Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roswell Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
Expired drugs were found in one medication room and two medication carts after surveyors observed a Dulcolax suppository, hemorrhoidal suppositories, Bisacodyl stimulant laxative, and a resident-specific nitroglycerin tablet past their expiration dates. An LPN and the unit manager confirmed the expired items, and the Administrator and DON stated the charge nurse was expected to check carts and medication rooms weekly for expiration dates.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled substances, were not stored in locked or separately locked compartments as required.
A resident with dysphagia was left unsupervised with a meal, leading to choking and death. The facility failed to include necessary one-to-one meal assistance in the care plan, despite medical orders and evaluations indicating the need. Staff interviews revealed issues with care plan audits and documentation, contributing to the oversight.
A resident with dysphagia and complex medical needs was left unsupervised with a meal, leading to a fatal choking incident. The resident required one-on-one assistance during meals, which was not provided due to a breakdown in staff communication and adherence to care plans. The facility's failure to update the care plan and ensure proper supervision resulted in the resident's death.
The facility failed to provide adequate supervision and care planning, resulting in Immediate Jeopardy for a resident who choked and expired after being left unsupervised with a meal. Other residents suffered harm due to falls, burns, and IV complications. Staff interviews revealed gaps in communication and oversight, contributing to these deficiencies.
Two residents in an LTC facility suffered injuries due to inadequate supervision. One resident, requiring two-person assistance, was transferred by a single CNA, resulting in a femur fracture. Another resident sustained second-degree burns from hot coffee served without temperature checks. Both incidents highlight lapses in safety protocols.
A resident with a complex medical history experienced harm due to inadequate monitoring of IV therapy. The LPN failed to document or check the IV infusion rate every two hours, leading to infiltration and significant swelling. Emergency services were called, and the resident was transported to the hospital for treatment.
The facility did not maintain cleanliness around the garbage dumpsters, with the dumpster lid left open and debris present underneath. The Dietary Manager confirmed these issues and had previously raised concerns with the housekeeping manager, but the source of the debris was unknown.
The facility failed to follow infection control protocols during incontinent care for several residents. Observations revealed that CNAs did not wash or sanitize hands between handling soiled and clean items, nor change gloves as required. Interviews with staff confirmed these lapses, indicating a systemic issue in adhering to infection control protocols.
The call light system on the Jasmine Unit was found to be malfunctioning, preventing residents from calling for assistance. A resident reported the issue had persisted since the weekend, and staff were unaware until a surveyor's inspection. Maintenance checks were inconsistent, contributing to the problem. Temporary measures, such as distributing bells, were implemented.
A resident's advanced directive was inaccurately documented in the EMR, showing both DNR and Full Code statuses. Despite the care plan and POLST form indicating DNR, staff were confused, and the resident was unaware of her code status, expressing a preference for resuscitation.
A resident with multiple diagnoses and moderate cognitive impairment was not provided with person-centered activities that met her preferences, such as reading books. Despite being on a 1:1 activity list, the resident did not receive books for her tablet, and the Interim Activities Director was unaware of this need until a surveyor's visit.
A resident with a pescatarian diet was not provided with adequate meal options to meet her dietary preferences, as the facility's menu only offered fish four times a month. Despite the resident's request for fish daily and the Registered Dietician's acknowledgment of this possibility, the care plan was not updated to reflect this need. Additionally, the resident was served undercooked vegetables and hard rice, unsuitable for her mechanical soft diet.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Expired Medications Found in Medication Storage Areas
Penalty
Summary
Drugs and biologicals were not properly audited for expiration dates in one of four medication rooms and two of nine medication carts. In the lower-level medication storage room, an observation and interview on 3/2/2026 at 10:45 am found a lone Dulcolax suppository with an expiration date of 07/2021, which an LPN confirmed. In Sapphire Hall medication cart A, observations on 3/26/2026 at 11:00 am and 11:10 am found a box of hemorrhoidal suppositories with an expiration date of September 2025, a bottle of Bisacodyl stimulant laxative with an expiration date of 2/2026, and a resident-specific nitroglycerin 0.4 mg tablet with an expiration date of 9/2025; these expired medications were confirmed by the unit manager, LPN AAA. The Administrator and DON stated that the expectation was for the regular charge nurse to check medication carts and medication rooms weekly for expiration dates. No medication storage policy was provided by the facility.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to comply with regulations regarding the proper labeling and secure storage of medications and controlled substances within the facility.
Failure to Implement Comprehensive Care Plan Leads to Resident's Death
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dysphagia, which ultimately led to the resident's death by choking on a sandwich. The resident, a male with a complex medical history including cerebral palsy, functional quadriplegia, and dysphagia, required total dependence on all activities of daily living and had been prescribed one-to-one assistance during meals to prevent choking or aspiration. Despite these requirements, the resident was left unsupervised with a meal for 32 minutes, during which time he choked on a sandwich and was later found unresponsive. The resident's care plan did not include the necessary intervention of one-to-one assistance while eating, despite the speech therapy evaluation and physician orders indicating the need for such supervision. The facility's failure to customize the care plan to address the resident's specific needs for meal supervision was a critical oversight. Additionally, the facility's MDS nurse did not include the dysphagia diagnosis in the resident's chart and care plan, which contributed to the lack of appropriate supervision during meals. Interviews with facility staff revealed a lack of clarity and accountability regarding the auditing of care plans and the inclusion of therapy diagnoses. The Director of Nursing acknowledged that audit processes were not perfect due to recent changes in ownership and leadership, while the MDS nurse admitted to not always entering therapy diagnoses with medical diagnoses. This lack of proper documentation and oversight resulted in the resident being left without the necessary supervision, leading to the tragic outcome.
Removal Plan
- The policy for comprehensive care plans was reviewed and/or revised by the Administrator and Regional Director of Clinical Operations without a recommendation for revisions.
- The MDS Nurse reviewed care plans for 45 of 45 in-house residents identified with a diagnosis of dysphagia. Thirty care plans were updated to include a diagnosis of dysphagia current and active care plans for dysphagia and appropriate levels of meal supervision.
- The DON in-serviced the MDS team and licensed nurses on the Center's Comprehensive Care Plan policy and development/implementation and adherence of care plans. (RNs nine of nine equaling 100%; LPNs 42 of 43 equaling 97.7%; OVERALL 98%).
- Employees on leave of absence, vacation, agency staff, or new hires will be re-educated by the Staff Development Coordinator, DON, or Nursing Supervisor prior to returning to duty, and will not be given an assignment until they are given additional on-site education.
- The DON and Regional Director of Clinical Operations reviewed residents in the past thirty days with a new diagnosis of dysphagia to ensure that care plans were updated as appropriate.
- The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee.
Failure to Supervise Resident with Dysphagia Leads to Fatal Choking Incident
Penalty
Summary
The facility failed to provide necessary supervision and assistance with Activities of Daily Living (ADL) care during meals for a resident diagnosed with dysphagia, which ultimately led to the resident's death by choking on a sandwich. The resident, a male with a complex medical history including cerebral palsy, functional quadriplegia, and dysphagia, required total dependence for ADL care and was non-verbal. Despite these needs, the resident was left unsupervised with a meal for 32 minutes, contrary to the prescribed one-on-one assistance during meals to prevent choking or aspiration. The resident's care plan was not updated to reflect the need for one-on-one assistance during meals, despite clear indications from the Speech Therapy Transitional Evaluation and Plan of Treatment that such supervision was necessary. The facility's policies on ADL and meal assistance were not adhered to, as the resident was left to consume a meal independently without the required supervision. This oversight was compounded by a lack of communication and coordination among staff, as evidenced by the CNA's decision to leave the resident's meal tray in the room without ensuring the resident was fed. Interviews with facility staff revealed a breakdown in the implementation of care plans and supervision protocols. The CNA assigned to feed the resident did not complete the task due to shift timing issues, and the subsequent CNA did not arrive in time to prevent the incident. The facility's Director of Nursing acknowledged gaps in the care planning process, citing frequent changes in ownership and leadership as contributing factors to the oversight. The failure to provide adequate supervision and assistance during meals directly resulted in the resident's death by choking.
Removal Plan
- The Regional Director of Operations and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation.
- The Administrator, DON, and the Regional Director of Clinical Operation conducted mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments.
- 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.
- The Administrator and DON assessed staffing levels during meal service to ensure adequate assistance.
- An emergency Quality Assurance and Performance Improvement Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis.
Failure in Supervision and Care Planning Leads to Resident Harm
Penalty
Summary
The facility's administration failed to ensure protective oversight, leading to a series of deficiencies that resulted in Immediate Jeopardy for one resident and harm to others. A resident, identified as R200, was found unresponsive in bed after being left unsupervised with a food tray for 30 minutes by a CNA. The resident, who had a diagnosis of dysphagia, expired due to choking. The facility had not developed a comprehensive care plan for R200 that addressed the need for supervision during meals, despite the resident's known condition. Additionally, the facility failed to prevent harm to other residents. One resident, R46, sustained a right femur fracture from a fall, while another, R206, suffered second-degree burns from spilled hot coffee. A third resident, R204, experienced pain and swelling from an infiltrated intravenous site, necessitating emergency room treatment. These incidents highlight the facility's failure to ensure adequate supervision and care, as well as the lack of proper care planning and staff training. Interviews with facility staff, including the DON and MDS Nurse, revealed gaps in communication and oversight. The DON admitted to not understanding why the dysphagia diagnosis was omitted from R200's care plan and acknowledged issues with the facility's audit processes due to frequent changes in ownership and leadership. The MDS Nurse confirmed the omission of therapy diagnoses in care plans and could not recall specific details about R200's condition. These deficiencies underscore the facility's failure to maintain accurate and comprehensive care plans and to ensure staff adherence to policies and procedures.
Removal Plan
- A Root Cause Analysis 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, Regional Director of Clinical Operations, Administrator, and DON.
- The administrator hosted an Ad Hoc QAPI meeting 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.
- The Regional Director of Operations, RDCO, Medical Director, Administrator, and DON reviewed residents receiving swallow therapy to identify residents with a diagnosis of dysphagia to ensure that care plans were updated as appropriate.
- The Administrator identified Improvement Activities and Performance Improvement Projects based on trends and identified potential opportunities upon completion of the care plan and swallowing therapy audit.
- A review of the residents receiving swallow therapy audit was reviewed by the IDT members to validate care plans were updated appropriately to identify the level of dining assistance required.
- The MDS Nurse(s) reviewed and updated care plans on residents identified with a diagnosis of dysphagia.
- The RDCO provided re-education 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.
- A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance.
- The assignments for meal supervision were revised to 45 residents assigned meal supervision as an intervention for their individualized risk.
- The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes.
- 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.
- Interviews were conducted with staff to ensure that staff were in-serviced and were knowledgeable of where to retrieve assignments on a daily basis, and to ensure that staff understood requirements for supervision, one-on-one assistance, and tray set-up for residents.
- A new Dining Time for Meal Delivered to Units was implemented with new dining times for breakfast, lunch, and dinner.
Inadequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents, resulting in harm. The first incident involved a resident with multiple diagnoses, including multiple sclerosis and dependence on a wheelchair, who required extensive assistance with transfers. Despite this, a CNA attempted to transfer the resident alone, resulting in the resident being lowered to the floor and sustaining a right femur fracture with a possible patella fracture. The resident had previously communicated the need for two-person assistance, but the CNA did not seek additional help. The second incident involved a resident with dementia and other medical conditions who sustained second-degree burns to the bilateral buttocks and left hip after spilling hot coffee. The coffee was served directly from the machine without temperature monitoring, and the resident was left to manage the hot beverage independently. The resident reported the incident to staff, but the severity of the burns was not immediately addressed, leading to the resident being sent to the hospital for treatment. Both incidents highlight a lack of adherence to safety protocols and inadequate supervision, resulting in significant injuries to the residents. The facility's failure to ensure proper transfer assistance and monitor the temperature of hot beverages contributed to these accidents, demonstrating a need for improved staff training and adherence to established safety policies.
Failure to Monitor IV Therapy Leads to Resident Harm
Penalty
Summary
The facility failed to properly monitor a resident receiving intravenous (IV) therapy, leading to complications. The resident, an elderly female with a complex medical history including normal pressure hydrocephalus, hypertension, and other conditions, was admitted to the facility and required IV fluids for nausea and vomiting. The facility's policy required qualified nursing staff to manage infusion therapy, but the assigned LPN did not adhere to the expected monitoring protocols. On the night in question, the LPN assigned to the resident's care failed to document or monitor the IV infusion rate every two hours as required. The LPN also took the resident's blood pressure on the same arm where the IV was inserted, which is against best practices as it can cause complications. Despite the resident's care plan indicating a risk for dehydration and the need for close monitoring, the LPN did not adequately check on the resident, resulting in the IV site becoming swollen and painful. The situation escalated when a family member called emergency services due to the resident's pain and the facility's lack of response. Upon arrival, paramedics noted significant swelling in the resident's arm, indicating that the IV had been infiltrated for several hours. The resident was transported to the hospital for further evaluation and treatment. The LPN involved did not respond to inquiries about the incident and later resigned from the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain cleanliness around the garbage dumpsters, as observed during a tour of the kitchen. The garbage dumpster, used by the entire facility, was found with its lid open when not in use, contrary to the facility's policy. Additionally, there was debris underneath the dumpster and an open blue trash can nearby. The Dietary Manager confirmed these observations and mentioned having previously raised concerns about the cleanliness of the dumpster area with the housekeeping manager. However, the source of the debris and the open trash can was unknown to her.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to adhere to infection control protocols related to hand hygiene during activities of daily living (ADL) care for several residents. The facility's policy on hand hygiene requires staff to wash or sanitize their hands before moving from a contaminated body site to a clean body site during resident care. However, observations revealed that staff did not follow these protocols during incontinent care for multiple residents. For instance, during incontinent care for a resident with moderate cognitive impairment and mobility issues, a CNA did not wash or sanitize hands between handling soiled and clean items, nor before applying barrier cream and a clean brief. This resident was at risk for skin breakdown and urinary tract infections due to incontinence, as noted in their care plan. Similar lapses were observed with other residents, including one with severe cognitive impairment and another who was cognitively intact, where CNAs failed to change gloves or sanitize hands between handling contaminated and clean items. Interviews with staff, including CNAs and the Director of Nursing, confirmed these lapses in protocol. The CNAs admitted to not washing or sanitizing hands between handling dirty and clean items, and the Director of Nursing acknowledged that gloves should be changed between handling soiled and clean briefs. These observations and interviews highlight a systemic issue in the facility's adherence to infection control protocols during ADL care.
Call Light System Malfunction on Jasmine Unit
Penalty
Summary
The facility failed to ensure that the call light communication system was functioning adequately on the Jasmine Unit, as observed by surveyors. The facility's policy requires staff to report any issues with the call light system immediately and provide alternative solutions until the problem is resolved. However, observations and interviews revealed that the call lights were not working in several rooms, and residents were unable to call for assistance. A resident, identified as R160, reported that the call lights had been out of order since the weekend, and she had to wait for staff to pass by and yell for help. The maintenance assistant confirmed that some call lights needed new batteries or light bulbs, but the issue persisted during the survey. The maintenance assistant stated that call light functionality is checked once or twice a week, but the maintenance director mentioned that under the new operating company, the checks are conducted monthly. This discrepancy in maintenance checks may have contributed to the prolonged malfunction of the call lights. An LPN was observed distributing bells to residents as a temporary measure, indicating a lack of awareness about the non-functioning call lights until the surveyor's inspection. The facility's failure to maintain a working call system compromised the residents' ability to request assistance, as evidenced by the non-functioning call lights in multiple rooms.
Conflicting Code Status Documentation in EMR
Penalty
Summary
The facility failed to ensure the accurate documentation of an advanced directive for a resident, leading to conflicting code statuses in the Electronic Medical Record (EMR). The resident, who was admitted with multiple diagnoses including Alzheimer's disease and vascular dementia, had a documented code status of both Do Not Resuscitate (DNR) and Full Code simultaneously. The EMR dashboard showed conflicting information, with the resident's care plan indicating a DNR status, while the Physician Orders listed both DNR and Full Code as active. The Physician Order for Life-sustaining Treatment (POLST) form, signed by the resident and medical staff, indicated a DNR status. Interviews with staff revealed confusion regarding the resident's code status. A Licensed Practical Nurse (LPN) stated that she would have treated the resident as Full Code based on the dashboard information. The Unit Manager mentioned updating the code status based on recent orders, while the Director of Nursing (DON) suggested a system glitch due to a change in facility ownership might have caused the discrepancy. The resident was unaware of her current code status and expressed a preference for resuscitation if needed, contradicting the documented DNR status.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide a resident, identified as R59, with person-centered activities that met her individual needs and preferences. R59, who has multiple diagnoses including Peripheral Vascular Disease, Hypertension, and moderate cognitive impairment, expressed a desire to be outside in all seasons and a love for reading. Despite these preferences being documented in her Activities Care Plan, which included a goal for her to participate in activities of choice 3-5 times weekly, R59 reported not receiving any books to read. During an interview, she mentioned having a reader but no books, and it was noted that she owns a tablet that requires books to be downloaded. The Interim Activities Director (IAD) was unaware of R59's need for books on her tablet until it was brought to her attention during a surveyor's visit. Although the IAD had a list for 1:1 activities and R59 was on it, the IAD's visits consisted mainly of talking to the residents rather than addressing specific activity requests. This lack of communication and follow-through on R59's stated preferences led to the deficiency in providing an ongoing program of activities tailored to her needs.
Failure to Accommodate Pescatarian Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's pescatarian dietary preferences, which include plant-based foods and fish, as required by the facility's Menu Policy. The resident, who has a complex medical history including parkinsonism, anemia, and dementia, expressed dissatisfaction with the food options provided, stating a preference for fish, cottage cheese, peas, and potato salad. Despite the resident's request for fish to be a daily option, the facility's menu only offered fish four times a month, failing to meet the resident's dietary needs. Observations and interviews revealed that the resident was served undercooked vegetables and rice that were too hard to consume, which did not align with her prescribed mechanical soft diet. The Kitchen Manager confirmed the inadequacy of the meal preparation and acknowledged the limited availability of fish options due to restricted order guides. Despite the Registered Dietician's acknowledgment that the resident could have fish daily, the updated care plan did not reflect any dietary interventions to provide fish daily, indicating a lack of follow-through in addressing the resident's dietary preferences.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roswell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Cobb Center For Nursing And Healing Llc | 4.8 mi | ★★★★★ | 5 | 0 |
| Sandy Springs Center For Nursing And Healing Llc | 8.8 mi | ★★★★★ | 11 | 0 |
| Pruitthealth - Brookhaven | 9.7 mi | ★★★★★ | 19 | 0 |
| Woodstock Center For Nursing And Healing Llc | 10.3 mi | ★★★★★ | 15 | 0 |
| Perimeter Rehabilitation Suites By Harborview | 10.4 mi | — | 25 | 1 |
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