Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 - Seaside during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed unlabeled dried onions, opened and unlabeled cheese, expired milk, employee food and drink stored with food items, and a bag of chicken sitting in water. The oven and fryer were also coated with heavy grease buildup. The DM confirmed the findings and acknowledged the kitchen was not being kept clean.
Expired and improperly stored medications and supplies were found in multiple medication storage areas, including the 100-hall and 400-hall med carts, a treatment cart, and a medication room. Staff observed expired compound cream, expired oral glucose gel, an expired IV solution, expired sterile supplies, a loose pill in a med cart drawer, and inhalation vials that were unboxed, outside of foil, and had illegible labels. An RN, LPN, wound care nurse, DHS, and pharmacy consultant confirmed the findings and acknowledged that carts and storage areas were not consistently secured or maintained.
A resident’s physician order remained Full Code even though the POLST and care plan indicated DNR/Allow Natural Death. The resident’s record, admission care plan notes, and staff interviews showed the banner reflected DNR status, but the code status order had not been updated to match the signed POLST.
A resident with moderate cognitive impairment and dependence for transfers had a care plan calling for assistance with toileting and transfers, including two to three staff for mechanical lift use. During an observed transfer to a shower bed, one CNA attempted the lift transfer alone with no other staff present, and the resident was left suspended in the air until assistance was requested.
A RN failed to prime a new semaglutide pen before giving it to a resident with diabetes and CKD, despite the resident’s care plan calling for ordered medication administration and blood sugar monitoring. After the injection, the RN walked across the hall with an exposed used needle before placing it in a sharps container, and both the IP and DHS confirmed that the pen required priming and the needle should have been disposed of immediately in the sharps container.
A resident with moderate cognitive impairment and dependence for transfers was observed suspended in a mechanical lift while a CNA attempted to move the resident to a shower bed without another staff member present. The facility’s lift procedure required two staff, and interviews confirmed the CNA was transferring the resident alone until assistance was requested after the surveyor observed the event.
A resident with acute and chronic respiratory failure with hypoxia and COPD was ordered oxygen at 4 LPM via NC, but observations showed the oxygen set at 3.5 LPM on multiple occasions. The DON confirmed the setting was incorrect after reviewing the record and stated nurses should follow orders and check oxygen levels several times a day.
The facility did not maintain its HVAC systems in good repair, leading to elevated indoor temperatures and the use of multiple portable AC units throughout the building. Temperature logs showed readings above 81°F on several occasions, and residents had previously raised concerns about AC functionality. Staff interviews confirmed ongoing HVAC issues and delays in obtaining repairs, with the situation affecting the comfort and safety of all residents.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow proper procedures for labeling, dating, and storage of food items in the kitchen. During a tour of the kitchen with the Dietary Manager, surveyors observed containers of dried onions in the walk-in pantry that had not been labeled, bags of cheese in the walk-in freezer that were opened and not labeled, expired milk dated 4/8/2025, and employee personal food and drink items stored in the freezer. A bag of chicken was also observed sitting in water in the sink. The kitchen was also observed to have inadequate cleaning of equipment and food preparation areas. The oven had a buildup of dark, thick, greasy substances coating the outside walls and oven doors, and the fryer was coated with a dark brown greasy substance. The Dietary Manager confirmed the observations during the tour and stated that the kitchen was cleaned weekly, daily, and monthly, and that he tried to come in on weekends to do a deep cleaning. He also acknowledged that if things were not kept clean in the kitchen it could lead to food borne illness, cross contamination, and other health issues for residents.
Expired and Improperly Stored Medications and Supplies
Penalty
Summary
Drugs and biologicals were not consistently stored and labeled in accordance with facility policy and accepted professional principles. Review of the medication storage policy showed that medication rooms, carts, and supplies are to be locked or attended by authorized staff, and that nurses are required to check medications for deterioration and expiration before administration and inspect storage areas and carts. During observation of the 100-hall medication cart, staff found hydrocortisone 1%/nystatin/zinc oxide/lidocaine 2% compound cream that had expired, one loose pill in the bottom of a drawer, and a box of ipratropium bromide 0.5 mg with albuterol sulfate 3 mg inhalation solution with an illegible label. Additional inhalation vials were found unboxed and outside of foil packaging, and the RN confirmed the expired cream, the loose pill, and the illegible label. Further observations identified sterile heel foam and sterile gauze on a treatment cart that was left unsecured and unlocked, and the wound care nurse confirmed she had left the cart unlocked and unattended and that the items were expired. On the 400-hall medication cart, diabetic oral glucose gel was found expired, and in the medication room between the 200-hall and 300-hall, a bag of dextrose 5% with 0.9% sodium chloride IV solution was found expired. The DHS confirmed the expired IV solution and stated that expired items should be removed from medication carts, medication rooms, or treatment carts. The pharmacy consultant also confirmed that sterile items have expiration dates and that all items should have legible labels.
Physician Order Did Not Match POLST DNR Status
Penalty
Summary
The facility failed to ensure that the physician orders were consistent with the Physician Order for Life-Sustaining Treatment (POLST) for one resident with an advance directive code status of Do Not Resuscitate (DNR). Review of the resident’s record showed diagnoses including unspecified sequelae, depression, and generalized anxiety disorder. The care plan identified the resident as DNR with full treatment, and the goal stated that if the resident’s heart stopped or breathing stopped, CPR would not be initiated in honor of the resident’s DNR wishes. The POLST on file was signed by two physicians and the resident’s representative and indicated Allow Natural Death and DNR in the event of cardiopulmonary arrest. However, the physician order remained Full Code with a start date before discovery and an end date after discovery. Meeting notes from the admission care plan conference stated that DNR was chosen by the resident and that a POLST form had been placed on file. Staff interviews confirmed that the banner indicated the resident was DNR, while the physician order still showed Full Code, and the unit manager stated he was responsible for updating the code status after receiving and verifying the signed POLST.
Failure to Follow Care Plan During Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement the care plan for one sampled resident, R48, who had a Quarterly MDS showing a BIMS score of 10, indicating moderate cognitive impairment, and was dependent for transfers on Section GG. The care plan dated 1/5/2025 identified R48 as being at risk for falls related to a history of falls at home and use of an antidepressant for poor appetite. Interventions included assistance for toileting and transfers as needed, with two to three staff for transfer via mechanical lift. During an observation on 9/4/2025 at 9:36 a.m., R48 was observed suspended in the air via a mechanical lift in the doorway of the room while CNA DD attempted to transfer the resident to a shower bed positioned in front of the door. No other staff were present in the room during the transfer. After the surveyor discovered the situation, CNA DD asked the Medical Records Director for assistance with the transfer. The DHS stated in interview that staff were expected to follow the care plan and that the care plan should be updated in real time.
Failure to Prime Semaglutide Pen and Safely Dispose of Used Needle
Penalty
Summary
The facility failed to prime a semaglutide injection pen before administering it to a resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease type 2, and hemiplegia and hemiparesis following a cerebral infarction. The resident’s care plan identified a risk for hyper/hypoglycemia and directed staff to administer medications as ordered, check blood sugar before meals and at bedtime, monitor for signs and symptoms of hyperglycemia or hypoglycemia, and notify the medical provider of abnormal results. During an observation and interview, the RN obtained a new semaglutide pen, turned the dial to the ordered dose, and administered the medication without priming the pen. The RN stated she forgot to prime the pen and acknowledged that it should be primed every time. The facility also failed to dispose of the used needle safely after the injection. After administering the medication, the RN walked from the resident’s room across the main hall to the medication cart with the exposed used needle pointed outward before placing it in a sharps container. The RN stated she walked down the hall with an exposed used needle and said the policy was to pull the cart near the door and then throw the needle away in the sharps container. The IP/Clinical Competency Coordinator and the DHS both confirmed that insulin pens required priming and that needles were to be disposed of in the sharps container, with the cart positioned at the doorway so the sharps container would be nearby. The DHS acknowledged that walking down the hallway with an exposed needle was dangerous.
Unsafe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical lift. The facility procedure titled, "Transferring a Resident Using a Mechanical Lift," stated that the lift is a two-person device and that one caregiver should not use it alone. The resident involved had a Quarterly MDS showing a BIMS score of 10, indicating moderate cognitive impairment, and was dependent for transfers. The care plan identified the resident as at risk for falls and directed assistance for toileting and transfers as needed with two to three staff for transfer via mechanical lift. During observation, the resident was suspended in the air via a mechanical lift in the doorway of the room while a CNA attempted to transfer the resident to a shower bed positioned in front of the door. No other staff were in the room with the CNA during the transfer. After the surveyor discovered the situation, the CNA asked the Medical Records Director for assistance. Interviews confirmed that the CNA had been transferring the resident alone, that the second person was not present throughout the transfer, and that staff understood two people were required the entire time a resident was being transferred using a mechanical lift. The LPN in the room stated she was administering medications to the roommate and did not assist with the lift transfer.
Failure to Follow Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to follow a physician order for oxygen therapy for one resident with diagnoses including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident’s record showed an order for oxygen at 4 liters per minute via nasal cannula at 9 pm, and the most recent MDS indicated the resident required oxygen therapy and had a BIMS score of 14, showing little to no cognitive impairment. Observations on 9/2/2025 and 9/3/2025 showed the resident receiving oxygen at 3.5 liters per minute via nasal cannula instead of the ordered 4 liters per minute. During an observation and interview, the DON confirmed the oxygen was set at 3.5 liters per minute but should have been set at 4 liters per minute after checking the medical record. The DON stated nurses should follow orders and that oxygen levels should be checked several times a day to ensure residents were receiving the correct amount of oxygen.
Failure to Maintain Functional HVAC Systems Resulting in Elevated Indoor Temperatures
Penalty
Summary
The facility failed to ensure that its heat and air-conditioning systems were in working order and properly maintained, resulting in the use of multiple portable AC units throughout the building. Observations revealed that temperatures in various areas of the facility, including hallways and common spaces, ranged from 75 to 81 degrees Fahrenheit, with temperature logs documenting readings as high as 85.6 degrees Fahrenheit on several occasions. Despite the presence of portable AC units, some residents were observed using blankets or personal fans, but none reported feeling hot or uncomfortable during interviews. Resident Council minutes indicated prior concerns about AC functionality during the summer months. Staff interviews confirmed that the facility had ongoing issues with the HVAC system, with the Maintenance Director and Administrator both acknowledging delays in obtaining new units and parts. The Ombudsman reported that residents had expressed frustration with recurring heat issues in previous years, and the Director of Health Services noted that AC problems were a yearly occurrence. The facility's temperature monitoring practices included regular checks by staff, but the persistent HVAC deficiencies had the potential to affect the safety, comfort, and functional conditions for all residents.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resorts At Pooler Inc | 5.6 mi | ★★★★★ | 6 | 0 |
| Savannah Post Acute Llc | 7.7 mi | ★★★★★ | 2 | 0 |
| Candler Skilled Nursing Unit | 9.2 mi | ★★★★★ | 3 | 0 |
| Azalealand Nursing Home | 10.6 mi | ★★★★★ | 6 | 0 |
| Thunderbolt Care Center Llc | 10.9 mi | — | 0 | 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.