Above 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 Candler Skilled Nursing Unit during CMS and state inspections, most recent first.
Incomplete Care Plans for Bed Rail Use: Three residents had bed rails in use without complete person-centered care plans addressing the devices. One resident with dementia and multiple chronic conditions, one resident admitted with tension pneumothorax, and one resident status post femur fracture repair all had bed rails observed in the up position, but the records showed no bed rail assessment and no physician order for the bilateral upper and lower rails. Staff confirmed the rails were being used for safety, positioning, mobility, or fall prevention, and one LPN stated the rails should have been included in the care plan.
A facility failed to ensure three residents were free from bedrail restraint. Residents with cognitive impairment and mobility limitations had no bed rail orders or assessments in the record, yet observations showed bilateral upper and lower bed rails up, including one resident with all four rails raised. An LPN stated the rails were used for safety and fall prevention, and the DON confirmed the lack of orders and assessments and that four raised rails were considered a restraint.
Infection control practices were not consistently followed during IV infusion, PICC dressing care, wound care, colostomy care, and dirty linen handling. An LPN, RN, DON, wound care nurse, and CNA were observed not wearing gowns when indicated by the facility’s own policies and not consistently performing hand hygiene or glove changes between dirty and clean tasks. Observations included improper sterile technique during a PICC dressing change, bare-hand handling of wound supplies, scissors kept in a pocket without cleaning, gloves worn outside the room, and soiled linens handled in contact with staff scrubs.
The facility failed to maintain sanitation standards in its kitchen, with discolored hand-washing sinks, scarred cutting boards, and dirty equipment and floors. Despite cleaning schedules indicating tasks were completed, the kitchen was found with food debris and grease. The Chef and NCM acknowledged the unsanitary conditions, and the Chef admitted to not replacing cutting boards. The previous DM's departure left the NCM and Chef without guidance on locating cleaning logs, leading to a failure in meeting food service safety standards.
Incomplete Care Plans for Bed Rail Use
Penalty
Summary
The facility did not fully develop or carry out a complete person-centered care plan for three sampled residents whose bed rails were being used without being addressed in the care plan. The facility’s policy titled Documentation of Patient Care stated that care plans address the primary reasons for admission and contain outcomes and interventions. For each of the three residents, the record showed no bed rail assessment and no physician order for the bilateral upper and lower bed rails that were observed in use. For one resident admitted with acute kidney injury on chronic kidney injury and multiple diagnoses including dementia, CKD, HTN, heart failure, and atrial fibrillation, the care plan dated 03/14/2026 did not address bed rails. The resident had a BIMS score of 06 and required partial to moderate assistance with bed mobility and transfers. A consent form for protective devices dated 03/12/2026 documented that side rail use was recommended for positioning and mobility, and observations on 03/24/2026, 03/25/2026, and 03/26/2026 showed bilateral upper and lower bed rails in the up position. Staff confirmed the rails were used because the resident was confused and for safety. For the resident admitted with tension pneumothorax, the care plan dated 03/18/2026 addressed restraints use as side rails times two, but the record had no order for bilateral upper and lower bed rails and no bed rail assessment. The resident had a BIMS score of 12 and required supervision or touch assistance for several transfers. Observations showed two upper rails and a left lower rail in use, and later bilateral upper and lower bed rails in the up position. For the resident admitted status post closed femur fracture repair, the care plan dated 03/19/2026 did not address bed rails, there was no bed rail assessment, and no physician order for bilateral upper and lower bed rails. The resident had a BIMS score of 11 and required partial to moderate assistance with transfers. Observations on multiple dates showed bilateral upper and lower bed rails in the up position, and an LPN stated the rails were used to prevent falls and should have been part of the care plan.
Bedrails Used Without Orders or Assessments
Penalty
Summary
The facility failed to ensure that residents R12, R40, and R41 were free from bedrail restraint. The facility policy stated that restraint use should be limited to clinically appropriate and adequately justified situations, and that bed rails were not considered restraints only when less than four were raised or when the patient could lower the rails when desired. However, for each of these residents, the record showed no physician order for bilateral upper and lower bed rails and no bed rail assessment in the chart. R12 was admitted with acute kidney injury on chronic kidney injury and had diagnoses including dementia, CKD, HTN, heart failure, and atrial fibrillation. The MDS documented severe cognitive impairment and need for partial to moderate assistance with bed mobility and transfers. A consent form for protective devices stated side rail use was recommended for positioning and mobility, but observations on multiple occasions showed bilateral upper and lower bed rails in the up position. During interview, R12 stated she wanted to get up and was yelling out. An LPN confirmed the rails were up and later stated the side rails were used for R12 because she was confused and for her safety, and that four rails were used when no one was at bedside. R40 was admitted with tension pneumothorax and had moderate cognitive impairment with supervision or touch assistance needed for some transfers. The record contained no bed rail order and no bed rail assessment, though a consent form documented two side rails as recommended equipment. Observations showed two upper rails and a left lower rail up, and later all four rails up. R40 stated he tried to move around in the bed and that they usually had all the bedrails up. R41 was admitted status post closed femur fracture repair and had moderate cognitive impairment with partial to moderate assistance needed for transfers. The record also lacked a bed rail order and assessment, while a consent form documented side rail use as recommended equipment. Observations repeatedly showed bilateral upper and lower bed rails in the up position, and an LPN stated the rails were used to prevent falls and was unsure whether consent was in place. The DON confirmed there were no bed rail orders or assessments for these residents and stated that bilateral upper and lower bed rails in the up position was considered a restraint.
Infection Control Practices Not Consistently Followed During IV Care, Wound Care, and Linen Handling
Penalty
Summary
The facility did not ensure that nurses consistently followed infection control practices during peripheral venous catheter infusions for two residents, peripheral catheter care for one resident, wound care for one resident, and bed-linen handling for two residents. Review of facility policies on Isolation Categories, Central Venous Catheters, and Hand Hygiene showed expectations for hand hygiene before and after glove use, before and after touching potentially contaminated articles, and for sterile technique during catheter dressing changes. One resident had severe cognitive impairment, acute kidney injury on chronic kidney disease, dementia, hypertension, atrial fibrillation, sepsis, and was receiving IV medications and antibiotics. During observation, an LPN prepared and administered meropenem through the resident’s PICC line without wearing a gown. During a later PICC dressing change, the DON and the LPN were observed preparing supplies without gowns. The DON used sterile gloves to remove the dressing and Biopatch, then used the same gloves to remove gray gloves from the wall box and apply them. She cleaned the site with an alcohol swab followed by a chlorhexidine swab using a back-and-forth motion, removed her gloves, sanitized her hands, and continued the dressing change. The DON later confirmed she should have had another pair of sterile gloves and acknowledged that she was not wearing a gown during the procedure. Another resident was receiving IV fluconazole through a peripheral venous catheter. An RN was observed administering the infusion without wearing a gown and stated she had never been instructed to wear one for that task. During wound care for another resident with wounds to the right calf, left ankle, and left calf, an RN was observed without a gown, sanitizing hands and applying gloves, removing dressings, cleaning wounds, applying Santyl directly from the tube, placing the tube on the pad under the resident, touching silver alginate with bare hands to cut it, and changing gloves without sanitizing hands between tasks. The RN acknowledged she did not do everything correctly and confirmed the Santyl tube and scissors had been placed on the field during the dressing change. During colostomy care for one resident, a wound care nurse was observed without a gown using scissors from her pocket to cut off the resident’s brief and returning the scissors to her pocket without cleaning them. She exited the room while still wearing gloves to get more supplies, then changed the resident after the colostomy leaked onto the bed and gown. She placed the top sheet, gown, and towel used to clean around the colostomy on the floor. In the same room, an RN entered without a gown, sanitized hands, applied gloves, rolled feces-soiled linen under the resident, tucked clean linens underneath the soiled linens, and placed a feces-soiled fitted sheet into the trash can. A CNA was also observed carrying dirty linens from another resident’s room with the linens in direct contact with her scrubs and placing them into a soiled-linen hamper after a meal tray had been placed on top of the hamper. The CNA stated linens should not contact her clothing and that there had not been a linen bag in the room.
Failure to Maintain Sanitation Standards in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as observed during a survey. The hand-washing sinks were discolored, and cutting boards in use were scarred and discolored, indicating they were not replaced as required by the facility's policy. Kitchen equipment, including preparation tables, shelves, drawers, stoves, grills, ovens, and refrigerators, were found with food debris, grease, and burnt food buildup. The ice machine and carts were also dirty, and the kitchen floors had food debris and discoloration. The facility's policies on sanitation and equipment cleaning were not effectively implemented. Although cleaning schedules from September 2024 to February 2025 indicated tasks were completed, the actual state of the kitchen contradicted these records. The contracted company had recently cleaned the equipment, but the daily cleaning logs were not available for review, and the Chef was unaware of their existence. The Nutritional Clinical Manager (NCM) and Chef acknowledged the unsanitary conditions, and the Chef admitted to not replacing cutting boards and being unaware of the last replacement date. Interviews revealed that the NCM rarely entered the kitchen, and the Chef, who had been employed for three months, was not fully aware of the cleaning procedures or the location of cleaning logs. The previous Dietary Manager had left a month prior, leaving the NCM and Chef without guidance on locating necessary documentation. The Chef stated that maintaining a clean kitchen was his expectation, but the observations indicated a failure to meet professional standards for food service safety, potentially placing residents at risk for foodborne illness.
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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 Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azalealand Nursing Home | 1.6 mi | ★★★★★ | 6 | 0 |
| Savannah Post Acute Llc | 2.1 mi | ★★★★★ | 2 | 0 |
| Riverview Health & Rehab Ctr | 2.8 mi | ★★★★★ | 11 | 0 |
| Thunderbolt Care Center Llc | 2.8 mi | — | 0 | 0 |
| Abercorn Rehabilitation Center | 4.4 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.