Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Resorts At Pooler Inc during CMS and state inspections, most recent first.
Food items in the kitchen and resident pantry were found without required labels, in-dates, or expiration dates, and several items were already expired. Surveyors observed undated bread, onions, bananas, hashbrowns, Brussels sprouts, hot chocolate, and tea, along with gravy that had passed its use-by date. In the resident pantry, an LPN confirmed expired snack cakes, potato salad past its best-if-used-by date, and another container of food with no date.
Dumpster Area Not Kept Free of Debris: The facility failed to keep the outdoor garbage and refuse area free of debris. A chair, bed frame, wheelchair, countertop, trash can, pallets, and other wood pieces were observed in the dumpster area, and the Maintenance Director confirmed the trash cans were open and that the items had been there for two to three days. He stated the items were not picked up with routine trash service and that Maintenance was typically responsible for keeping the area clean; the Administrator said she was not aware of the dumpster issues.
A resident with severe cognitive impairment, hemiplegia, and total incontinence was observed receiving incontinent care while the privacy curtain did not fully encircle the bed and her bare body below the waist was exposed to anyone entering the room. The resident stated staff never pulled the privacy curtains during ADL care and said she would feel embarrassed if someone walked in. The DON confirmed the CNAs failed to ensure privacy, and both CNAs acknowledged they did not fully pull the curtains around the bed.
A resident with stage 4 sacral pressure ulcer, paraplegia, and DM with diabetic autonomic polyneuropathy had multiple wound care products and an insulin glargine pen left on top of a table in the room, despite a self-administration evaluation showing the resident was not capable of self-administering meds and no order for self-administration. The resident said he could not apply wound treatment or give himself insulin, and the DON and an LPN confirmed the unsecured items were present in the room.
A resident with chronic respiratory failure with hypoxia had a physician order for oxygen at 2 L/min via NC continuously for SOB, and the care plan directed staff to provide oxygen as ordered. Observations showed the resident receiving oxygen at 2.5 L/min from an oxygen concentrator and later at 1 L/min from a portable oxygen cylinder, rather than the ordered flow rate. The MDS Coordinator stated staff were expected to follow the care plan and check the order before administering oxygen.
A resident with COPD and acute respiratory failure had a C-PAP mask left uncovered on the bedside table, with the DON and an LPN confirming it was not stored in a clean, labeled bag as expected. Another resident with shortness of breath and chronic respiratory failure had an order for oxygen at 2 LPM, but was observed receiving oxygen at 2.5 LPM from a concentrator and later at 1 LPM from a portable cylinder; an LPN confirmed the incorrect flow rate.
A resident with hypertension was administered Sotalol without the required blood pressure checks prior to each dose, as specified in the physician's order. An LPN confirmed not performing the checks, and the order was not properly entered into the electronic record to prompt this evaluation. The Regional DON acknowledged that the standard practice and physician's order were not followed.
A resident with osteomyelitis did not receive several scheduled doses of IV cefazolin because the order was not confirmed in the electronic record system, delaying pharmacy delivery. The pharmacy only became aware of the order after an urgent call from facility staff, and the medication was not administered until the order was properly confirmed. No adverse effects were documented.
A resident with hypertension was given Amlodipine Besylate even though physician orders required the medication to be held for systolic blood pressure below 130. Documentation showed the medication was administered on several occasions when the resident's blood pressure was under the specified threshold. Both an LPN and the DON confirmed that the medication should not have been given based on the recorded blood pressure readings.
A resident with a stage four pressure ulcer was not placed under Enhanced Barrier Precautions as required, and an LPN performed a dressing change using only gloves without a gown. No PPE was available in or outside the resident's room, and both the LPN and DON confirmed that EBP protocols were not followed during the observed care.
The facility failed to maintain an effective infection prevention and control program due to the absence of ongoing surveillance and documentation using the McGeer criteria for January and February 2024. The ICP, who took over the program in January, did not apply the criteria until March, despite being trained. The DON did not verify the use of the criteria, resulting in inadequate infection control measures.
The facility failed to ensure a clean and homelike environment in two halls, with issues such as stained ceiling tiles, dust on ventilation units, and broken sheetrock. Observations revealed cluttered and disorganized resident rooms, missing fixtures, and unsanitary conditions. Staff interviews indicated understaffing in housekeeping and ongoing maintenance issues, with the Administrator aware of the needed repairs.
The facility failed to provide written bed hold information to residents or their representatives during transfers to hospitals, as required by policy. This deficiency affected four residents, with transfer documents lacking details on bed hold rates and duration. Staff interviews confirmed the omission, with the DON acknowledging the absence of a separate bed hold agreement indicating room rates or requiring signatures.
A resident with multiple health conditions was found self-administering medications without a physician's order or proper assessment. The medications, including an inhaler and an injectable pen, were stored in an unlocked drawer at the bedside, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to procedures for self-administration and medication storage.
The facility failed to submit a PASRR Level II for a resident after a new schizophrenia diagnosis and did not implement PASRR Level II recommendations for another resident with serious mental illness. The Social Service Director did not submit the required screening, and the Unit Manager did not refer the resident to psychiatric services, despite the need for specialized services.
The facility failed to properly store oxygen equipment for two residents, as required by their policy. Observations showed that nebulizer masks were left uncovered and unlabeled, contrary to the procedure of placing them in plastic bags when not in use. The residents had significant respiratory conditions, and the Director of Nursing acknowledged the oversight.
Food Items Found Undated or Expired in Kitchen and Resident Pantry
Penalty
Summary
The facility failed to ensure food items were labeled, dated, and not beyond their expiration date in accordance with its Dietary Services policy and Food Storage Guide. During the initial kitchen tour, surveyors observed bread on a rack with no expiration date, two partial bags of opened bread with no open date or expiration date, a box of onions with no in-date or expiration date, two boxes of bananas without expiration dates, a container of gravy in the reach-in refrigerator with a use-by date of 12/3/2025, a box of hot chocolate with no expiration date, four boxes of tea with an expiration date of April 23, 2025, and frozen items including hashbrowns and Brussels sprouts that lacked required dates. The Dietary Manager confirmed that the tea and hot chocolate were past expiration and acknowledged that kitchen items should have in-dates and expiration dates. In the resident food pantry, surveyors found a pack of pre-packaged snack cakes with an expiration date of 10/11/2025, a container of food in a bag with no in-date or expiration date, and a container of potato salad with a best-if-used-by date of 11/16/2025. An LPN confirmed these findings. The Administrator later denied knowledge of problems related to labeling and dating in the kitchen or resident pantry and stated that the Housekeeping Supervisor typically checked the refrigerator and that items were discarded after three days.
Dumpster Area Not Kept Free of Debris
Penalty
Summary
The facility failed to ensure that the outdoor garbage and refuse area was free from debris. During observation of the dumpster area, a chair, a bed frame, a wheelchair, a countertop, a trash can, pallets, and other wood pieces were seen in the dumpster area. The Maintenance Director stated that the dumpsters were emptied every Monday, Wednesday, and Friday, confirmed that the trash cans were open and should have been closed, and reported that the bed frame, chair, countertop, trash can, wheelchair, and pallets had been at the dumpster site for two to three days. He also stated that someone normally picked up the items but had not been able to contact the person, that the refuse vendor would not pick up these items with routine trash pickup, and that the Maintenance Department was typically responsible for keeping the dumpster area clean. The Administrator stated she was not aware of dumpster issues related to the items around the dumpsters.
Failure to Maintain Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure resident privacy during incontinent care for one resident with significant care needs. Review of the resident’s EHR showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The Quarterly MDS dated 10/1/2025 documented a BIMS score of 3, indicating severe cognitive impairment, dependence for ADLs, and that the resident was always incontinent of bladder and frequently incontinent of bowel. During observation on 12/5/2025 at 9:21 a.m., two CNAs were providing incontinent care to the resident. The privacy curtain did not completely encircle the bed, and the resident was observed with no covering on her bare body below the waist, allowing exposure to other persons entering the room. The resident stated the staff never pulled the privacy curtains at the bottom of the bed during ADL care and that she would feel embarrassed if someone walked into the room while she was receiving incontinent care. The DON reviewed photographic evidence and confirmed the CNAs failed to ensure the privacy curtains were pulled completely around the bed. Both CNAs later confirmed they did not pull the curtains to ensure privacy, and one CNA stated she was unaware to pull the long curtain from the window to add privacy.
Unauthorized Medication and Wound Supplies Left at Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident, who had diagnoses including stage 4 sacral pressure ulcer, paraplegia, and type 2 diabetes mellitus with diabetic autonomic polyneuropathy, did not have unauthorized and unsecured medication and medicated treatment products at the bedside. The resident’s record showed physician orders for insulin and multiple wound treatments, and a self-administration evaluation dated 12/3/2025 determined the resident was not capable of self-administering medications. There was no order for medication self-administration. During a concurrent observation and interview on 12/5/2025 at 10:17 AM, surveyors observed one tube of silicone cream, one bottle of sodium hypochlorite solution, one bottle of antifungal powder, six antimicrobial dressings, one tube of ostomy paste, and one insulin glargine injection pen lying on top of the table inside the resident’s room. The resident stated he was unable to apply wound treatment or administer insulin himself and said the items had been on the table since he was admitted from the hospital. Later that day, the DON and an LPN both confirmed the medication and wound treatment products were on top of the table in the room, and the DON stated that medications and wound supplies brought from the hospital should be given to the nurse and not left unattended in the resident’s room.
Failure to Follow Oxygen Care Plan
Penalty
Summary
The facility failed to follow the plan of care for one sampled resident with chronic respiratory failure with hypoxia. The resident had a physician order dated 11/5/2025 for oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath, and the care plan included the intervention to provide oxygen as ordered. Observations showed the resident receiving oxygen at 2.5 liters per minute from an oxygen concentrator while lying in bed on 12/5/2025, and later receiving oxygen at 1 liter per minute from a portable oxygen cylinder while sitting in the dining room on 12/6/2025. During a telephone interview, the MDS Coordinator stated her expectation was for staff to follow the care plan and explained that providing oxygen as ordered meant nurses should check the order prior to administering oxygen because the order may change.
C-PAP Equipment Not Stored Properly and Oxygen Flow Rate Set Incorrectly
Penalty
Summary
Infection control measures were not followed for a resident with COPD, acute respiratory failure with hypoxia, and morbid obesity who used a C-PAP machine. The resident was cognitively intact with a BIMS score of 14 and had physician orders to use the C-PAP each evening, clean the mask and heater with soap and water, and store the equipment appropriately. During observation, the C-PAP machine and mask were found lying uncovered on the bedside table with no bag or cover nearby, and the resident stated staff had not covered it since admission. The DON confirmed the uncovered mask and stated her expectation was that the night nurses ensure the C-PAP mask had a clean, labeled bag and that day shift staff ensure the mask was covered when not in use. An LPN also confirmed the mask was uncovered and acknowledged responsibility for covering it. The facility also failed to ensure the oxygen flow rate was set correctly for a resident with shortness of breath and chronic respiratory failure with hypoxia. The resident had an order for oxygen at 2 LPM via nasal cannula continuously. On observation, the resident was receiving oxygen from a concentrator set at 2.5 LPM, and later was observed in the dining room receiving oxygen from a portable cylinder at 1 LPM. An LPN confirmed the oxygen was being delivered at 1 LPM and should have been 2 LPM. The DON stated the resident had no history of adjusting the oxygen flow rate and that staff were expected to follow the physician's orders when administering oxygen.
Failure to Obtain Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
The facility failed to follow professional standards of practice by not obtaining and documenting a blood pressure reading prior to administering a prescribed blood pressure medication to a resident diagnosed with hypertension. According to the physician's order, the medication Sotalol was to be held if the resident's systolic blood pressure was less than 110 or diastolic blood pressure was less than 70. However, review of the Medication Administration Record showed that the medication was administered multiple times without any documented blood pressure readings beforehand. Interviews with facility staff confirmed that the required blood pressure checks were not performed prior to medication administration. An LPN acknowledged not taking the resident's blood pressure before giving the medication and noted that the order was not correctly entered into the electronic record system, omitting the instruction to check blood pressure each time. The Regional Director of Nursing also confirmed that the nurse should have followed the physician's order to obtain the blood pressure prior to administering the medication.
Delay in Antibiotic Administration Due to Unconfirmed Pharmacy Order
Penalty
Summary
The facility failed to ensure that a physician-ordered antibiotic, cefazolin, was available and administered as scheduled for a resident diagnosed with osteomyelitis of the thoracic vertebra. The resident was admitted with this diagnosis and had a physician's order for intravenous cefazolin to be given every eight hours. However, review of the medication administration record showed that the first dose was not given until two days after the scheduled start date, and several scheduled doses were missed and not documented as administered. Interviews with facility staff and the pharmacist revealed that the delay occurred because the antibiotic order was not confirmed in the electronic record system, which prevented the pharmacy from processing and delivering the medication in a timely manner. The pharmacist stated that the pharmacy only became aware of the order after an urgent call from the facility, and the order was not transmitted until it was confirmed by a nurse. The DON explained that the facility's process requires a nurse to enter and another nurse to confirm the order in the system before the pharmacy can send the medication. The resident did not experience any documented adverse effects from the missed doses.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received a blood pressure medication, Amlodipine Besylate 5 mg, despite physician orders specifying the medication should be held if the resident's systolic blood pressure (SBP) was less than 130. Review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's documented SBP was below the ordered threshold, including readings of 111/92 and 123/75. The facility's policy required verification of physician orders and performance of necessary evaluations, such as blood pressure checks, prior to medication administration. Interviews with facility staff confirmed that the medication should not have been given based on the recorded blood pressure readings. The LPN could not explain why the medication was administered despite the low SBP, and the DON acknowledged that the medication should have been held according to the physician's order and facility policy. This failure resulted in the resident receiving unnecessary medication.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a resident with a stage four pressure ulcer, acquired while in the facility, was not placed under Enhanced Barrier Precautions (EBP) as required by facility policy. During a dressing change, an LPN was observed wearing only gloves and not a gown, which is mandated for wound care under EBP guidelines. Additionally, there was no personal protective equipment (PPE) available in or outside the resident's room for staff to access during care. Interviews with the LPN and the Director of Nursing confirmed that the resident should have been under EBP due to the open wound and that the appropriate PPE, including a gown, should have been used during the dressing change. The failure to follow EBP protocols was directly observed and acknowledged by staff, and the lack of accessible PPE further contributed to the deficiency.
Inadequate Infection Control Program Due to Lack of Surveillance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of ongoing surveillance, recognition, investigation, and control of infections for January and February 2024. The facility's policy on infection control outlined objectives such as preventing, detecting, investigating, and controlling infections, maintaining a safe environment, and keeping records of incidents and corrective actions. However, the facility did not adhere to these guidelines, as there was no documentation of infection surveillance using the McGeer criteria or any other standardized criteria during the specified months. Interviews with the Infection Control Preventionist (ICP) and the Director of Nursing (DON) revealed that the ICP, who took over the infection control program in January 2024, did not use the McGeer criteria until March 2024, despite having completed training on it. The ICP admitted to counting all infections and antibiotic use without applying the McGeer criteria. The DON, who trusted the ICP to use the criteria, did not verify the infection control documentation, leading to a lack of proper infection surveillance and control measures during the initial months of 2024.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike, and well-repaired environment for residents in two of its halls, Hall B and Hall C. Observations revealed multiple issues, including stained ceiling tiles, dust on ventilation units, dirty privacy curtains, and broken sheetrock in several rooms. Additionally, some rooms had missing or broken fixtures, such as a missing doorknob on a closet door and the absence of paper towel dispensers in bathrooms, leading to unsanitary conditions. Further observations highlighted clutter and disorganization in resident rooms, with items such as meal tray tops, bags of miscellaneous items, and cardboard boxes scattered throughout. Some rooms had visible damage to walls, including scraped marks and exposed sheetrock, while others had stained privacy curtains and unclean bathroom facilities. These conditions were confirmed during walking rounds with the facility's Administrator, Maintenance Director, and Housekeeping Supervisor. Interviews with facility staff revealed that the housekeeping department was understaffed, impacting their ability to maintain cleanliness and order. The Housekeeping Supervisor stated that rooms were deep cleaned daily, but the observations contradicted this claim. The Maintenance Director mentioned that repairs were prioritized and logged daily, yet several issues remained unresolved. The Administrator acknowledged the need for repairs and was in communication with the corporate office to address these deficiencies.
Failure to Provide Bed Hold Information During Resident Transfers
Penalty
Summary
The facility failed to provide written bed hold information to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for four residents who were transferred to hospitals or stabilization units. The facility's policy mandates that two notices related to bed hold policies be issued: one at admission and another at the time of transfer. However, the review of records for these residents revealed that the Notice of Transfer or Discharge forms did not include information about the rates at which the bed hold would be contingently held, nor did they specify when the bed hold would begin or end. Interviews with staff, including an LPN, a Unit Manager, and the Director of Nursing (DON), confirmed that the bed hold policy was not properly communicated. The LPN and Unit Manager indicated that the bed hold policy should be included in the transfer documents, but it was not. The DON stated that the bed hold information is documented at the bottom of the Notice of Transfer or Discharge form, but acknowledged that there is no separate bed hold agreement indicating the room rate or requiring a signature from the resident or their representative. This lack of proper documentation and communication could potentially lead to denial of re-admission and loss of the resident's home following hospitalization.
Unauthorized Medication Storage and Self-Administration
Penalty
Summary
The facility failed to ensure that unauthorized medications at the bedside were safely stored and did not obtain a physician order for a resident to self-administer medications. This deficiency was observed during a medication administration session involving a resident with multiple diagnoses, including pneumonia, COPD, type 2 diabetes mellitus, and others. The resident was found to have a BIMS score indicating cognitive intactness, yet a self-medication evaluation marked all questions as 'Can Not Do.' Despite this, the resident was self-administering medications brought from home, which were stored in an unlocked drawer at the bedside. During an observation, a plastic bag containing an Anoro Ellipta inhaler, an Ozempic pen-injector, and an albuterol inhaler was found in the resident's nightstand. The Ozempic pen was not stored in a refrigerator as required. Interviews with the LPN and the resident revealed that the medications were self-administered by the resident without proper assessment or physician orders. The facility's policies required a self-administration assessment and a physician's order for residents to self-administer medications, which were not followed in this case. Interviews with the DON and other staff confirmed that the resident had not been assessed to self-administer medications and that there were no physician orders for such. The staff was unaware of the medications being stored at the bedside, and the DON acknowledged that the medications should have been stored securely and the Ozempic refrigerated. The facility's failure to adhere to its policies placed the resident at risk for unsafe medication use.
Failure to Submit and Implement PASRR Level II
Penalty
Summary
The facility failed to submit a PASRR Level II for a resident after a new diagnosis of schizophrenia was added. The resident, who was admitted with anxiety disorder and depression, received a new diagnosis of schizophrenia, which was confirmed by the Director of Nursing (DON). However, the Social Service Director (SSD) did not submit the required PASRR Level II screening to the Georgia Medicaid Management Information System (GAMMIS) following this new diagnosis. This oversight was acknowledged by the SSD during an interview. Additionally, the facility did not implement the recommendations of a PASRR Level II for another resident who was admitted with multiple mental health diagnoses, including bipolar disorder and PTSD. Although the resident had a PASRR Level II indicating the need for specialized services for serious mental illness (SMI), no such services were being provided. The Unit Manager admitted that the resident was not referred to psychiatric services after admission, despite the expectation that residents requiring specialized services should receive them.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the safe storage of oxygen equipment for two residents receiving oxygen therapy, as observed by surveyors. The facility's policy, last reviewed on August 23, 2023, mandates that nasal cannulas or oxygen masks be placed in a plastic bag when not in use. However, observations revealed that a nebulizer mask for one resident was left uncovered on a recliner seat, and for another resident, the nebulizer mask was found unbagged and unlabeled on a chest of drawers and on a bedside table over two consecutive days. The residents involved had significant medical conditions requiring respiratory care. One resident was admitted with acute and chronic respiratory failure, pneumonia, and other related conditions, while the other had diagnoses including pneumonia, chronic obstructive pulmonary disease, and acute pulmonary edema. The Director of Nursing confirmed that the nebulizer masks should have been stored in plastic bags after each use and acknowledged the surveyor's observations of the deficiency.
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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 Pooler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Seaside | 5.6 mi | ★★★★★ | 12 | 0 |
| Savannah Post Acute Llc | 8.4 mi | ★★★★★ | 2 | 0 |
| Candler Skilled Nursing Unit | 10.5 mi | ★★★★★ | 3 | 0 |
| Abercorn Rehabilitation Center | 10.6 mi | ★★★★★ | 11 | 0 |
| Bryan County Hlth & Rehab Ctr | 11.7 mi | ★★★★★ | 12 | 0 |
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