Inspection Reports for
Roswell Nursing & Rehab Center

The facility was found deficient in multiple areas including failure to provide a pescatarian diet as requested by a resident, inadequate infection control practices during incontinent care, failure to provide nursing care according to care plans resulting in a resident's death by choking, lack of person-centered activities for a resident, and failure to maintain cleanliness around garbage dumpsters.

Multiple complaint intake numbers were investigated in conjunction with the standard survey. Several complaints were unsubstantiated, some substantiated without deficiencies, and others substantiated with deficiencies including the Immediate Jeopardy related to resident R200's choking death.

The facility was found not in substantial compliance with multiple deficiencies including Immediate Jeopardy related to failure to provide adequate supervision during meals resulting in a resident's death by choking, failure to accurately document advanced directives, failure to provide person-centered activities, inadequate supervision to prevent accidents resulting in fractures and burns, failure to monitor IV therapy causing infiltration and pain, failure to provide appropriate diet per resident preferences, failure to maintain clean garbage areas, failure to ensure call light system functionality, and failure to follow infection control protocols during incontinent care.

The facility was found not in substantial compliance with life safety code requirements, including issues with self-closing doors, exit signage lighting, combustible storage in mechanical rooms, improper cooking equipment separation, and unsealed penetrations above smoke barriers.

Complaint Intake Numbers GA00232775, GA00232697, GA00232503, and GA00233101 were investigated in conjunction with the standard survey.

The facility was found not in substantial compliance with multiple deficiencies including failure to ensure proper documentation of Do Not Resuscitate orders, inadequate oxygen use and monitoring, insufficient assistance with activities of daily living, lack of contracture management, poor meal quality, unsanitary kitchen storage and ice machines, improper COVID-19 infection control practices, failure to obtain vaccination consents prior to COVID-19 vaccine administration, and inadequate cleaning of resident rooms.

The facility was found deficient in multiple areas including food service quality, infection control practices related to COVID-19, nursing care for resident needs, contracture management, and sanitation of kitchen storage and ice machines. Several residents reported dissatisfaction with food quality, and infection control lapses were noted in PPE management and COVID-19 symptom monitoring. Nursing care deficiencies included inadequate oxygen therapy monitoring, insufficient assistance with activities of daily living, and lack of contracture management. The dry storage room and basement ice maker were not maintained in a sanitary manner.

The facility was found not in substantial compliance with emergency preparedness and multiple fire safety requirements including fire alarm system maintenance, sprinkler system maintenance, corridor door smoke resistance, and electrical safety. Specific deficiencies included unlabeled fire alarm batteries, loaded sprinkler head, missing sprinkler system data plate, resident doors not latching properly to resist smoke, and blocked electrical panel access.

The facility was found not to be in compliance with infection control regulations due to failure to maintain and implement an effective infection prevention and control program. Specifically, a Corporate Maintenance staff member entered and re-entered the Observation Unit without sanitizing hands or donning required PPE, risking cross-contamination.

The facility was found deficient in monitoring behaviors and side effects for a resident on antidepressant medication, developing a comprehensive care plan for self-administration of medications, and securing portable oxygen tanks properly. Policies related to psychotropic drug monitoring and care planning lacked necessary documentation.

The survey was a recertification with complaints survey. No deficiencies were issued related to specific complaint intakes GA00202778, GA00202088, GA00199021, GA00199884, GA00199293.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to evaluate and document safe self-administration of medications, failure to develop comprehensive care plans, inadequate updating of care plans for fall risk, unsecured oxygen tanks, duplicate medications, lack of monitoring for psychotropic medication side effects, and failure to implement an antibiotic stewardship program.

The facility was found not in substantial compliance with the Life Safety Code due to failure to maintain the wet sprinkler system, evidenced by a yellow tag on the sprinkler riser, and failure to seal multiple penetrations above the ceiling at smoke barriers in Jasmine Place and Emerald Court/Memory Care.

Complaint Intake Numbers GA00191417, GA00191356, GA00190910, GA00190845, GA00190868 and GA00190551 were investigated. Five of these were substantiated with deficiencies cited.

The facility was found not in substantial compliance with multiple regulatory requirements including accounting of resident funds, safe and clean environment, care plan implementation, medication administration, infection control, staffing information posting, and food safety.

The facility failed to ensure proper medication management for antianxiety and psychotropic medications, did not follow care plans for resident hygiene and behavior monitoring, and had multiple infection control deficiencies including improper disinfection of glucometers and unsanitary storage of personal care equipment.