Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Savannah Nursing And Rehabilitation during CMS and state inspections, most recent first.
Kitchen Sanitation Deficiencies: The facility failed to maintain a clean and sanitary kitchen environment. Observations found brown particles in and on the deep fryer and baskets, an oil-like substance dripping onto the floor, dried substances on food storage container lids and sides, splattered residue on metal racks, a burnt black buildup on the stove, sticky brown residue on the tabletop mini grill, and a black substance between the plastic barrier and the handwashing sink. The CDM acknowledged these conditions should not have been present.
Failure to Return Resident Funds Within Required Timeframe: A resident with Alzheimer’s disease, dementia, HTN, schizophrenia, and acute kidney failure expired, and the facility did not send the resident fund balance of $4,394.97 to the estate within the required 30-day timeframe. Staff described a refund process involving system entry, admin approval, and check printing, and the ADM confirmed the check was not sent within 30 days.
PEG Tube Placement Check Not Performed per Orders: A resident with a PEG tube, severe cognitive impairment, and orders for enteral medication administration had tube placement checked by an LPN using auscultation with a 30 mL water flush. The LPN administered crushed and enteral medications after this process, despite facility policy and physician orders requiring placement to be checked by aspiration and auscultation.
The facility failed to store food properly, with unlabeled and expired items found in nourishment and kitchen refrigerators. An open, unlabeled, and undated tray of desserts was observed in the kitchen's walk-in refrigerator, and two expired nutritional supplements were found in the Hall Nutrition Refrigerator. The Dietary Manager, RN, and DON confirmed these items should have been labeled and dated.
An LPN failed to maintain infection control practices during tracheostomy care for a resident with severe cognitive impairment and multiple medical conditions. The LPN did not perform hand hygiene after removing gloves and gown and failed to clean the pulse oximeter used during the procedure. The deficiency was confirmed by the LPN and the DON, highlighting a breach in the facility's infection prevention policy.
A resident with Alzheimer's and Dementia experienced a change in condition and received a new physician order for an indwelling catheter, but the responsible party was not notified as required by facility policy. The resident was assessed as moderately impaired for decision-making and rarely understood. The DON confirmed the notification should have occurred.
Surveyors identified improper food storage practices when they observed an open, unlabeled, and undated tray of desserts in the kitchen walk-in refrigerator and two unlabeled, expired nutritional supplements in a nourishment refrigerator. The Dietary Manager, an RN, and the DON all confirmed that such items should not be present, indicating a failure to follow food storage policies.
A resident with a tracheostomy and severe cognitive impairment received care from an LPN who failed to perform hand hygiene after removing gloves and gown, and did not immediately clean a reusable pulse oximeter after use. Both the LPN and DON confirmed these actions were not in line with infection control policy.
A resident with cognitive impairment experienced a significant change in condition, including decreased responsiveness and low blood pressure, and later required catheterization by physician order. In both instances, there was no documentation that the responsible party was notified, despite facility policy requiring such notification. The DON confirmed that notification should have occurred.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment during observations of the deep fryer, fryer baskets, storage containers, metal racks, stove surfaces, tabletop mini grill, and handwashing sink area. Small brown particles were found on top of and inside the deep fryer and fryer baskets, an oil-like substance was dripping from the fryer onto the floor, and a dark brown gummy substance was present on the floor beside the fryer. Sugar, flour, meal, and brown sugar were stored in large plastic containers with clear lids that had dried white substances and loose brown and white particles on the lids and down the sides, and the metal storage racks had dried, splattered brown substances and tan particles on their surfaces. Additional kitchen observations showed the stove surfaces covered in a dried, burnt black substance, the tabletop mini grill with sticky brown residue and brown particles, and a black substance between the clear plastic barrier and the handwashing sink. The facility policies reviewed stated that food would be stored, prepared, and served in accordance with professional standards of food service safety and that adequate cleaning and sanitizing would minimize the risk of food borne illnesses. During interview, the CDM acknowledged that there should not have been the black substance near the sink, the oil-like substance and food particles around the fryer, the dried black buildup on the stovetop, the dried splattered substances on the metal racks, the sticky brown residue on the mini grill, or the dried substances and loose particles on the storage container lids and sides.
Failure to Return Resident Funds Within Required Timeframe
Penalty
Summary
The facility failed to reimburse resident funds within 30 days after discharge, eviction, or death for 1 of 1 sampled residents reviewed for personal fund accounts. Facility policy titled, Resident Personal Funds, stated that upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and a final account of those funds to the resident or, in the case of death, to the individual or probate jurisdiction administering the resident's estate, in accordance with State law. Resident #107 was admitted with diagnoses including Alzheimer's Disease, Dementia, Hypertension, Schizophrenia, and Acute Kidney Failure. The discharge summary showed the resident expired. Review of the resident fund account showed a returned check dated [DATE] for the account balance of $4,394.97, which was issued 6 days past the allotted 30-day time period. During interview, the Assistant Business Office Manager described the refund process as entering the request into the system, waiting 24-48 business hours for administrator approval, and then having the cash handler print the refund check. The Administrator stated that the check had to be sent back to the family within 30 days and confirmed that Resident #107's check was not sent within that time frame.
PEG Tube Placement Check Not Performed per Orders
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a PEG tube to prevent complications. Resident #13 was admitted with diagnoses including diabetes, traumatic brain injury, and gastrostomy, and was assessed as severely cognitively impaired with a BIMS score of 1. The care plan identified a nutritional problem and PEG tube use, and physician orders directed staff to check enteral tube placement by auscultation and aspiration every shift, flush the tube with 30 mL of water before and after medications, and administer enteral medications through the tube. During medication administration, an LPN prepared crushed and enteral medications for the resident and stated she was going to auscultate to check PEG placement. She connected a syringe without the plunger to the PEG tube, placed a stethoscope on the resident’s abdomen, and poured 30 mL of water into the syringe by gravity, stating the tube was patent. She then administered the medications and flushed with 30 cc of water. The LPN did not follow the facility policy or the physician’s orders for checking PEG placement before giving the medications. In interview, the LPN stated she may have gotten the competency mixed up, and the DON stated staff should follow physician’s orders rather than checking PEG placement by auscultating with a 30-cc water flush.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure proper food storage practices in accordance with professional standards, as evidenced by the presence of unlabeled and expired items in nourishment and kitchen refrigerators. During an observation in the kitchen's walk-in refrigerator, an open, unlabeled, and undated tray of leftover desserts was found. The Dietary Manager acknowledged that these items should have been labeled and dated. Additionally, in the Hall Nutrition Refrigerator, two nutritional supplements were discovered to be unlabeled and expired. Interviews with a Registered Nurse and the Director of Nursing confirmed that expired and unlabeled items should not be present in the nutritional refrigerators.
Infection Control Deficiency During Tracheostomy Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices during tracheostomy care for a resident. The facility's policy on infection prevention and control, dated 10/24/2022, requires staff to perform hand hygiene after handling contaminated objects, after removing personal protective equipment (PPE), and before and after performing resident care procedures. Additionally, reusable equipment must be cleaned with a germicidal detergent before being stored for reuse. However, during an observation on 11/20/2024, an LPN performed tracheostomy care for a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy, without performing hand hygiene after removing gloves and gown. The LPN also failed to clean the pulse oximeter used during the procedure before exiting the resident's room. The deficiency was further confirmed during an interview with the LPN, who acknowledged the failure to wash hands and sanitize the pulse oximeter immediately after use. The Director of Nursing also confirmed that staff should wash their hands after removing gloves and sanitize reusable medical equipment after use. The resident involved in the incident was admitted with diagnoses including traumatic brain injury, hemiplegia, gastrostomy, and tracheostomy, and was dependent on staff for all activities of daily living except feeding. The failure to adhere to the facility's infection control policy during tracheostomy care for this resident was identified as a deficiency by the surveyors.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition and new physician orders for a resident. The facility's policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or treatment. However, the medical record review revealed that the responsible party for a resident with Alzheimer's Disease, Dementia, and other conditions was not informed of a change in the resident's condition on a specific date when the resident was difficult to awaken and had low blood pressure. Additionally, there was no documentation that the responsible party was notified of a new physician order for an indwelling catheter. The resident was assessed as moderately impaired for daily decision-making skills and rarely or never understood, according to the comprehensive and quarterly Minimum Data Set assessments. During an interview, the Director of Nursing confirmed that the responsible party should have been notified of the changes in condition and new orders. This oversight indicates a failure to adhere to the facility's policy on notifying responsible parties of significant changes in a resident's condition or treatment.
Improper Food Storage: Unlabeled and Expired Items Found
Penalty
Summary
The facility failed to properly store food items in accordance with its own policy and professional standards for food service safety. During observations, surveyors found an open, unlabeled, and undated tray of leftover desserts in the kitchen walk-in refrigerator, as well as two unlabeled and expired nutritional supplements in the 100/200 Hall nourishment refrigerator. Interviews with the Dietary Manager, a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that expired and unlabeled items should not be present in the nutritional refrigerators, indicating a lapse in adherence to established food storage protocols. No specific residents or patient medical histories were mentioned in relation to the deficiency.
Failure to Perform Hand Hygiene and Clean Equipment After Tracheostomy Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow infection prevention and control protocols during tracheostomy care for a resident with a history of traumatic brain injury, hemiplegia, gastrostomy, and tracheostomy. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living except feeding, required regular suctioning and tracheostomy care. During an observed episode of tracheostomy care, the LPN removed gloves and gown, handled a pulse oximeter, and exited the resident's room without performing hand hygiene as required by facility policy. Additionally, the LPN did not immediately clean the reusable pulse oximeter after use, instead carrying it to the nurse station before wiping it down and returning it to the medication cart. Both the LPN and the Director of Nursing confirmed during interviews that hand hygiene should have been performed after glove removal and that reusable equipment should be sanitized after use, in accordance with facility policy.
Failure to Notify Responsible Party of Change in Condition and New Orders
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition and new physician orders, as required by facility policy. Specifically, a resident with diagnoses including Alzheimer's Disease, Dementia, Psychotic Disturbance, Behavioral Disturbance, and Agitation experienced a significant change in condition when a CNA reported the resident was more difficult to awaken, had a low blood pressure of 88/48, and only responded to a sternal rub. The resident was placed in Trendelenburg position, and blood pressure increased, but there was no documentation that the responsible party was informed of this change in condition. Additionally, several days later, the same resident had not voided during a shift and was catheterized, with a Foley catheter inserted per physician order. Again, there was no documentation that the responsible party was notified of the new physician order for the indwelling catheter. The resident was assessed as moderately impaired for daily decision-making skills and rarely or never understood, further emphasizing the importance of notifying the responsible party. The Director of Nursing confirmed that the responsible party should have been notified of both the change in condition and the new orders.
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Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — 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
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Nursing homes near Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hardin County Nh | 1.9 mi | ★★★★★ | 5 | 0 |
| Park Rest Hardin County Health Center | 2 mi | ★★★★★ | 0 | 0 |
| Hardin Home | 2 mi | ★★★★★ | 0 | 0 |
| Adamsville Healthcare And Rehabilitation Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Harbert Hills Academy N H | 9.9 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.