Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Savannah Heights during CMS and state inspections, most recent first.
The deficiency centers on the facility’s failure to maintain effective fall‑prevention measures and functioning chair/bed alarms for several residents with varying levels of cognitive impairment and mobility needs. One resident with intact cognition experienced multiple falls from bed while sitting or attempting to get up, with incident reports and the care plan lacking new or revised interventions. Another resident with dementia, TBI, and a history of falls had numerous falls in the room, hallway, and country kitchen, often during self‑transfers or attempts to walk without devices, yet the care plan was not updated with additional, specific interventions despite a provider order to monitor behaviors related to self‑transfers and alarms. A third resident with severe cognitive impairment and documented alarm use had falls where the chair or bed alarm did not sound, even though it was plugged in, and staff acknowledged that one alarm type had delayed or absent activation. Interviews with the MDS coordinator, DON, ADON, LPNs, and CNAs showed inconsistent post‑fall assessment, reliance on re‑education, lack of formal root cause analysis, uncertainty about who updates care plans, and incomplete documentation of fall interventions, all contributing to inadequate supervision and unaddressed accident hazards.
A resident who was dependent on staff for transfers and toileting due to COPD and fall risk had her bedside commode left unemptied after use on multiple occasions. Several CNAs observed the commode containing urine and feces at the start of their shifts, with inconsistent reporting to nursing or administration. The DON and Administrator were unaware of the issue, despite facility policy requiring prompt cleaning to maintain resident dignity.
A facility failed to notify a resident’s family before a chest x-ray was performed and failed to timely notify the physician when another resident returned from the hospital with discharge orders that were not started as ordered. The first resident had severe cognitive impairment and a traumatic brain injury, while the second resident returned after treatment for hypoxia, pneumonia, a small pneumothorax, and a rib fracture. Staff gave mixed accounts of who was responsible for family notification, and the record lacked documentation of physician notification regarding the delayed start of hospital discharge medications.
Failure to notify the LTC Ombudsman of discharge/readmission status occurred for 3 residents reviewed for the discharge process. One resident was unresponsive and fully dependent with severe neurologic diagnoses, another had COPD with hypoxia and was sent to the ED then returned, and a third had CHF, acute respiratory failure with hypoxia, and atrial flutter and was transferred to the hospital. The record also showed missing discharge and entry MDS assessments for one resident, and the BOM confirmed the Ombudsman notifications were not completed.
A facility failed to ensure that a resident with moderately impaired cognition could safely self-administer medications. The resident's care plan noted impaired thought processes, yet a bottle of chlorhexidine gluconate solution was found accessible in the bathroom. The clinical record lacked documentation of the resident's ability to self-administer safely, and the acting DON admitted the mouthwash should have been secured. The Administrator could not find a policy on self-administration of medications.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with anxiety, chronic pain, and hypertension. Despite a policy requiring such documentation, the Care Plan did not include directives for these interventions, and the Medication Administration Records lacked evidence of attempts prior to medication administration. Interviews confirmed staff were expected to document interventions, but this was not reflected in practice.
A resident with intact cognition required assistance with ADLs, and the facility failed to respond to their call lights within the 15-minute policy timeframe. The All Alarms Report showed multiple instances of delayed responses, ranging from 17 to 41 minutes. The resident reported timing the responses and noted a 20-minute delay when needing bathroom assistance. The facility's administrator confirmed the expectation for staff to respond within 15 minutes.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with anxiety, chronic pain, and hypertension. The resident's Care Plan did not address anxiolytic use or instruct staff to attempt non-pharmacological interventions first. Despite facility policy, there was no documentation of such interventions, confirmed by staff interviews.
The facility failed to offer the pneumococcal vaccine at the recommended times for two residents. Immunization records showed that the residents received the PCV13 and PPSV23 vaccines, but there was no documentation of the facility offering the vaccine as per guidelines. The Administrator noted a discrepancy in the Iowa Immunization Registry, which contributed to the oversight.
A resident with severe cognitive impairment experienced an unwitnessed fall, and the facility failed to complete the required neurological assessments. Despite the resident denying pain or hitting her head, multiple neuro checks were missed. Staff interviews revealed that the assessments were not conducted due to the resident being at meals or staff assuming they were unnecessary. The facility's policy required frequent neuro assessments for at least 72 hours following an unwitnessed fall.
A resident with severe cognitive impairment and a history of falls was left unsupervised in her room in a wheelchair, contrary to her care plan. She attempted to transfer herself to the toilet and fell, although no injuries were reported. Staff interviews and facility policies confirmed that the resident should not have been left alone in her room.
Failure to Maintain Effective Fall Prevention and Functioning Alarms for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the environment was free from accident hazards and that residents received adequate supervision and effective fall-prevention interventions, including properly functioning chair/bed alarms. For one resident with intact cognition who used a wheelchair and walker and was independent with mobility, multiple falls were documented over a short period. Nursing notes described repeated episodes of this resident sliding or rolling from the bed to the floor, often while sitting or lying on the edge of the bed, reaching for items, or attempting to get up. These falls resulted in bruises, lacerations, and reopened scabs. Incident reports for these falls lacked documentation of new or revised interventions, and the resident’s care plan did not reflect the repeated falls or any updated fall-prevention strategies beyond prior education not to sit on the side of the bed. Another resident with moderately impaired cognition, a history of stroke, non‑Alzheimer’s dementia, TBI, and multiple prior falls was care planned for fall risk with general interventions such as anticipating needs, ensuring call light access, and appropriate footwear, later adding that the resident could be taken near the nurse station for more supervision. Despite this, numerous falls were documented in various locations, including the hallway, resident room, in front of the closet, in the country kitchen, and near recliners and wheelchairs. Several falls involved self‑transfers, attempts to walk without assistive devices, or attempts to move between chairs and wheelchairs, sometimes associated with seizures or raising the bed to an unsafe height and turning up the TV volume so that alarms could not be heard. Nursing notes repeatedly described the resident being found on the floor, sometimes with lacerations, hematomas, or scattered bruising from numerous falls. The care plan did not show new or revised interventions corresponding to these repeated falls, even though a physician order required documentation of behaviors related to self‑transfers and alarm use. A third resident with severely impaired cognition, gait/balance problems, and multiple psychotropic and insulin medications was care planned for fall risk with an intervention to ensure alarms were in place and functioning properly, supported by a physician order to check alarms four times daily. This resident experienced falls where she was found sitting on the floor next to the bed or after ambulating independently and hitting her head on the bedstand, resulting in a laceration. An incident report documented that the resident’s chair alarm was not going off at the time of one fall, and another nursing note stated that the bed alarm was plugged in and working but did not sound when the resident was found on the floor with emesis present. Staff interviews revealed that one type of alarm box had a delayed response or sometimes did not go off, and that the DON was aware of issues with certain alarm units. Interviews with the MDS coordinator, DON, ADON, LPNs, and CNAs showed that post‑fall interventions were often limited to re‑education, that care plans were not consistently or promptly updated after falls, that root cause analyses were not formally documented, and that staff were uncertain about where fall interventions were documented and who was responsible for updating care plans. These actions and inactions contributed to the failure to ensure effective supervision, functioning alarms, and timely, resident‑specific interventions to prevent recurrent falls for the residents reviewed.
Failure to Maintain Resident Dignity by Not Emptying Bedside Commode
Penalty
Summary
Staff interviews, record review, and facility policy revealed that the facility failed to maintain resident dignity by not emptying a bedside commode after providing toileting assistance for a resident who was dependent on staff for transfers and toileting hygiene. The resident, who had intact cognition and required a mechanical lift with two staff for transfers due to chronic obstructive pulmonary disease (COPD) and fall risk, was found to have her bedside commode left unemptied on multiple occasions. Several CNAs reported noticing the commode containing urine and feces when starting their shifts, with some stating they had informed nurses about the issue, while others did not report it due to previous inaction. The resident was aware of the situation and commented on it to staff. The Director of Nursing (DON) and Administrator were unaware of the issue, as staff had not consistently reported it to them. The facility's policy requires that residents be treated with respect and dignity, and that the environment should promote quality of life. Despite this, the commode was not promptly emptied and cleaned after use, as expected by facility policy and as stated by the DON. The failure to empty the commode after use was confirmed by multiple staff members and was not addressed in a timely manner, resulting in a lack of dignified care for the resident.
Failure to Notify Family of Diagnostic Test and Physician of Delayed Post-Hospital Orders
Penalty
Summary
The facility failed to notify a family member before a chest x-ray was performed for a resident with severely impaired cognition and a diagnosis of traumatic brain injury. The resident had increased coughing and congestion, and a provider gave verbal orders for a chest x-ray. The x-ray showed a streaky opacity at the left lung base representing infiltrate versus atelectasis and mild increase in bilateral interstitial opacities. The resident’s daughter later stated she was not called about the chest x-ray and did not learn about it until the facility called about antibiotics after they had already been started. Staff interviews showed inconsistent understanding of who was responsible for family notification. One LPN stated the nurse who entered the order should notify the family and that the facility policy was to notify family with any new medication orders or changes. Another LPN stated the nurse on shift made the calls and documented them, but also said the day nurse was supposed to notify the family because she was ending her shift. The DON stated she notified families as she put in orders and expected nursing staff to notify families of changes and document when completed. The Administrator confirmed the family was not notified of the chest x-ray and said the task was not completed. The facility also failed to timely notify the physician when a resident returned from hospitalization. The resident was sent to the ED for hypoxia and later returned with discharge instructions for cefuroxime, azithromycin, prednisone, and ipratropium-albuterol, with start dates of 8/05/25. The discharge orders were found in the resident’s bag and were entered and started on 8/06/25 instead of the ordered start date. The record lacked physician notification that the hospital discharge orders were not started as ordered. An LPN confirmed the orders were found in the room and denied notifying the primary care provider, and an RN stated she assessed the resident after return but denied completing re-admission paperwork or assessments upon return.
Failure to Notify Ombudsman of Resident Discharge and Readmission Status
Penalty
Summary
The facility failed to provide notification of resident discharge/readmission status to the Long Term Care Ombudsman for 3 of 3 residents reviewed for the discharge process. Resident #2 had an MDS assessment dated 7/25/25 showing the resident was unresponsive or unable to complete BIMS, required full dependence on staff for care needs, and had diagnoses including anoxic brain damage, quadriplegia, and epilepsy. The record showed discharge-return anticipated and entry assessments completed in April and May 2025, but the report identified a failure to notify the Ombudsman regarding the resident's discharge/readmission status. Resident #8 had an MDS assessment dated 7/11/25 showing a BIMS score of 15/15 and diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and seizure disorder. Nursing documentation showed the resident was sent to the emergency department for hypoxia and later returned from the hospital, and a 72-hour post-hospital evaluation was completed, but the EHR lacked a discharge MDS assessment for the hospital transfer and lacked an entry assessment upon return. Resident #38 had diagnoses including CHF, acute respiratory failure with hypoxia, and atrial flutter, and the record showed transfer to the hospital by EMS with transfer paperwork and physician notification, followed by hospital communication that the resident would transfer to another facility. The administrator stated the only Ombudsman notification list completed for 2025 was for April and that the April list was blank, and the Business Office Manager confirmed she was responsible for sending the notifications and had forgotten to do them.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that only residents capable of safely self-administering medications had access to them. This deficiency was identified for one resident who had a history of traumatic brain dysfunction, anxiety, and morbid obesity, with a BIMS score indicating moderately impaired cognition. The resident's care plan noted impaired thought processes due to a traumatic brain injury. Despite this, a bottle of chlorhexidine gluconate solution, prescribed as a medicated oral rinse, was observed on the sink in the resident's bathroom, accessible to the resident. The clinical record lacked documentation confirming the resident's ability to self-administer medications safely. The acting DON acknowledged that the mouthwash should have been secured in a lock box and suggested it was left out by staff after use. Additionally, the facility's Administrator could not locate a policy regarding the self-administration of medications.
Failure to Document Non-Pharmacological Interventions for Anxiolytic Use
Penalty
Summary
The facility failed to address the use of anxiolytics on the Care Plan for a resident diagnosed with generalized anxiety disorder, chronic pain, and hypertension. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Despite having a policy that required documentation of non-pharmacological interventions prior to administering PRN (as needed) medications, the facility did not document such interventions before administering lorazepam, an anxiolytic, to the resident on multiple occasions in July 2024. The Care Plan, as of late August 2024, did not include directives for staff to attempt non-pharmacological interventions before administering PRN anxiolytics. Interviews with the facility's Administrator and a Registered Nurse (RN) revealed that staff were expected to document three non-pharmacological interventions prior to administering an anxiolytic, but this was not reflected in the resident's Care Plan or the Medication Administration Records (MARs). The facility's failure to document these interventions and update the Care Plan contributed to the deficiency identified during the survey.
Delayed Call Light Response for a Resident
Penalty
Summary
The facility failed to respond to call lights in a timely manner for one resident, identified as Resident #135, who was reviewed for staffing concerns. The resident, who had intact cognition with a BIMS score of 15 out of 15, required assistance with activities of daily living as noted in their care plan. The facility's All Alarms Report for the period from August 21 to August 28, 2024, showed multiple instances where the call light response times for this resident exceeded the facility's policy of responding within 15 minutes. Specific instances included response times ranging from 17 to 41 minutes. On August 26, 2024, the resident reported that it took staff 20 minutes to respond when they needed to use the bathroom. The resident also mentioned timing the staff's response using a clock on the wall. The facility's administrator acknowledged that staff should respond to call lights as close to 15 minutes as possible, according to the facility's undated policy on answering call lights.
Failure to Document Non-Pharmacological Interventions Before PRN Anxiolytics
Penalty
Summary
The facility failed to document non-pharmacological interventions prior to administering PRN anxiolytics to a resident with generalized anxiety disorder, chronic pain, and hypertension. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The Medication Administration Records (MAR) for July and August 2024 showed multiple administrations of lorazepam, an anxiolytic, without documentation of attempted non-pharmacological interventions. The resident's Care Plan did not address the use of anxiolytics or instruct staff to attempt non-pharmacological interventions before administering PRN anxiolytics. Despite the facility's policy requiring documentation of such interventions, including relaxation, repositioning, and food/beverages, there was no evidence of these steps being documented. Interviews with the Administrator and a Registered Nurse confirmed that staff were expected to document three non-pharmacological interventions prior to administering PRN anxiolytics, which was not done in this case.
Failure to Offer Pneumococcal Vaccine at Recommended Times
Penalty
Summary
The facility failed to offer the pneumococcal vaccine at the recommended times for two residents, as identified during a clinical record review. Resident #26's immunization record indicated that they received the PCV13 vaccine in 2016 and the PPSV23 vaccine in 2012. Similarly, Resident #13's record showed they received the PCV13 vaccine in 2018 and the PPSV23 vaccine in 2010. However, there was no documentation to confirm that the facility offered the pneumococcal vaccine to these residents as per the recommended guidelines. The facility's policy, reviewed in February 2024, stated that residents would be offered the pneumococcal vaccine upon admission, following current CDC or Iowa Department of Public Health guidelines. During an interview, the Administrator acknowledged a discrepancy in the Iowa Immunization Registry Information System (IRIS), which listed two pneumococcal vaccinations for the same date for both residents, leading to an incorrect assumption of series completion. This oversight contributed to the failure in offering the vaccine as required.
Failure to Complete Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to complete the required neurological assessments following an unwitnessed fall for a resident with severe cognitive impairment. The resident, who had a history of unspecified dementia and anxiety, fell in her room while attempting to transfer herself to the toilet. Although the resident was found laughing and denied pain or hitting her head, the facility's protocol required neuro assessments to be initiated due to the unwitnessed nature of the fall and the resident's low BIMS score. The neuro assessments were not completed as required. Documentation revealed multiple missed checks, including 15-minute, 30-minute, hourly, and 4-hour checks. Staff interviews indicated that the assessments were not conducted because the resident was at meals or because staff believed the assessments were unnecessary since the resident did not exhibit signs of head injury. The LPNs involved admitted to not performing the checks due to being occupied with other tasks or assuming fewer checks were needed. The facility's policy mandated frequent neurological assessments for at least 72 hours following an unwitnessed fall, regardless of whether the resident showed immediate signs of head injury. The Director of Nursing confirmed that the neuro assessments were not completed as required and stated that the assessments should be offered to residents even if they are at meals, with abnormal results reported to the provider. The failure to adhere to this protocol represents a significant deficiency in the care provided to the resident.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment, resulting in a fall. The resident, who had a history of dementia and was at moderate risk for falls, was left unsupervised in her room while in a wheelchair. Despite the care plan specifying that the resident should not be left alone in her wheelchair in her room and should be transferred to her bed or recliner, staff did not adhere to these guidelines. The resident attempted to transfer herself to the toilet, resulting in a fall, although no injuries were reported. The incident occurred when the resident moved herself from a common area to her room without staff assistance. The resident's door was closed, and she was found on the floor by a CNA with the alarm sounding. The resident was laughing and did not report any pain or injuries. The facility's policy required staff to check on residents every two hours, but the resident was left unattended for a period exceeding this timeframe. Interviews with staff and the Director of Nursing confirmed that the resident should not have been left alone in her room in a wheelchair. The facility's fall risk policy and care planning policy were not followed, leading to the resident's fall. The staff's failure to adhere to the care plan and supervision requirements directly contributed to the incident.
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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 Mount Pleasant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Health And Rehabilitation | 1.2 mi | ★★★★★ | 6 | 0 |
| Park Place | 1.6 mi | ★★★★★ | 1 | 0 |
| New London Specialty Care | 7.1 mi | ★★★★★ | 6 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 12.1 mi | ★★★★★ | 0 | 0 |
| Parkview Home | 14.7 mi | ★★★★★ | 0 | 0 |
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