Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Savannah Post Acute Llc during CMS and state inspections, most recent first.
A resident with bilateral PE, DVT, stroke, and HTN had a care plan that called for medication administration and documentation of side effects and effectiveness, but the MAR and clinical record showed no documented monitoring for side effects from Eliquis. The NP stated residents on anticoagulants need monitoring for medication side effects, and the DON confirmed nurses were expected to follow the care plan and that no such documentation was present.
Phenytoin was administered at the same time as a high-protein house supplement for a resident at risk for seizures. An LPN gave both together during med pass, while the MAR showed the Dilantin and supplement were scheduled close enough to overlap. The pharmacy consultant stated Dilantin should be separated from the supplement, and the resident’s phenytoin level was below the normal range.
A respiratory nurse technician provided tracheostomy care to a resident with an indwelling medical device without wearing a gown, as required by the facility's Enhanced Barrier Precautions policy. Although the technician wore a mask and gloves, the omission of a gown was inconsistent with posted signage and staff expectations, resulting in a failure to adhere to infection control protocols.
A resident with morbid obesity and muscle weakness, requiring maximal assistance with toileting and always incontinent, was repeatedly provided with incontinence briefs that were too small due to supply shortages. This led to leakage, embarrassment, and the need for additional bathing. Staff and supply personnel confirmed the shortage of the correct size briefs and the use of improperly sized products, resulting in a failure to maintain the resident's dignity.
A resident with significant cognitive and medical impairments reported a sexual abuse allegation to a nurse, who documented the incident in the progress notes but did not notify other staff or the Administrator. This resulted in the allegation not being reported to the State Agency within the required timeframe, contrary to facility policy.
A resident who was transferred to the hospital on two occasions did not receive a written bed hold notice as required by facility policy. Although an LPN included a blank bed hold policy in the transport packet, nothing was given directly to the resident. The DON confirmed that the resident should have received written notification at the time of each transfer, but no documentation was found.
A resident's MDS assessment was not accurately coded to reflect a PASRR Level II evaluation and associated serious mental illness, despite documentation of relevant diagnoses and an existing PASRR Level II approval. The MDS Coordinator was unaware of the resident's PASRR Level II status, leading to the deficiency.
A resident with documented bipolar disorder and anxiety disorder was not referred for a required PASRR Level II assessment. Review of the MDS and EMR confirmed the absence of the assessment, and the administrator verified that the necessary submission had not been made.
The facility did not develop or implement person-centered care plans for oxygen therapy as required, resulting in one resident lacking oxygen interventions in their care plan and two residents receiving oxygen at higher flow rates than ordered. Staff confirmed that care plan interventions were not addressed or followed, despite physician orders and documented care needs.
A resident with significant lower extremity impairment and a care plan requiring leg elevation was repeatedly observed in a wheelchair without a leg rest or footrest, leaving his right leg unsupported. The resident could not attach the device independently and did not receive staff assistance, despite staff acknowledging the necessity of the support due to his medical conditions.
Three residents with respiratory conditions were administered oxygen at flow rates higher than those ordered by their physicians. Staff, including an RT and LPN, acknowledged the discrepancies, and the DON confirmed that oxygen was not provided according to orders. Facility policy required verification and adherence to physician orders for oxygen administration.
Several residents with intact cognition reported not being offered meal choices when eating in their rooms, receiving only the meal provided or a peanut butter and jelly sandwich as an alternative. Observations showed discrepancies between posted menus, tray tickets, and actual meals served, with residents not informed of their options. The Dietary Manager and Administrator confirmed these practices did not align with facility policy.
A resident with dementia and cognitive impairments exhibited wandering and exit-seeking behaviors, but the facility failed to include these issues in the care plan until after the resident eloped. The facility's policy requires comprehensive care plans, but staff confirmed the absence of interventions for elopement prior to the incident.
A resident with dementia and cognitive impairments eloped from the facility and was unaccounted for over an hour due to inadequate supervision and failure to follow the elopement risk policy. The resident exhibited exit-seeking behavior, but no elopement risk assessment or alarm was in place. The front door was not properly secured, and staff were not consistently present to monitor it, allowing the resident to exit unnoticed.
The facility failed to ensure adequate nursing staff for the first quarter of 2024, resulting in a One-Star Staffing Rating due to issues such as failure to submit PBJ data by the deadline and more than four days without RN staffing hours. The deficiency had the potential to adversely affect the care and services provided to the 109 residents.
The facility failed to ensure that three of four Certified Medication Aides (CMAs) completed a Medication Administration Competency Skills Checklist before administering medications to residents. Interviews and document reviews revealed missing competency checklists, and both the Director of Nursing (DON) and Administrator were unaware of the oversight.
The facility failed to maintain kitchen cleanliness and equipment maintenance, with observations of grease buildup, rust, and expired quaternary test strips. Interviews revealed a lack of a cleaning schedule and inadequate deep cleaning. The VP of Clinical Operations confirmed the deficiencies and emphasized the need for proper maintenance.
The facility failed to maintain the outdoor garbage and refuse area in a sanitary manner, with two dumpsters found open and surrounded by uncompressed empty boxes and visible trash bags. The District Manager confirmed that the previous day's dumpster pick-up had not been made, and the kitchen staff was responsible for maintaining the dumpsters.
The facility failed to ensure proper infection control practices were followed during a COVID-19 outbreak. Staff did not change masks when entering and exiting COVID-19 TBP rooms and left TBP room doors open, despite the facility's policies. Interviews revealed a lack of awareness and adherence to these policies.
The facility failed to periodically review antibiotic prescribing practices and did not document follow-up measures for infection control data over 12 months. The Antibiotic Stewardship Log lacked documentation, and the Antibiotic Medications Reports did not include necessary details such as organism susceptibility or if infections met McGeers criteria. The DON confirmed that trending, surveillance, and monthly infection control meetings were not conducted.
The facility failed to designate a qualified Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. Infection tracking and trending were not completed since November 2023, and monthly infection control meetings were not conducted. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program.
The facility failed to complete 42 out of 101 grievance forms, resulting in unresolved grievances and dissatisfaction among residents. Interviews revealed that residents did not receive follow-up or resolution for their grievances, and some were unaware of the grievance process. The Administrator confirmed the ineffectiveness of the grievance process.
The facility failed to ensure that three residents did not have unsecured and unauthorized medication or medicated treatment products at their bedside. Medications were found unsecured in the rooms of residents who had not been assessed for self-administration, posing potential risks. Staff were unaware of the presence of these medications, and the DON confirmed that no residents had been assessed for safe self-administration.
The facility failed to post a complete listing of how to report abuse, including necessary contact details and instructions. Observations revealed the posted information only included a phone number. Most residents were unaware of what to report or how to report it, and the DON confirmed the posting lacked essential details.
The facility failed to report the misappropriation of property to the State Survey Agency for two residents who were investigated for abuse. Both residents reported missing money, but the grievances were not reported to the State Agency as required by the facility's policy. Interviews revealed that the facility did not follow its reporting process.
The facility failed to thoroughly investigate abuse and misappropriation allegations for four residents. Key personnel were not informed, and proper procedures for investigation and documentation were not followed, leaving residents without resolution or communication regarding their concerns.
The facility failed to develop or implement comprehensive care plans for three residents, leading to potential risks for medical complications and unmet needs. One resident lacked a care plan for contracture management and had undocumented oxygen therapy. Another resident's dialysis care plan was not followed due to missing communication forms. A third resident did not have a care plan for oxygen therapy despite relevant diagnoses. The DON and an LPN confirmed these deficiencies.
The facility failed to provide scheduled baths or showers for a resident with multiple diagnoses, including muscle weakness and bilateral below-the-knee amputations. Despite the resident's care plan indicating the need for supervision with minimal assistance for ADL care, documentation revealed that the resident only received two showers in the past 25 days. Interviews confirmed the resident had not received a shower in two weeks, and the Director of Nursing acknowledged the failure to adhere to the bathing schedule.
A resident readmitted with multifocal pneumonia did not receive prescribed Levaquin due to a failure in transcribing the medication order. The delay in administering the antibiotic was acknowledged by both the LPN and DON, who confirmed the oversight and lapse in care.
A resident with limited ROM did not receive the necessary PROM exercises and splint application as required by her condition. Staff were unaware of the resident's needs, and the facility's policy on contracture management was not followed, resulting in the resident not receiving the necessary care to prevent worsening contracture.
The facility failed to provide proper respiratory care for four residents, including not ensuring current physician's orders for oxygen therapy, not maintaining clean oxygen concentrators and filters, not providing humidification for oxygen therapy, and not documenting daily tracheostomy inner cannula changes. Staff interviews confirmed these deficiencies.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring dialysis services. Despite a policy mandating the completion and submission of dialysis communication forms, the forms were missing and not being sent to the dialysis clinic. Staff interviews confirmed the deficiency, and the dialysis clinic had stopped following up after repeated failures to receive the forms.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to implement a care plan to monitor for adverse effects from anticoagulant medication for one resident with diagnoses including bilateral pulmonary embolism, deep vein thrombosis, stroke, and hypertension. The resident’s quarterly MDS documented these active diagnoses, and the care plan, initiated for bilateral pulmonary embolism and deep vein thrombosis, included interventions to administer medications as ordered and document side effects and effectiveness. The resident’s MAR showed an order for Eliquis 5 mg, two tablets twice a day for 7 days, then 5 mg one tablet twice a day for 100 days. Review of the MAR and clinical record found no documented monitoring for side effects from Eliquis. The NP stated that a resident receiving an anticoagulant would need to be monitored for medication side effects, and the DON confirmed nurses were expected to follow the care plan and that there was no documentation of monitoring for side effects from the anticoagulant.
Phenytoin Given With High-Protein Supplement
Penalty
Summary
The facility failed to ensure that phenytoin was not administered at the same time as a high-protein supplement for one resident who was at risk for seizure activity. The resident’s care plan identified seizure risk, and the MAR showed Dilantin Infatabs 50 mg chewable tablets ordered three times daily at 9:00 a.m., 2:00 p.m., and 9:00 p.m., while a house supplement was ordered twice daily at 10:00 a.m. and 2:00 p.m. The MAR documented both medications as administered as ordered from 10/1/2025 through 10/22/2025, with the supplement consumed at 50 to 100 percent. During medication pass observation, an LPN administered Dilantin and the house supplement to the resident at the same time. The pharmacy consultant stated the house supplement had high protein levels and that Dilantin should be given one hour before or two hours after the supplement. The resident’s lab results showed a phenytoin level of 9.5 ug/ml, below the normal range of 10 to 20 ug/ml. The DON stated there were no safety alerts in place for contraindications, and the Administrator stated medication schedules were entered by the nurse or nurse practitioner and the pharmacy made recommendations for medications.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that respiratory staff followed infection control practices during tracheostomy care for a resident with a tracheostomy. According to the facility's Enhanced Barrier Precautions (EBP) policy, staff are required to wear gowns and gloves during high-contact care activities, such as tracheostomy care, for residents with indwelling medical devices. Observation revealed that the respiratory nurse technician provided tracheostomy care to a resident who was dependent for activities of daily living and had multiple diagnoses, including respiratory failure, without wearing a gown as required by the EBP protocol. The technician wore only a mask and gloves during the procedure, despite signage on the resident's door indicating the need for both gown and gloves. Interviews with staff confirmed inconsistent understanding and implementation of the EBP requirements. The respiratory nurse technician stated that he wore a gown only for residents on contact isolation precautions, not for those on EBP, while another respiratory nurse technician and the Director of Nursing both indicated that a gown should be worn during tracheostomy care for residents on EBP. This inconsistency in following established infection control protocols led to the deficiency identified during the survey.
Failure to Provide Correct Size Incontinence Briefs Compromises Resident Dignity
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced the dignity and respect of a resident who required maximal assistance with toileting hygiene and was always incontinent of bladder and bowel. The resident, who had diagnoses including morbid obesity and muscle weakness, reported that the facility often ran out of the correct size incontinence brief, resulting in the use of a smaller size that caused leakage. This situation led the resident to feel embarrassed and to request a bath each time leakage occurred. Staff interviews confirmed that residents were measured for brief size and that there were occasions when the correct size was unavailable, leading to the use of briefs from other residents' supplies, which might not fit properly. The Central Supplies Clerk acknowledged that the facility was running out of the 3x-size briefs, and the Administrator was aware that the resident was receiving a smaller brief than needed. The care plan for the resident included regular checks and provision of incontinence care, but the lack of appropriate supplies resulted in a failure to uphold the resident's dignity.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. According to the facility's policy, any allegation of neglect, exploitation, mistreatment, or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. However, a review of the clinical record and incident report revealed that a resident, who was unable to complete a cognitive interview and had diagnoses including schizophrenia, diabetes mellitus with hyperglycemia, and muscle weakness, reported to the nurse's station that a man was in her room and attempted to sexually assault her. The nurse who received this report only documented the incident in the progress notes and did not notify other staff or the Administrator. As a result, the allegation was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing confirmed that the delay occurred because the nurse failed to follow reporting procedures, and the Administrator acknowledged that the incident was not reported as required by policy. There was no documentation indicating that the abuse allegation was communicated to appropriate personnel or authorities in a timely manner.
Failure to Provide Written Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to one resident during two separate transfers to the hospital. According to the facility's Bed Hold and Returns Policy, residents and their representatives are to receive written information prior to transfer that details their rights and limitations regarding bed holds, the reserve bed payment policy, and the facility per diem rate for holding a bed. Review of the resident's clinical record showed no evidence that such a notice was provided during either transfer. The resident, who was cognitively intact and acted as his own responsible party, confirmed in an interview that he did not receive a written bed hold notice on either occasion. Staff interviews revealed that the process for providing bed hold information was not consistently followed. An LPN stated that while she included a blank bed hold policy in the packet sent with transport, she did not provide anything in writing directly to the resident. The DON confirmed that the resident should have received a written bed hold policy at the time of each transfer and acknowledged that there was no record of this occurring for the resident in question.
Inaccurate MDS Coding for PASRR Level II Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a Pre-Admission Screening and Resident Review (PASRR) Level II. Review of the resident's annual MDS indicated that Section A did not reflect that the resident had been evaluated by Level II PASRR and determined to have a serious mental illness or related condition, despite Section I documenting diagnoses such as anxiety disorder, depression, and bipolar disorder. Further review of the electronic medical record confirmed the resident's admission and a PASRR Level II approval date. During staff interview, the MDS Coordinator acknowledged being unaware of the PASRR Level II approval for the resident, resulting in the inaccurate coding on the MDS.
Failure to Complete PASRR Level II Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of bipolar disorder with psychotic features and anxiety disorder received a required Pre-Admission Screening and Resident Review (PASRR) Level II assessment. Review of the resident's Annual Minimum Data Set (MDS) and electronic medical record (EMR) showed no evidence of a PASRR Level II evaluation, despite documentation of serious mental illness. The resident was not included on the facility's list of individuals with PASRR Level II, and the administrator confirmed that no submission for the assessment had been made, even though it was required based on the resident's diagnoses.
Failure to Develop and Implement Person-Centered Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for residents receiving oxygen therapy, as required by their own policy. For one resident with diagnoses including COPD and acute respiratory failure with hypoxia, the care plan did not include any interventions for the use of oxygen, despite a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Observations showed this resident was receiving oxygen at a higher flow rate of 3.5 LPM. For two other residents with similar respiratory diagnoses and physician orders for oxygen at 2 LPM, care plans did include interventions for oxygen use, but staff did not follow these interventions, as both residents were observed receiving oxygen at 3.5 LPM instead of the ordered rate. Staff interviews confirmed that the care plan interventions were not addressed or followed for these residents, and the MDS Coordinator acknowledged that the care plan serves as a blueprint for nursing care. The failure to develop and implement appropriate, individualized care plans for oxygen therapy was identified through review of medical records, care plans, physician orders, and direct observation of care.
Failure to Provide Wheelchair Leg Rest Support for Resident with Lower Extremity Impairment
Penalty
Summary
A resident with multiple medical conditions, including peripheral vascular disease, a stage four pressure ulcer, contracture of the right knee, hemiplegia, and an above-knee amputation, was observed on several occasions sitting in a wheelchair without a supportive leg rest or footrest. The resident was seen propelling himself in the hallway and sitting in various areas of the facility with his right lower extremity elevated and unsupported, despite having a care plan intervention to elevate his legs when sitting. The resident reported that he had a leg rest with an attached footrest but was unable to attach it himself and did not receive assistance from staff. Staff interviews confirmed that the resident should not be positioned in his wheelchair without the leg rest/footrest due to his medical conditions, including an ankle ulcer and contracture. The DON stated she was unaware that the device was not attached and that it was the responsibility of nursing staff to ensure the leg rest/footrest was applied daily. The failure to provide and secure the supportive device as required resulted in the resident repeatedly being left without necessary support for his lower extremity.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy to three residents in accordance with physician orders. For one resident with COPD and acute respiratory failure, observations showed oxygen was delivered at 3.5 LPM via nasal cannula, despite a physician order for 2 LPM continuously. Another resident with COPD was observed receiving oxygen at 4.5 LPM, while the physician order specified 2 LPM. The respiratory therapist acknowledged increasing the flow rate due to a low oxygen saturation reading but confirmed this was not per the physician's order. The Director of Nursing confirmed that both residents were receiving oxygen at incorrect flow rates and stated that staff should not alter oxygen flow without a physician's order. A third resident, with COPD and chronic respiratory failure, was observed receiving oxygen at 3.5 LPM, though the physician order was for 2 LPM. The resident reported that the oxygen had been set at 3.5 LPM since admission, and a nurse confirmed the discrepancy between the order and the administered flow rate. The nurse also stated that it was the responsibility of nursing staff to ensure the correct oxygen flow rate. These findings were based on observations, staff interviews, and review of medical records and facility policy.
Failure to Offer Meal Choices and Follow Menus
Penalty
Summary
The facility failed to ensure that residents were offered meal choices and that menus were followed as required by policy. Multiple residents with little to no cognitive impairment reported that when they received meals in their rooms, they were not given a choice of food, and the only alternative offered was a peanut butter and jelly sandwich. Residents stated they received whatever the facility provided without being informed of the menu or given an opportunity to select their meals. This lack of choice was specifically noted for residents who ate in their rooms, while those who ate in the dining room were able to make meal selections. Additionally, there were discrepancies between the meals listed on the posted menus, the meal tray tickets, and the actual food served to residents. For example, one resident was served meals that did not match either the tray ticket or the posted menu on two separate occasions. The Dietary Manager confirmed that residents receiving meals in their rooms were not informed of their meal options and could not explain the inconsistencies between the posted menus, tray tickets, and meals served. The Administrator acknowledged that all residents should be informed of the menu and offered alternatives, and that the posted meals should be served as written.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of wandering and exit-seeking behaviors, which increased the potential for the resident not to receive appropriate treatment and care. The facility's policy on Person Centered Care Plans mandates that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, addressing their physical, psychosocial, and functional needs. However, the resident's care plan lacked focus areas, goals, or interventions for wandering or elopement until after an incident occurred. The resident, diagnosed with dementia and other cognitive impairments, exhibited wandering behavior and exit-seeking tendencies, as documented in the clinical records and staff interviews. Despite these behaviors being noted, the care plan did not include interventions for elopement until after the resident was found outside the facility. Interviews with the Director of Nursing, the Administrator, and the MDS Coordinator confirmed the absence of a care plan addressing these behaviors prior to the incident, highlighting a delay in assessing the resident for elopement risks.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight to prevent the elopement of a resident diagnosed with dementia and other cognitive impairments. The resident, identified as R1, was able to exit the facility and remain unaccounted for by staff for over an hour. The facility's policy on elopement risk and prevention was not followed, as no elopement risk assessment was completed for R1 prior to the incident, despite documented behaviors indicating a risk of wandering and exit-seeking. On the day of the incident, R1 exhibited increased agitation and confusion, expressing a desire to leave the facility and return home. Staff interviews revealed that R1 had a history of asking to go home and had been confused for several months. Despite these behaviors, no wander or elopement alarm was used for R1, and the resident was able to leave the facility through the front door, which was not properly secured. The front exit door had a delay in latching, and staff were not consistently present to monitor the door, allowing R1 to exit unnoticed. Interviews with staff indicated a lack of training and awareness regarding elopement prevention. The receptionist, who was responsible for monitoring the front door, was not present at the time of R1's exit, and the door was not locked. Maintenance staff were unaware of the door's malfunction until after the incident. The Director of Nursing confirmed the delay in assessing R1 for elopement risk, and the facility's failure to ensure staff presence at the front door contributed to the resident's unsupervised departure.
Inadequate Nursing Staff for Q1 2024
Penalty
Summary
The facility failed to ensure adequate nursing staff for the first quarter of 2024, as evidenced by a review of the Payroll-Based Journal (PBJ) Staffing Data Report and the Facility Assessment Tool 2024. The PBJ Staffing Data Report for Quarter 1 2024 revealed that the facility triggered a One-Star Staffing Rating due to several issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The Facility Assessment Tool 2024 indicated that the average daily census was 106 to 109 residents, and the staffing plan documented the number of staff available to meet residents' needs, which included eight licensed nurses for days and four for evenings, 12 CNAs for days and eight for evenings, four to six CNAs for nights, and one to two CMTs available for care during those shifts. Interviews with the Director of Nursing (DON) and the Nursing Scheduler (NS) III revealed that they were aware of the facility's one-star staffing rating for the first quarter of 2024, attributing it to the facility's high turnover rate and reliance on staffing agencies. The Administrator also acknowledged awareness of the one-star staffing rating. The deficient practice had the potential to adversely affect the care and services provided to the 109 residents residing in the facility.
Failure to Ensure Medication Administration Competency for CMAs
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) met professional standards of quality by not providing evidence that three of four CMAs completed a Medication Administration Competency Skills Checklist before being allowed to administer medications to residents. This deficiency was identified through staff interviews and a review of facility documents, which revealed that the required competency checklists were missing for the majority of the CMAs employed at the facility. The facility's document titled Certified Medication Aide Bi-Annual Checklist indicated that an RN or Pharmacist should conduct an annual competency assessment, but this was not adhered to for three of the four CMAs reviewed. Interviews with the CMAs and the Director of Nursing (DON) confirmed the lack of completed competency checklists. One CMA stated she had only been observed once by a consultant pharmacist since being hired, while another CMA reported not having completed any medication administration skills checkoff. The DON acknowledged awareness of the requirement but could not provide additional information or documentation to confirm the completion of the checklists. The Administrator was also unaware that the CMAs had not completed the required checkoffs, indicating a lapse in oversight and adherence to the facility's own policies and procedures.
Kitchen Cleanliness and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen walls, floors, and equipment were clean and free of rust, debris, and grease buildup, and also failed to use un-expired quaternary test strips in the three-compartment sink. Observations revealed a sticky, brown, greasy substance and debris behind the oven and surrounding area, a dusty ventilation unit on the juice machine, and a build-up of rust and dust on the fire extinguisher located next to the handwashing sink. Additionally, water puddles were observed on the floor near the three-compartment sink, and the water from the handwashing sink would not turn off completely. The Food Service Manager (FSM) confirmed these observations. Expired quaternary test strips were also found in use at the three-compartment sink, which was confirmed by the FSM. Interviews with dietary aides revealed a lack of a cleaning list or schedule, and it was noted that water was usually present on the floor around the sinks. The FSM stated that although staff did a lot of scrubbing and cleaning, the grease and grime buildup was due to the old building. Dietary aides confirmed that they had never seen anyone clean the ventilation units or filters, nor had they observed deep cleaning or repairs in the kitchen. During a walk-through, the VP of Clinical Operations confirmed that the kitchen was not clean and needed deep cleaning, and that the fire extinguisher near the hand-washing sink needed cleaning. The VP expressed expectations that dietary staff should maintain cleanliness in the kitchen and ensure all equipment is in good working condition.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was free of litter and maintained in a sanitary manner for two of two dumpsters. During an initial observation, the Food Service Manager and the District Manager verified that the dumpsters were open and filled with visible black trash bags and boxes. Additionally, uncompressed empty boxes were found surrounding the dumpsters. The District Manager and FSM confirmed that the dumpsters should have been closed and free of trash or boxes on the ground around them. In an interview, the District Manager confirmed that the previous day's dumpster pick-up had not been made, and the Maintenance Director had called for an alternative pick-up. The District Manager also confirmed that maintaining the dumpsters was the kitchen staff's responsibility. The facility's policies on garbage disposal and environmental maintenance were reviewed, revealing that the procedures were not followed as required, leading to the observed deficiencies.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices were followed to prevent the transmission and spread of COVID-19. Specifically, staff did not change their masks when entering and exiting COVID-19 Transmission-Based Precaution (TBP) rooms and did not close the doors of two COVID-19 TBP rooms during care. Observations revealed that staff, including a Restorative Aide, Certified Nursing Assistants (CNAs), and a housekeeper, repeatedly left TBP room doors open and did not change their masks as required by the facility's policies. These actions occurred despite the facility being in an outbreak status, with 31 residents and 11 staff members testing positive for COVID-19. Interviews with staff indicated a lack of awareness and adherence to the facility's infection control policies. For instance, a Restorative Aide admitted she did not realize the TBP room doors were open and acknowledged that they should remain closed. Additionally, a CNA revealed she had not received updated COVID-19 or infection control education since the current outbreak began. The Director of Nursing (DON) confirmed that she was only recently made aware of the issue with the TBP room doors being left open and stated that staff were re-educated on the importance of containing the spread of infections and illness.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and did not document follow-up measures in response to the data for 12 of 12 months of infection control data reviewed. The facility's policy titled Antibiotic Stewardship, dated 2/1/2024, stated that antibiotics would be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. However, the facility's Antibiotic Stewardship Log lacked documentation for several months, and there was no testing data to determine if infections met the McGeers criteria or were facility or community-acquired. Additionally, the Antibiotic Medications Reports from the pharmacy did not document the organism, if a culture was performed, or the organism's susceptibility to the prescribed antibiotic, nor did it indicate if the McGeers criteria were met or if the infection was a true infection. The facility's calculated infection rate was the only documented data for April 2023 through March 2024. The Director of Nursing (DON) confirmed that the program's trending, surveillance, and monthly calculation rates were not being monitored, and monthly infection control meetings were not conducted in the facility. The President of Clinical Services revealed that the Infection Control Program, particularly the Antibiotic Stewardship Program, did not utilize floor plan mapping effectively or track organisms and perform surveillance. She had educated the DON on the process but had not followed up to see if it was implemented. The DON stated that there had not been a specific person monitoring the Antibiotic Stewardship Program since December 2023.
Failure to Designate and Support Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to the role of Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. This deficiency was identified through record reviews, staff interviews, and a review of the facility document titled Healthcare Center Infection Preventionist. The facility's infection surveillance documentation was missing from November 2023 to April 2024, and there were no line listings for infectious illnesses for January, February, and March 2024. The Director of Nursing (DON) and the newly appointed ICP confirmed that infection tracking and trending had not been completed since November 2023, and monthly infection control meetings were not conducted during this period. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program. The DON stated that she was responsible for infection control from March 2023 through December 2023, and a staff member who is no longer employed by the facility was responsible for infection control in January 2024. No one was responsible for infection control from February 2024 through March 2024, and the new ICP began the position in April 2024. The DON also mentioned that she had requested help from the Corporation's President but did not receive adequate support. The lack of proper infection surveillance and documentation, along with the absence of a designated and trained ICP, contributed to the facility's failure to maintain an effective Infection Prevention program, potentially putting all residents at risk of infectious diseases. The facility had a census of 109 residents at the time of the survey.
Incomplete Grievance Forms and Lack of Follow-Up
Penalty
Summary
The facility failed to thoroughly complete resident grievance forms, resulting in unresolved grievances and dissatisfaction among residents. A review of 101 grievance forms revealed that 42 were incomplete, lacking evidence of thorough investigation, resolution, and follow-up to ensure resident satisfaction. During a Resident Council Meeting, several residents reported that they had filed grievances but did not receive any follow-up or resolution. Some residents were unaware of the grievance process altogether. Interviews with staff, including the Activity Director and the Administrator, confirmed that the grievance process was ineffective. The Activity Director mentioned that she would submit complaints to the Administrator if residents reported no follow-up. The Administrator, who started working at the facility on 2/5/2024, acknowledged the problem with the grievance process and confirmed that no effective process was in place when she began her tenure. The deficiency had the potential to adversely affect any resident who filed a grievance.
Unsecured and Unauthorized Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents (R30, R32, and R71) did not have unsecured and unauthorized medication or medicated treatment products at their bedside. For R30, a bottle of fluticasone was found unsecured on the bedside table, and the resident had not been assessed for self-administration of medication. The Infection Control Preventionist confirmed the presence of the medication but did not remove it, and the Director of Nursing confirmed that R30 was not assessed for self-administration. Licensed Practical Nurses were unaware of the medication at the bedside and confirmed that R30 was not assessed for self-administration. For R32, a container of Alka Seltzer Cold Medicine and a jar of Zinc Oxide Skin Protectant cream were found unsecured on the bedside table. R32 had a moderate cognitive impairment and had not been assessed for self-administration of medication. The medications were removed by an LPN who confirmed that the resident was not assessed for self-administration and that the zinc oxide ointment was not ordered. For R71, a bottle of rubbing alcohol and a bottle of hydrogen peroxide were found unsecured on the bedside nightstand. The resident had not been assessed for self-administration of medication, and the LPN confirmed the unsecured medications and removed them. The DON stated that no residents in the facility had been assessed for safe self-administration of medications.
Incomplete Abuse Reporting Information
Penalty
Summary
The facility failed to post a complete listing of how to report abuse and the types of abuse, including a mailing address, email address, and information on how to report to the State Agency in a manner accessible to residents and visitors. During the initial tour and daily walks throughout the building, it was observed that the posted information only included a phone number for the Georgia Department of Community Services. During a Resident Council Meeting, the majority of residents did not know what information to report or how to report it, and none could identify the location of the posting. The Director of Nursing confirmed the posting lacked the correct agency name, address, telephone number, and detailed instructions on reporting different types of abuse. The Administrator also confirmed the incomplete information on the sign and acknowledged the issue.
Failure to Report Misappropriation of Property
Penalty
Summary
The facility failed to report the misappropriation of property to the State Survey Agency (SSA) for two residents who were investigated for abuse. Resident 41 reported missing six hundred dollars, which he claimed to have handed to the receptionist upon admission. The Social Service Assistant (SSA) documented the grievance but did not report it to the Social Services Director (SSD) or the State Agency. Similarly, Resident 45 reported missing $7.80, which she had placed in her bra. The SSA documented this grievance but also failed to report it to the State Agency. Both grievances were not signed or dated by the Administrator, indicating a lapse in the reporting process. Interviews with the residents, SSA, Director of Nursing (DON), and the Administrator revealed that the facility did not follow its policy for reporting allegations of misappropriation of property. The DON was unaware of the missing money incidents, and the Administrator did not recall being informed about them. The facility's policy required that such allegations be reported to the State Agency within 24 hours, but this was not done. The Administrator acknowledged that the initial report should have been filed with the State Agency, the police notified, and a five-day follow-up report sent to the State office after the investigation.
Failure to Investigate Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that abuse allegations, specifically an allegation of physical abuse and allegations of misappropriation of resident property, were thoroughly investigated for four residents. The facility's policy required that all allegations be investigated and documented, but this was not done in several instances. For example, a resident with severe cognitive impairment reported physical abuse, but the investigation was not documented, and key personnel were not informed. The Director of Nursing (DON) and the Administrator were unaware of the incident, and the Social Services Director (SSD) admitted to not following proper procedures for investigation and documentation. Another resident with moderate cognitive impairment reported missing $600, but the investigation was incomplete. The Social Service Assistant (SSA) checked the facility's safe but did not follow up further or inform the resident about the investigation's outcome. The grievance form was not signed by the Administrator, and the resident was left without any resolution or communication regarding the missing money. Two other residents also reported missing money, but their allegations were not thoroughly investigated. One resident reported $7.80 missing, and the SSA did not document interviews with other residents or staff. Another resident reported $36 missing, and the SSD did not document the investigation or interview staff who had access to the resident's room. The DON and the Administrator were unaware of these incidents, and the facility did not follow its policy for investigating and documenting such allegations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop or implement comprehensive, person-centered care plans for three residents, leading to potential risks for medical complications and unmet needs. For one resident, the facility did not develop a care plan for contracture management despite the resident's diagnoses of hemiplegia, hemiparesis, and functional quadriplegia. Additionally, the care plan for oxygen therapy was not followed, as evidenced by the lack of documentation for oxygen administration and oxygen saturation checks. The Director of Nursing (DON) confirmed these deficiencies during an interview, acknowledging the absence of a contracture management care plan and the failure to document respiratory care interventions. Another resident's care plan for dialysis was not properly implemented, as there were no current dialysis communication forms in the electronic medical record (EMR), with the last one filed several months prior. The DON confirmed that the care plan interventions were not being followed due to the lack of communication with the dialysis center. Additionally, a third resident did not have a care plan for oxygen therapy despite having diagnoses of acute respiratory failure and pneumonia. The DON and a Licensed Practical Nurse (LPN) both verified the absence of the care plan, and the Administrator was unaware of this deficiency. These failures indicate a lack of adherence to the facility's policy on developing and implementing individualized care plans.
Failure to Provide Scheduled Baths or Showers
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL), specifically baths or showers, for one resident (R5) out of 54 sampled residents. The facility's policy titled Bathing-Shower, effective 2/1/2024, outlines the purpose and procedure for bathing residents, including providing the opportunity to bathe according to preference and revising the bathing plan as needed. Despite this policy, R5, who has multiple diagnoses including muscle weakness, type 2 diabetes mellitus, and bilateral below-the-knee amputations, did not receive the required assistance with bathing. R5's care plan, revised on 3/7/2024, indicated the need for supervision with minimal assistance for ADL care, including bathing. However, documentation revealed that R5 only received two showers in the past 25 days, and there was no record of any baths from April 1, 2024, to April 6, 2024. Interviews with R5 confirmed that he had not received a shower in two weeks, despite being scheduled for showers twice a week. The Director of Nursing (DON) confirmed that bath sheets, which track when showers or baths are given, were completed for all residents, and any refusals were to be documented and reported for care plan revisions. However, the DON acknowledged that only two bath sheets were completed for R5 in the last 25 days, indicating a failure to provide the scheduled baths or showers. Interviews with Certified Nursing Assistants (CNAs) revealed that staff generally followed the bath schedule, but if a bath sheet was not completed, it meant the shower or bath was not provided. This failure to adhere to the bathing schedule and properly document care placed R5 at risk for unmet needs and a diminished quality of life.
Failure to Transcribe and Administer Antibiotic Medication Order
Penalty
Summary
The facility failed to transcribe and administer an antibiotic medication order for a resident (R49) as prescribed by the physician, resulting in a delay in treatment. R49 was readmitted to the facility from an acute care hospital with a diagnosis of multifocal pneumonia and a discharge medication list that included Levaquin 750 mg daily for five days starting on 4/5/2024. However, the medication order was not transcribed into the electronic medical record (EMR) upon the resident's return, and the medication was not administered until 4/10/2024, five days after the prescribed start date. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that the floor nurses were responsible for transcribing physician orders when residents returned from hospital stays. The LPN acknowledged the oversight and confirmed that the order for Levaquin was not entered into the EMR until 4/10/2024. The DON also acknowledged the lapse in care due to the delay in transcribing the medication order, which resulted in the resident not receiving the necessary antibiotic treatment in a timely manner.
Failure to Provide Necessary PROM and Splinting for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary passive range of motion (PROM) exercises and splint application to address her condition. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without any splint or device in her hands to prevent contracture. The facility's policy on contracture management was not followed, as the resident was not on the restorative caseload and did not receive the required PROM or splinting services as indicated by her condition and previous therapy recommendations. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for PROM and splinting. The Restorative Aides and Licensed Practical Nurse (LPN) responsible for the Restorative Nursing Program were unaware that the resident required these services. The Certified Nursing Assistants (CNAs) assigned to the resident did not perform or document the necessary exercises and splint application. The Rehabilitation Manager confirmed that the resident would benefit from therapy services and needed ROM for her left hand and an orthotic device for her right hand, but no referrals for screening had been made by the nursing department. The Director of Nursing (DON) acknowledged that the resident should have remained on the Restorative Nursing Program if a splint was required and that nursing staff should have informed her of any changes in the resident's condition. The DON was unaware that the resident no longer received PROM and splinting for her right hand or that her left hand had limited ROM. This lack of communication and adherence to the facility's policy resulted in the resident not receiving the necessary care to maintain or improve her ROM, potentially leading to worsening contracture, pain, or skin breakdown.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents receiving respiratory services. Specifically, the facility did not ensure there was a current physician's order for oxygen therapy and oxygen saturation checks before administering oxygen, did not maintain clean oxygen concentrators and filters, and did not provide humidification for oxygen therapy for one resident. Additionally, the facility failed to document daily tracheostomy inner cannula changes for another resident, and did not clarify a physician's order for oxygen for a third resident. The facility also failed to follow physician's orders for oxygen, ensure the oxygen concentrator had a filter, and label and store respiratory equipment in a sanitary manner for a fourth resident. One resident with acute and chronic respiratory failure was observed receiving oxygen via nasal cannula at 4 liters per minute, but the oxygen concentrator's filter was dirty, and the humidification container was empty. The electronic medical record revealed no current order for oxygen therapy or oxygen saturation checks, and the Medication Administration Record did not document oxygen administration or saturation checks for the current month. Interviews with staff confirmed the deficiencies in maintaining the oxygen equipment and ensuring proper documentation and orders. Another resident with a tracheostomy had a physician's order to change the inner cannula daily, but there was no documentation that this was done for several days. Staff interviews confirmed the lack of documentation and adherence to the physician's order. A third resident's oxygen concentrator filter was found to be dirty, and the physician's order for oxygen therapy was not clearly defined. The fourth resident's oxygen concentrator did not have a filter, and the nasal cannula was not stored properly, with observations showing it lying on the floor and not in a protective bag. Staff interviews confirmed these deficiencies and the failure to follow physician's orders for oxygen therapy.
Failure to Ensure Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident (R60) who required dialysis services. The facility's policy titled Dialysis Care, effective 2/1/2024, mandated pre and post care for dialysis residents, including the completion and submission of dialysis communication forms to the dialysis center. However, a review of R60's electronic medical record revealed that the only dialysis communication form documented was dated 10/2023, despite a physician's order for dialysis services three times a week. Interviews with staff, including the Registered Nurse (RN), Director of Nursing (DON), and Central Supply/Medical Record Licensed Practical Nurse (LPN), confirmed that the dialysis communication forms were missing and not being sent to the dialysis clinic as required. The dialysis clinic had contacted the facility to request the forms but eventually stopped following up after the facility continued to fail to submit them. The deficiency was further corroborated by the Dialysis RN, who confirmed that the facility was not submitting R60's dialysis communication forms to the dialysis clinic at the time of the resident's dialysis appointments. The Administrator was also unaware of the issue and stated that her expectations were for the nursing staff to send the dialysis communication form to each dialysis appointment. This failure to adhere to the facility's policy and ensure proper communication with the dialysis center had the potential to place R60 at risk for medical complications, unmet needs, and a diminished quality of life.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 97 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Candler Skilled Nursing Unit | 2.1 mi | ★★★★★ | 3 | 0 |
| Azalealand Nursing Home | 3.6 mi | ★★★★★ | 6 | 0 |
| Abercorn Rehabilitation Center | 4.3 mi | ★★★★★ | 11 | 0 |
| Thunderbolt Care Center Llc | 4.8 mi | — | 0 | 0 |
| Riverview Health & Rehab Ctr | 4.9 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.