Inspection Reports for Roswell Nursing & Rehab Center

The facility failed to ensure residents dependent on staff for activities of daily living received showers as scheduled, placing residents at risk of diminished quality of life. Additionally, the facility failed to properly secure medications, resulting in unsecured medications and pills found on the floor, posing risks of medication diversion and errors.

The facility was found to have multiple deficiencies including failure to accurately document advance directives, failure to develop and implement comprehensive care plans especially related to dysphagia and supervision during meals resulting in resident death, inadequate assistance with activities of daily living, failure to prevent accidents resulting in fractures and burns, failure to monitor IV therapy leading to infiltration and emergency room visit, failure to accommodate dietary preferences, failure to maintain clean garbage areas, failure to provide effective administrative oversight, failure to follow infection control protocols during incontinent care, and failure to maintain a working call light system on one unit.

The facility was found to have multiple deficiencies including failure to accurately document advance directives, failure to develop and implement comprehensive care plans especially related to dysphagia, inadequate supervision during meals resulting in resident death, failure to provide adequate assistance with activities of daily living, inadequate infection control practices, failure to provide diets consistent with resident preferences, failure to maintain safe environment and call light systems, and failure to provide appropriate oversight and staff education. Immediate Jeopardy was identified related to resident safety and care, which was removed after corrective actions were implemented.

The facility was found deficient in multiple areas including failure to ensure proper documentation of Do Not Resuscitate orders, incomplete implementation of care plans for oxygen use and vital sign monitoring, inadequate assistance with activities of daily living, lack of contracture management and range of motion care, serving unpalatable and unattractive food, unsanitary kitchen and ice machine conditions, inadequate infection prevention and control practices including improper PPE disposal and COVID-19 symptom monitoring, failure to obtain vaccination consent prior to COVID-19 vaccine administration, and failure to maintain clean resident rooms on several units.

The facility was found deficient in multiple areas including failure to ensure proper documentation of Do Not Resuscitate orders, incomplete implementation of care plans especially related to oxygen use and vital sign monitoring, inadequate assistance with activities of daily living, lack of contracture management and range of motion care, serving unpalatable and unattractive food, unsanitary conditions in kitchen storage and ice machines, inadequate infection prevention and control practices including improper PPE disposal and COVID-19 symptom monitoring, failure to obtain vaccination consent prior to COVID-19 vaccine administration, and failure to maintain clean resident rooms on several units.

The facility failed to properly evaluate and document safe self-administration of eye drops for a resident, develop comprehensive care plans including fall risk interventions, secure portable oxygen tanks, prevent duplicate medications, monitor psychotropic medication side effects, and implement a program to monitor antibiotic use. These deficiencies posed potential risks for resident safety and care quality.