200's room at 7:15 pm and exited at 7:21 pm with Resident R200's food tray. CNA FF reported that at approximately 7:15 pm, Resident R200 was found to be unresponsive. A review of the EMR revealed that Resident R200 had a banner alert in his chart with orders/special instructions for the following: UP 90 DEGREES TO EAT; SIT UP 30 MINUTES

AFTER EATING; ALTERNATE LIQUIDS AND SOLIDS SLOWLY. It was revealed that Resident R200 was provided with a meal, including a sandwich, to consume independently for 32 minutes without the required one-on-one supervision when eating or drinking on [DATE REDACTED].

A review of Resident R200's Care Plan revealed his care plan was not updated to include one-on-one assistance while eating and drinking as an intervention for complication risks of dysphagia.

A review of the Medical Examiner's report and photos of the scene revealed a half-eaten slice of bread on Resident R200's pillow and a half-eaten slice of bread on the floor next to the resident's bed. It was documented that

the cause of death was Resident R200 choked on a sandwich on [DATE REDACTED].

During an interview on [DATE REDACTED] at 9:30 am, the DON stated that she did not understand why the MDS nurse failed to include the dysphagia diagnosis on the care plan. The DON stated that the facility has had many transfers of ownership and leadership in the last year and that audit processes are not perfect right now in relation to the MDS assessments and care plans.

During an interview on [DATE REDACTED] at 12:05 p.m., the SLP, who is the Director of Rehabilitation, stated that s/he remembered prescribing Resident R200 one-on-one assistance during meals to ensure that Resident R200 was eating at a proper pace and not eating or drinking too fast.

During an interview on [DATE REDACTED] 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 Resident R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that Resident 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. She stated, If the doctor saw the person when they got here and he didn't include it in the diagnosis list, it may have been that he didn't feel they had dysphasia anymore.

The facility implemented the following actions to remove the IJ:

Resident R200 expired at the center on ,d+[DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 The Regional Director of Operations (RDO) and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation, on [DATE REDACTED], without recommendation for changes/revisions. Level of Harm - Immediate jeopardy to resident health or On [DATE REDACTED], the Administrator, DON, and the Regional Director of Clinical Operation (RDCO) conducted safety mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments: nine of nine RNs; 42 of 43 LPNs; and 64 of 64 CNAs). Employees on leave of absence, vacation, agency Residents Affected - Few staff, and/or new hires will be re-educated by the Staff Development Coordinator (SDC), DON, or Nursing Supervisor prior to returning to duty and will not be given an assignment until they are given additional on-site education.

On [DATE REDACTED], the DON and/or Administrator retrained nursing staff that ADL care/meal assistance must continue uninterrupted and cannot be halted or delayed due to a shift change.

On ,d+[DATE REDACTED], the Administrator and DON assessed staffing levels during meal service to ensure adequate assistance.

On [DATE REDACTED], an emergency Quality Assurance and Performance Improvement (QAPI) Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis.

All corrective actions were alleged to be completed on [DATE REDACTED] and the lJ was alleged to be removed on [DATE REDACTED].

The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:

A review of the facility's census list revealed that Resident R200 expired at the facility with an effective stop billing date of [DATE REDACTED] at 8:00 pm.

A review of the facility policy titled Assistance with Meals dated [DATE REDACTED], revealed that the following individuals reviewed the policy for accuracy: The administrator signed on [DATE REDACTED]; RDO signed on [DATE REDACTED]; RDCO signed on [DATE REDACTED]; the DON signed on [DATE REDACTED]; and the Medical Director was documented as attending via the phone on [DATE REDACTED].

A review of the facility's education/in-service record revealed the following: The presenters of in-service were

the clinical leadership that was composed of the DON, Unit Manager (UM), and RDCO. The date of the education was [DATE REDACTED].

The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included a review of the comprehensive care plan policy (including development/implementation and adherence) and the ADL policy (including supervision of dependent residents during meal assistance, ADL care, and meal assistance).

A review of the facility's active employee list below was the breakdown of direct care staff (CNAs) and Nurses (LPNs and RNs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 During an interview on [DATE REDACTED] at 2:49 pm, the count for the active employees matched the number provided by the administrator. Per the RDCO, there were several employees who were crossed off the list, and they Level of Harm - Immediate were terminated. Additionally, there was an in-service with staff names on the list with an R next to their jeopardy to resident health or name indicating they had refused in-service. safety

On [DATE REDACTED] at 3:19 pm, the Administrator was asked to provide an active list of employees and include an Residents Affected - Few updated list of staff that received the in-serving.

On [DATE REDACTED] at 9:08 pm, the Director of Regulatory Compliance (DRC) provided an updated Active Employee list.

During an interview on [DATE REDACTED] at 7:55 am, the Administrator revealed the list that was provided by the DRC was on the active employee list and reflected on all the staff that were interviewed. This list included both active employees and staff that were reeducated/in-serviced. Some CNAs do work multiple shifts; UMs primarily work 7:00 am through 3:00 pm with one-weekend day shift per month.

The following staff were interviewed on [DATE REDACTED] to [DATE REDACTED] to certify the education/in-services: [DATE REDACTED] at 7:42 am (CNA JJ); [DATE REDACTED] at 7:45 am (CNA KK); [DATE REDACTED] at 10:53 am (CNA LL); [DATE REDACTED] at 11:02 am (LPN MM); [DATE REDACTED] at 11:15 am (LPN NN); [DATE REDACTED] at 11:23 am (CNA OO); [DATE REDACTED] at 11:23 am (CNA PP); [DATE REDACTED] at 11:41 am (UM/LPN QQ); [DATE REDACTED] at 11:51 am (CNA RR); [DATE REDACTED] at 12:01 pm (CNA SS); [DATE REDACTED] at 12:09 pm (UM/LPN TT); [DATE REDACTED] at 12:18 pm (CNA UU); [DATE REDACTED] at 12:23 pm (CNA VV); [DATE REDACTED] at 12:34 pm (CNA WW); [DATE REDACTED] at 5:45 am (RN YY); [DATE REDACTED] at 5:58 am (CNA ZZ); [DATE REDACTED] at 6:13 am (CNA AAA); [DATE REDACTED] at 6:30 am (RN BBB); [DATE REDACTED] at 6:50 am (LPN CCC); [DATE REDACTED] at 7:07 am (LPN DDD); [DATE REDACTED] at 7:15 am (CNA EEE); and [DATE REDACTED] at 7:21 am (CNA FFF).

A review of the facility's education/in-service record revealed the following:

The presenters of the in-service were the Clinical leadership that was composed of the (DON, UM, and RDCO). The date of the education was [DATE REDACTED].

The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included: Comprehensive care plan policy (including development/implementation and adherence); ADL policy including supervision of dependent residents during meal assistance; reeducation related to meal assistance must continue uninterrupted until individual service is complete; assistance with meals policy; assignment of assisted diners (ensure orders match tray card and care plan/Kardex). Interviews were conducted on [DATE REDACTED] from 7:42 am through [DATE REDACTED] with no concerns.

Several interviews were conducted with nursing staff (CNAs and nurses) to determine what happens when food is delivered late. Staff confirmed that they are to finish feeding/providing assistance to residents even if that means they will be staying past their scheduled time.

During an interview on [DATE REDACTED] at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage.

During an interview on [DATE REDACTED] at 12:09 pm, UM/LPN TT stated that staff must have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 During an interview on [DATE REDACTED] at 12:34 pm, CNA WW stated one of the re-educations was to ensure the proper meal tray delivery processes. Level of Harm - Immediate jeopardy to resident health or The Administrator and the DON completed a review of staffing levels to ensure adequate assistance safety availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADL dining to ensure staff assistance is available. Residents Affected - Few

The Administrator and DON reviewed the assignments sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment.

A review of the facility's daily assignment sheets included the following: The staff who are scheduled, residents who are identified as 'need to feed' residents identified as NPO, and snack times. Residents were identified by room and bed numbers that needed to be fed.

The monthly QAPI meeting was conducted on [DATE REDACTED]. The presenter/facilitator was the facility Administrator.

The duration of the meeting was 30 minutes. The team members included DON, Medical Director, UM, Assistant DON, Scheduler, RDO, VP of Clinical Services, Social Service Directors, MDS, Maintenance Director, Activities Director, Business Office Manager, and the RDCO. Per the attendance sign-in sheet, the following individuals were in attendance: The administrator, RDO, RDCO, Assistant DON, DON, Director of Regulatory Compliance (RDC), Staffing Coordinator, three Unit Managers, Infection Control Preventionist, Social Services, Dietary Manager, Registered Dietician, Director of Therapy, Central Supply, Medical Records, Maintenance Director, MDS, Business Office Manager/Human Resources, Director of Housekeeping, Staff Development Coordinator, and Assistant Administrator. The meeting overview was to

review the IJ concerns. A brief narrative description of the QAPI meeting was documented. An updated get-up list for nursing was created. Each root cause had its corresponding corrective action, responsible individual(s) have been identified with a timeline determined to be ongoing,

All corrective actions were completed on [DATE REDACTED] and the lJ was removed on [DATE REDACTED].

49472

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49687 potential for actual harm Based on staff and resident interviews, record review, and review of the facility policy titled, Activities, the Residents Affected - Few facility failed to ensure an ongoing program of activities based on preferences for one of one resident (R) (Resident R59) reviewed for activities. The resident was not provided with person-centered activities that would meet their individual needs and preferences.

Findings included:

A review of the policy titled Activities revised January 2024, the policy revealed that each resident's interest and needs will be assessed on a routine basis. The assessment shall include but is not limited to: Activity assessment to include resident's interests, preferences, and needed adaptation.

A review of the Electronic Medical Record (EMR) revealed that Resident R59 was originally admitted to the facility on [DATE REDACTED] with multiple diagnoses including, Peripheral Vascular Disease, Hypertension, Hypothyroidism, Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Anorexia, Dysphagia and Gout. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R59 had a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident R59 had moderate cognitive impairment.

During an interview on 1/13/2025 at 12:58 pm, Resident R59 revealed she would like to be outside in the summer and winter, loves to read, and would like books to read. Resident R59 went to her dresser behind her; however, there were no books.

A review of Resident R59's Activities Care Plan, dated 1/21/2025 revealed Resident R59's goal was to attend/participate in activities of choice 3-5 times weekly by next review date. Additionally, Resident R59's preferred activities included watching TV and reading books.

During an interview on 2/13/2025 at 12:28 pm, the Interim Activities Director (IAD) revealed that Resident R59 had shown an interest in religious services and had received a Bible. The IAD added that the facility has someone come every Friday to read to the residents. The IAD also offers the residents books, paper, and magazines. The IAD has a 1:1 list that she utilizes for residents who require or prefer 1:1 activity. A review of

the list of residents that require 1:1 activity provided by the IAD revealed that Resident R59 is on the list.

During an interview on 2/18/2025 at 10:25 am, Resident R59 stated she still hasn't received any books to read. She has a reader but no books. Resident R59 also noted that the IAD will visit with her sometimes but maybe someone else must tell her to bring her some books.

During an interview on 2/18/2025 at 11:39 am, the IAD and the surveyor went to the Resident R59's room to ascertain

the request for books. It was determined that the Resident R59 owns a tablet, and she needed to have books downloaded to it. The IAD stated this was the first time she had heard about this from the Resident R59. When asked what the IAD does during the 1:1 activity visit, IAD stated she just visits and talks to the residents on the list.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49687 Residents Affected - Few Based on resident and staff interviews, record review, and review of the facility's policy titled Incidents and Accidents, the facility failed to provide adequate supervision to prevent accidents for two of four sampled residents (R) (Resident R46 and Resident R206) reviewed for accidents hazards. Harm was identified to have occurred (1) on 9/25/2023 when Resident R46 sustained a fall resulting in a right femur fracture with possible patella fracture, and (2)

on 6/4/2023 when Resident R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee.

Findings included:

1. A review of the Electronic Medical Record (EMR) revealed that Resident R46 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including multiple sclerosis, insomnia, restless legs syndrome, dependence on a wheelchair, overactive bladder, other muscle spasms, major depressive disorder, bipolar disorder, hyperlipidemia, and urinary tract infection. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R46 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident R46 was cognitively intact.

A review of the Resident R46's quarterly MDS assessment dated [DATE REDACTED] revealed that for transfers, Resident R46 required extensive assistance with two persons' physical assistance.

A review of Resident R46's nursing progress note dated 9/25/2023 revealed that Resident R46 was telling the officer that she had fallen earlier in the day and injured her knee. It was noted that the resident stated, I have complained of pain all day. The day shift nurse was passing along to (the writer) while doing room-to-room walking report that the resident had been lowered to the floor earlier on the day shift due to losing her balance with the Certified Nursing Assistant (CNA) and was lowered the resident to the floor.

A review of Resident R46's hospital record dated 9/25/2023 revealed Resident R46's X-ray of the right knee with findings to include an acute intra-articular fracture of the distal femur with apparent extension to the patellofemoral joint.

A review of the facility's policy titled Incidents and Accidents revised January 2024 revealed that an 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.

During an interview on 1/15/2025 at 1:56 pm, Resident R46 revealed that she was dropped by a CNA during a transfer and broke he right leg. Resident R46 explained that she told the CNA there should be two staff transferring her however, the CNA didn't ask for assistance from another staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 2/19/2025 at 3:21 pm, the DON confirmed Resident R46 required two-person assistance. The DON continued that the facility had included the intervention of a mechanical lift in the incident report to Level of Harm - Actual harm ensure 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 Residents Affected - Few the CNA does not work at the facility anymore and that she was a contract employee.

2. A review of the EMR revealed that Resident R206 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including dementia, encephalopathy, hypertension, chronic kidney disease, unspecified abnormalities of gait and mobility, anemia, and acute kidney failure. A review of the Admission MDS assessment dated [DATE REDACTED] revealed that Resident R206 had a BIMS score of 13, indicating Resident R206 was cognitively intact.

A review of Resident R206's progress notes dated 6/4/2023 revealed that the CNA notified the nurse that Resident R206 was complaining of pain in the buttocks area; the nurse assessed Resident R206's buttocks and noticed skin breakdown; and a skin protectant was applied. Later, Resident R206 came to the nurse asking for help with his leg where he had spilled coffee. It was noted that Resident R206 specifically told the nurse he spilled coffee on the left side of his leg.

The nurse assisted Resident R206 to his room and assessed the resident's left side. The nurse observed burns and blisters on the left side of his leg.

A review of Resident R206's progress notes dated 6/5/2023 revealed that the Unit Manager requested for the resident's buttock to be assessed related to coffee burn. The buttocks assessment noted the resident had three burn wounds. When the resident was asked how he burned himself he stated, I spilled the damn hot coffee . and it hurts. The wound measurements were documented as: Right buttock, 17.0 x 6.5 x 0.1 cm, 100% Dermis, no exudate; Left buttock, 16.5 x 26.5 x 0.1 cm, 90% Dermis & 10% Skin, no exudate; Left hip, 8.0 x 7.0 x 0.1 cm, 100% Dermis, no exudate.

A review of the EMR revealed that Resident R206 was sent to the nearest hospital on 6/5/2023 to be treated for the coffee burn and did not return to the facility.

A review of the EMR revealed that Resident R206 sustained second-degree burns to the bilateral buttock and the left hip and that Resident R206 refused to return to the facility.

During an interview on 1/27/2025 at 11:35 am, the Dietary Manager stated that the hydration cart is provided

during the meal service and confirmed that the temperature of the coffee is not monitored.

During an interview on 2/6/2025 at 3:10 pm, the Dietary Manager stated she heard about the resident who sustained the coffee burn. According to the Dietary Manager, two dietary aides were giving the resident coffee in his mug straight from the coffee machine. The Dietary Manager continued that the Director of Regulatory Compliance (DRC) notified the kitchen staff to start taking the temperature of the coffee on 2/5/2025.

During an observation on 2/6/2025 at 3:12 pm, the temperature of the coffee for breakfast and lunch on 2/6/2025 was not taken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 2/12/2025 at 10:33 am, Former Administrator CC revealed that Resident R206 had received coffee from an agency aide. Resident R206 then complained to staff he had spilled the hot coffee on himself, and it Level of Harm - Actual harm was burning. The CNA reported the concerns to the nurse who was also an agency nurse. The Former Administrator CC stated that he found out about the incident approximately 24 hours later and that the staff Residents Affected - Few was reeducated. The corrective action included that the dietary manager should monitor the temperature of

the coffee and that it should be documented before serving the residents. The Former Administrator CC further added that the other corrective action was that the kitchen staff would pour the coffee in the facility's cups, not in residents' mugs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47794

Residents Affected - Few 49472

Based on interviews, record review, and review of the facility policy titled Infusion Therapy, the facility failed to monitor one of 19 sampled residents (R) (Resident R204) for complications related to intravenous (IV) therapy, resulting in infiltration of the IV. Harm was identified to have occurred on 8/27/2024 when this failure caused Resident R204 to experience pain and swelling, resulting in Resident R204 being sent to the emergency room (ER) for treatment and observation per family request.

Findings included:

A review of the undated facility policy titled, Infusion Therapy, revealed that the facility . will have qualified nursing staff present on all shifts to manage the care of patients receiving infusion therapy or maintain access devices. Additional training will be provided as needed for specific therapies.

A review of the Admission Record revealed Resident R204 was an [AGE] year-old female admitted to the facility on [DATE REDACTED] with a medical history of normal pressure hydrocephalus, essential hypertension, cerebrospinal fluid drainage device, adult failure to thrive, hyperlipidemia, hypomagnesemia, hypokalemia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, muscle weakness.

A review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 8/29/2024, revealed Resident R200 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was mildly impaired and that the resident requires substantial assistance with all Activities of Daily Living (ADL) care.

A review of the care plan dated 7/14/2024 revealed that Resident R204 was at risk for dehydration or potential fluid deficit related to poor intake. Interventions included that directed staff was to encourage resident to drink fluids of choice, ensure access to cold water whenever possible, monitor vital signs as ordered and as needed (PRN), notify physician (MD) of significant abnormalities, observe/report PRN any signs/symptoms of dehydration, decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes (initiated 7/15/2024), obtain and monitor lab/diagnostic work as ordered, report results to MD and followup as indicated (initiated 7/15/2024).

A review of the physician orders dated 8/26/2024 revealed that Resident R204 was ordered Dextrose 5 1/2 normal saline at 60 ml hour x 2-liter one time only for Nausea and Vomiting until 8/26/2024 at 11:59 pm.

A review of the Infection Note on 8/26/2024 at 6:16 pm by the Assistant Director of Nursing (DON)/Infection Prevention Coordinator (IPC) revealed that Resident R204 had recently been readmitted with diagnoses of acute metabolic encephalopathy, altered mental status, recurrent urinary tract infection (UTI), failure to thrive, and was currently being treated for pneumonia, on antibiotics Cefpodoxime 10 milliliters (ml) every 12 hours x 5 days. A line is inserted for IV fluids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 A review of the nursing assignments revealed that Licensed Practical Nurse (LPN) DD was assigned to manage Resident R204's IV therapy on the 7:00 pm through 7:00 am shift. Per the DON, LPN DD also attended an Level of Harm - Actual harm in-service for IV Management prior to her shift.

Residents Affected - Few A review of Resident R204's vitals taken by LPN DD on 8/26/2024 at 9:30 pm revealed that her blood pressure was 140/73 mmHg; lying left arm. (Note: LPN DD took blood pressure on the same arm the IV was implanted. Potential complications: The application of a blood pressure cuff on an arm with an IV can cause blood to flow back into the IV line, potentially disrupting the infusion or creating clots). LPN DD documented a pain score for Resident R204 as 0 out of 10.

During an interview on 1/29/2025 at 9:50 am, the DON confirmed that her expectations were that nurses were supposed to be rounding at least every couple of hours when a resident has a continuous IV.

A review of the 24-hour nurse logs and progress notes revealed no evidence that LPN DD monitored or documented Resident R204's infusion rate amounts every two hours throughout the 7:00 pm through 7:00 am shift.

A review of the police investigation report revealed that a family member called the emergency line on 8/27/2024 at 2:52 am with complaints that Resident R204 was in pain and her nursing call light was being ignored at

the facility.

A review of the Health Status Note dated 8/27/2024 at 2:50 am and documented by LPN DD on the status of Resident R204's IV revealed, (Resident R204's) IV site to right (left) arm noted swollen, IV fluids stopped, arm elevated on pillow. Provider made aware. No orders to transfer to the hospital for further evaluation and treat.

A review of the Physician's orders dated 8/26/2024 at 11:59 pm called for the IV to be discontinued.

A review of Health Status Note dated 8/27/2024 at 3:30 am, revealed that LPN DD documented the status of

the Resident R204's IV revealed, Resident R204 transported via stretcher x 2 EMT personnel to preferred hospital. No complaints, no distress noted. LPN DD did not respond to attempts to be interviewed via phone or while on-site at the facility about the incident. LPN DD later resigned from employment at the facility.

A review of the police report dated 8/27/2024 revealed that Paramedic RRR and EMT SSS arrived and were shocked by how much the arm had swollen. Paramedic RRR stated that the IV gauge used was the smallest possible, normally used on infants and that caregivers should have noticed that it was blown immediately. Paramedic RRR stated 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.

During an interview on 1/24/2025 at 10:42 am, LPN III, the night shift supervisor on 8/27/2024, stated that nurses are on two-hour rotations where they check on each patient in their care. LPN III stated, The Police Department was already walking through the building when I got up there, and they did call EMS. You know, I can't answer for what LPN DD did, you will have to ask her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 A review of emergency room records dated 8/27/2024 revealed that Resident R204 arrived with weakness, IV infiltration, left arm pain, and left arm swelling. Resident R204 was administered hydrocodone dash acetaminophen Level of Harm - Actual harm (Norco 10 milligrams - 325 milligrams oral tablet) for pain, Clonidine 0.1 milligrams, and ondansetron (Zofran) 4 milligrams. Resident R204's ultrasound result of the left arm was negative for blot clots. Resident R204 was later discharged Residents Affected - Few from the hospital on 8/27/2024 and admitted back to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47794

Residents Affected - Few Based on observations, interviews, record review, and a review of the facility policy titled, Menu Policy, the facility failed to offer one of 19 sampled residents (R) (Resident R5) a diet that suits her pescatarian diet (a diet that includes plant-based foods and fish and other seafood) preferences.

Findings included:

A review of the facility's undated policy titled, Menu Policy revealed that menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Menu items and available snacks reflect the religious, cultural, and ethnic preferences of the residents.

A review of the Admission Record revealed Resident R5 was an [AGE] year-old female that was admitted to the facility

on [DATE REDACTED] with diagnosis of parkinsonism, anemia, essential hypertension, type 2 diabetes, hyperlipidemia, dementia, anxiety disorder, major depressive disorder, coronary artery disease, acute kidney failure, bipolar disorder, obsessive-compulsive disorder, suicidal ideations, paraplegia, gastroesophageal reflux disease, rheumatoid arthritis, pruritus, and glaucoma.

A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R5 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating mild to moderate cognitive impairment and that Resident R5 required supervision with eating.

A review of the Care Plan for Resident R5 dated 2/12/2025 revealed resident Resident R5 was at nutritional risk related to having a fair appetite, history of weight fluctuations, history of poor appetite, history of wounds, edentulous, vegetarian preference (fish ok), and mechanically altered diet. Interventions to care include administering medications as ordered, observing/reporting any signs/symptoms of dysphagia, observing/reporting to the medical doctor (MD) signs/symptoms of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in one week, >5% in one month, >7.5% in three months, >10% in six months, obtain lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve supplements as ordered. Provide and serve diet as ordered. Registered Dietician (RD) to evaluate and make diet change recommendations as needed (PRN). Observation

During an interview with Resident R5 on 1/14/2025 at 10:46 am it was noted Resident R5 had some hearing impairment. She stated that she was unhappy with her food choices. She does not eat meat, pork, beef, or chicken. She prefers fish, cottage cheese, peas, and potato salad. She would like fish to be a daily option.

During an interview and observation on 2/12/2025 at 12:52 pm during lunch observation Resident R5 expressed she did not like the food, she ate the mixed vegetables and pudding dessert. Resident R5 stated, The vegetables were too hard, I could not eat them. She requested to speak with the dietitian about her food preferences. Observation of Resident R5's plate had roasted zucchini and carrots (firm texture), mixed vegetables (yellow carrots, orange carrots, green beans, onions, green and red bell peppers) (mostly eaten), and uneaten rice. Resident R5 is prescribed

a mechanical soft diet with regular liquids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During an interview and observation on 2/12/2025 at 1:30 pm, Kitchen Manager UUU assessed Resident R5's lunch plate and meal ticket to confirm the accuracy of a vegetarian mechanical soft diet. She admitted that the Level of Harm - Minimal harm or zucchini and carrots were undercooked, and the rice had hard bits in it; too hard for the resident to consume. potential for actual harm

A review of the facility's October 2024 through February 2025 posted monthly menu revealed fish being Residents Affected - Few offered only four times for four meals of the month. Resident R5's pescatarian diet requires a fish option for all three meals of the day, daily.

During an interview on 2/12/2025 at 5:37 pm, the Registered Dietician (RD) stated that she would observe food preparation in the kitchen and assess Resident R5 at dinner service, as Resident R5's quarterly assessment was due that day. She stated that Resident R5 could have fish daily.

A review of the updated care plan dated 2/12/2025 revealed no dietary interventions to provide Resident R5 with fish daily.

During an interview and observation on 2/13/2025 at 3:18 pm with UUU, the Kitchen Manager stated that the nurses are supposed to inform them of what the resident wanted to eat. She confirmed they do have alternates and that every nursing station had a menu, and the nurses were responsible for making sure the residents who were bedbound chose the meal. The only fish I have access to are tuna, flounder, breaded cod, and catfish nuggets. I won't buy the catfish nuggets that are trash fish covered in batter. Especially if you're not cutting the filets yourself. But I can't order regular catfish, it's not on my order guide. We have restricted order guides.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 49687 potential for actual harm Based on observations, staff interviews, and a review of the facility's policy titled, Disposal of Garbage Residents Affected - Some Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from dirt and debris.

In addition, the facility failed to ensure the sliding door was kept closed when not in use. The facility census was 189 residents.

Findings included:

A review of the facility's policy titled Disposal of Garbage Refuse, revised April 2024, documented that Surrounding area should be kept clean so that accumulation of debris and insect/rodent attraction are minimized.

During an initial tour of the kitchen accompanied by the facility's Dietary Manager (DM) on 1/13/2025 at 9:44 am, it was revealed that there was one garbage dumpster. The garbage dumpster had a lid that was left open while not in use and there was debris underneath the dumpster and an open blue trash can.

During an Interview on 1/13/2025 at 9:44 am, the DM revealed that the garbage dumpster was used by the whole facility. She stated that she had brought concerns to the housekeeping manager about the cleanliness of the dumpster's surrounding areas was a concern. She confirmed that there was debris underneath the dumpster and an open blue trash can. She confirmed that she did not know where the debris and trashcan came from.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 115422 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47794 jeopardy to resident health or safety Based on interviews and record review, the facility's Administration failed to provide protective oversight of

the facility ensuring that staff followed appropriate policies and procedures to prevent accidents and hazards Residents Affected - Few resulting in Immediate Jeopardy for resident (R) Resident R200 and Harm for Resident R46, Resident R206, and Resident R204.

On [DATE REDACTED], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE REDACTED] at 10:25 am. The noncompliance related to the IJ was identified to have existed on [DATE REDACTED].

An Acceptable Removal Plan was received on [DATE REDACTED]. 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 REDACTED]. 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.

Findings included:

1. On [DATE REDACTED], Resident R200 was found unresponsive in his bed after a Certified Nursing Assistant (CNA) EE dropped off the resident's food tray, leaving Resident R200 unsupervised with food for 30 minutes. Resident R200 expired in the facility, with the cause of death documented as choking.

Cross Refer