Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Pruitthealth - Savannah during CMS and state inspections, most recent first.
A Discharge MDS assessment was not completed within the required timeframe for a resident who was discharged, as mandated by the RAI Manual. Review of facility records showed that 36 MDS assessments were overdue. RN MDS Coordinators confirmed the delays and acknowledged that assessments were still in progress despite shared duties and remote assistance.
The facility did not provide required written transfer and bed hold notices to residents or their representatives during emergent hospital transfers. Multiple residents experienced acute events such as falls, respiratory distress, and unresponsiveness that led to hospital transfers, but there was no documentation of written notification in their records. Staff interviews confirmed a lack of awareness and practice regarding these notifications, and the facility only had forms for planned discharges, not for emergency transfers.
Multiple medication administration errors occurred, including the use of incorrect supplements, failure to prime insulin pens as required, late administration of anticoagulant and antifungal medications, and the substitution of cetirizine for loratadine, resulting in a resident receiving two allergy medications. Staff interviews confirmed these errors and a lack of adherence to facility policy and physician orders.
A resident with multiple medical conditions did not have their care plan reviewed or revised at least quarterly, as required. The last care conference was documented nearly a year prior, and staff confirmed that team turnover led to delays in completing care plan conferences.
Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident who was discharged, as required by the Resident Assessment Instrument (RAI) Manual. The manual specifies that a Discharge MDS assessment must be completed within 14 days of discharge for all types of discharges, including those to a private residence. Record review showed that the resident was admitted and later discharged, but the required Discharge MDS was not completed within the mandated timeframe. Additionally, a review of the facility's current MDS assessments revealed that 36 assessments were not completed within the required time frames. Interviews with two RN MDS Coordinators confirmed that the Discharge MDS for the discharged resident was still in progress and overdue. The coordinators acknowledged that they were behind on completing assessments, even with the assistance of remote staff. It was confirmed that three MDS Coordinators share the responsibility for timely completion of MDS assessments, and that the facility follows the RAI Manual as policy. The deficiency was identified through staff interviews, record review, and examination of the facility's MDS assessment records.
Failure to Provide Written Transfer and Bed Hold Notices During Emergent Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold policies and transfer notices to residents or their representatives during emergent hospital transfers, as required by both facility policy and federal regulations. This deficiency was identified through resident and staff interviews, record reviews, and examination of the facility's policy on involuntary transfers and discharges. The policy specifies that, for emergency transfers or discharges, documentation must be made in the medical record, and a Notice of Involuntary Transfer and Discharge form must be provided to the resident, their representative, and the resident's physician as soon as practicable, with a copy kept in the medical record. Seven residents who experienced emergent transfers to the hospital were reviewed, and in each case, there was no evidence that a written notice of transfer or bed hold policy was provided to the resident or their representative. The medical records for these residents documented various acute events, such as falls resulting in injury, unresponsiveness, and respiratory distress, which led to their transfer to the hospital. Despite these events, the required written notifications were not found in the records, and in some cases, residents and their representatives confirmed they did not receive any written information regarding the transfer, its reasons, or their appeal rights. Interviews with facility staff, including an LPN, the Administrator, the Social Worker, and the Interim Director of Health Services, revealed a lack of awareness and practice regarding the provision of written transfer and discharge notices. Staff members stated they had never filled out such notices for hospital transfers and were unaware of the requirement until it was brought to their attention during the survey. The facility only had forms for 30-day discharges, which were not used for emergent hospital transfers.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and manufacturer recommendations, resulting in a medication error rate of 13.64 percent. During medication administration observations, staff were found to have administered medications incorrectly on multiple occasions. For example, one nurse administered an over-the-counter calcium with vitamin D3 supplement instead of the prescribed Citrical D3 Plus Mg-Zn-copper-manganese supplement, and both the nurse and an APRN confirmed that the two products were not interchangeable. In another instance, a nurse failed to prime an insulin pen before administering Humulin R insulin, contrary to both manufacturer instructions and facility policy, and only held the pen in place for two seconds instead of the required ten seconds. Additionally, medications such as Eliquis and Nystatin were administered outside of the scheduled times as ordered by the physician, with staff acknowledging the late administration due to being delayed by other resident care needs. Further errors included the administration of cetirizine to a resident who had an order for loratadine, resulting in the resident receiving two different allergy medications. The nurse involved confirmed the error and stated that there was no over-the-counter loratadine available, leading to the substitution. The Director of Health Services confirmed expectations for proper medication administration, including priming insulin pens and adhering to scheduled medication times.
Failure to Review and Revise Resident Care Plan Quarterly
Penalty
Summary
The facility failed to review and revise the care plan for one resident as required, specifically not conducting care conferences at least quarterly. According to the facility's policy, each resident should have a person-centered baseline care plan followed by a comprehensive care plan developed after the Minimum Data Set (MDS) and Care Area Assessment (CAA) are completed. For the resident in question, who was admitted with multiple diagnoses including a history of urinary tract infections, acute kidney failure, and generalized muscle weakness, the last documented care conference was held nearly a year prior to the survey. Staff interviews confirmed that there was no documentation of a care plan conference for this resident since the last recorded date. The MDS Coordinator acknowledged that turnover in the MDS and RAI teams contributed to delays in completing care plan conferences. As a result, the resident's care plan was not reviewed or revised in accordance with facility policy and regulatory requirements.
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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) |
|---|---|---|---|---|
| Abercorn Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 0 |
| Azalealand Nursing Home | 4.6 mi | ★★★★★ | 6 | 0 |
| Candler Skilled Nursing Unit | 4.6 mi | ★★★★★ | 3 | 0 |
| Riverview Health & Rehab Ctr | 4.8 mi | ★★★★★ | 11 | 0 |
| Oaks Health Ctr At The Marshes Of Skidaway Island | 4.9 mi | ★★★★★ | 7 | 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.