Inspection Reports for Legacy at Savannah Quarters
101 SHEPHERD WAY, POOLER, GA, 31322.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 14, 2025, found no deficiencies. Earlier inspections generally showed no rule violations during complaint investigations, with multiple substantiated deficiencies occurring between 2020 and 2025. These deficiencies mainly involved issues with resident care, including insufficient staffing and delayed assistance, medication administration errors, failure to notify families after incidents, and lapses in abuse reporting and protective oversight. Complaint investigations were mostly unsubstantiated, with no fines, immediate jeopardy findings, or license actions listed in the available reports. The pattern suggests improvement over time, as recent inspections have not identified deficiencies after earlier concerns.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50006148.
Complaint Details
Investigation started and completed on 2025-10-14 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50005586 and #GA50005564.
Complaint Details
Investigation began on 2025-09-11 and ended on 2025-09-19 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50005312 and #GA50005318.
Complaint Details
Investigation was started on 2025-08-18 with an on-site visit at 12:00 pm and completed the same day. No violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50003259 and #GA50003592.
Complaint Details
Investigation started and completed on 2025-06-13 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Deficiencies: 0
Date: May 5, 2025
Visit Reason
The purpose of this visit was to conduct a CHOW inspection. The inspection started on 5/5/2025 with an onsite visit made at 10:00 am.
Findings
No specific findings or deficiencies are detailed in the report provided.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001825.
Complaint Details
Investigation was unannounced and completed on 2025-03-27; no violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001465 and #GA50001582.
Complaint Details
Investigation of intake #GA50001465 and #GA50001582 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00250957, #GA00251015, and #GA00250991.
Complaint Details
Investigation was related to complaint intakes #GA00250957, #GA00251015, and #GA00250991. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00252691.
Complaint Details
Investigation began on 2024-12-18, an on-site visit was made on 2024-12-18, and the investigation was completed on 2024-12-18.
Findings
No rules violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250102.
Complaint Details
Investigation started on 2024-09-25 and was completed on 2024-09-26. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00247151.
Complaint Details
Investigation of intake #GA00247151 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Apr 10, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245279. An on-site visit was made on 2024-04-10 and the investigation was completed on 2024-04-11.
Complaint Details
Investigation was complaint-related based on intake #GA00245279. The complaint was substantiated by findings of insufficient and inexperienced staff, delayed response times to call lights, and resident interviews confirming inadequate assistance.
Findings
The facility failed to provide sufficient staff assistance to keep residents clean and comfortable, as evidenced by delayed response times to call lights and insufficient staffing especially at night and on weekends. Multiple residents reported long waits for assistance, including one resident experiencing bowel incontinence due to delayed help.
Deficiencies (1)
Failed to provide sufficient staff assistance to keep residents clean and comfortable, with delayed response times to call lights and insufficient staffing.
Report Facts
Resident census: 81
Pendant alarm calls: 36
Pendant alarm calls: 19
Call wait times: 30
Call wait times: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 5, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243066.
Complaint Details
Investigation of intake #GA00243066 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The purpose of this visit was to investigate multiple complaint intake numbers related to the facility. An onsite visit was made on 12/13/2023 to investigate these complaints.
Complaint Details
The visit was complaint-related, investigating intake numbers GA0236624, GA00237341, GA00238021, GA00238125, GA00241238, GA00241325, GA00241629, GA00241712, and GA00241733. Resident #5 was reported missing by staff and found by police with injuries after eloping from the facility.
Findings
The facility failed to provide adequate assisted living care, including protective care and watchful oversight, for 1 of 6 sampled residents (Resident #5) who eloped from the facility without staff knowledge and sustained injuries. Resident #5 was found by police a mile down the road with minor injuries after eloping.
Deficiencies (1)
Facility failed to provide assisted living, including protective care and watchful oversight, meeting the needs of residents it admits and retains, as evidenced by Resident #5 eloping and sustaining injuries.
Report Facts
Sampled residents: 6
Resident #5 admission date: May 31, 2023
Incident date and time: Jul 19, 2023
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The purpose of this visit was to investigate intake # GA000240428.
Complaint Details
Investigation of intake # GA000240428 regarding missing physician orders and medication discontinuation documentation for Resident #2.
Findings
The facility failed to have physician's orders for medications and obtain specific discontinue orders for 1 of 3 sampled residents (Resident #2). Specifically, Ultram 50 mg was ordered but not available, and no documentation was provided for its discontinuation.
Deficiencies (1)
Failed to have physician's orders for medications and obtain specific discontinue orders for Resident #2.
Report Facts
Sampled residents: 3
Medication dosage: 50
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240763. An on-site visit was made on 11/16/2023, with the investigation completed on 11/28/2023.
Complaint Details
Investigation of intake #GA00240763 regarding failure to notify family or legal surrogate after Resident #3's fall. The complaint was substantiated based on observations, record reviews, and interviews.
Findings
The facility failed to ensure that in case of an accident or sudden adverse change in a resident's condition, appropriate actions were taken including notifying the resident's representative or legal surrogate. Specifically, Resident #3 had an unwitnessed fall causing bruising, but the family was not contacted as required by facility policy.
Deficiencies (1)
Failure to notify resident's family or legal surrogate after an unwitnessed fall resulting in bruising for Resident #3.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00238605, #GA00238345, #GA00238311, #GA00238248, #GA00238182) at the facility.
Complaint Details
Investigation was initiated on 2023-10-03 and completed on 2023-10-06 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00235945 with an onsite visit made to the facility on 6/20/23.
Complaint Details
Investigation of intake GA00235945; no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The purpose of this survey was to investigate complaint intakes #GA00233453 and GA00231279.
Complaint Details
Investigation of complaint intakes #GA00233453 and GA00231279 with no violations found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00227501.
Complaint Details
Investigation of intake GA00227501 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00223180 regarding medication administration issues.
Complaint Details
The visit was complaint-related to intake GA00223180. Resident interviews confirmed late medication administration on 5/8/22. Staff acknowledged the issue and noted a new medication aide covered for a sick employee. The facility had been previously cited for the same violation on 12/7/21.
Findings
The facility failed to provide medication administration services in accordance with physicians' orders and residents' needs for 3 of 4 sampled residents. Medications were given late on multiple occasions, including time-critical medications such as insulin.
Deficiencies (1)
Facility failed to provide medication administration services according to physicians' orders and residents' needs for 3 of 4 sampled residents, resulting in late medication administration.
Report Facts
Deficiencies cited: 1
Dates of late medication administration: 2
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 10, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate multiple intakes (#GA00222058, #GA00222018, #GA00221493, #GA00221510, #GA00221509, and #GA00221494) with on-site visits on 3/7/22 and 3/8/22, completed on 3/10/22.
Complaint Details
The investigation was complaint-driven based on multiple intake numbers. Staff B was found to have struck Resident #1 on the face and engaged in inappropriate behavior. Law enforcement was notified, and Staff B admitted to the physical abuse. Resident #1 reported feeling uncomfortable due to Staff B's actions. The complaint was substantiated.
Findings
The facility failed to ensure a direct access employee (Staff B) had a satisfactory fingerprint records check prior to employment and failed to protect a resident (Resident #1) from physical and possible sexual abuse by Staff B. Staff B struck Resident #1 on the face, entered the resident's apartment uninvited, and made the resident uncomfortable. Law enforcement was involved, and Staff B admitted to hitting the resident.
Deficiencies (3)
Failure to ensure a satisfactory fingerprint records check for Staff B prior to employment.
Failure to ensure the governing body implemented policies supporting dignity, respect, choice, independence, and privacy for residents, specifically related to Staff B's lack of criminal records check.
Failure to ensure residents were free from mental, verbal, sexual, and physical abuse, neglect, and exploitation, evidenced by Staff B striking Resident #1 and inappropriate conduct.
Report Facts
Number of sampled staff: 8
Number of sampled residents: 10
Date of incident: Feb 27, 2022
Date Staff B hired: Nov 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Direct access employee who lacked a criminal records check and was involved in abuse of Resident #1. | |
| Staff A | Interviewed staff who stated facility policy required criminal records checks for all staff including agency staff. | |
| Staff H | Staff who reported the incident of Staff B hitting Resident #1 to law enforcement. | |
| AA | Interviewed individual who confirmed Staff B was hired without a criminal records check and admitted hitting Resident #1. | |
| Resident #1 | Resident who was physically and verbally abused by Staff B. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00219340. An on-site visit was made on 11/30/21 and the investigation was completed on 12/7/21.
Complaint Details
Investigation was complaint-related, triggered by intake GA00219340. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to provide medication administration services in accordance with physicians' orders and residents' needs for 1 of 5 sampled residents (Resident #3). Medications scheduled for 8:00 p.m. were repeatedly administered late, between 9:12 p.m. and 10:26 p.m., which was problematic especially for pain medications and insulin.
Deficiencies (1)
Failure to administer 8:00 p.m. medications on time for Resident #3, with doses given as late as 10:26 p.m.
Report Facts
Medication administration times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 12/1/21 regarding late insulin injections | |
| Staff B | Interviewed on 12/7/21 regarding medication administration time frames and agency CMA performance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216024.
Complaint Details
Investigation began on 2021-07-21 and was completed on 2021-07-22. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00213648.
Complaint Details
Investigation of intake #GA00213648 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 1, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212699, #GA00213207, #GA00213224. The investigation started on 2021-03-15, with onsite visits on 2021-03-24 and 2021-04-01, and was completed on 2021-04-01.
Complaint Details
Investigation was complaint-related, initiated by intake #GA00212699, #GA00213207, #GA00213224. Staff B and Staff C were suspended during the investigation. A police report was filed. Resident #1 was found with a black eye on 2021-03-05. The injury likely occurred during the 3:00 p.m. to 11:00 p.m. shift. Staff interviews indicated Resident #1 was combative during care.
Findings
The facility failed to ensure a resident's right to be free from abuse and neglect, specifically Resident #1 who sustained a black eye of unknown origin on 2021-03-05. Staff involved were suspended and a police report was filed. The investigation included interviews, record reviews, and observations, revealing that Resident #1 became combative during care and staff did not fully follow protocols for managing combative behavior.
Deficiencies (1)
Facility failed to ensure each resident had the right to be free from abuse and neglect for Resident #1 who sustained a black eye of unknown origin.
Report Facts
Intake numbers: 3
Dates of onsite visits: 2
Resident sample size: 5
Staff B hire date: Jan 23, 2021
Staff C hire date: Jul 16, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in investigation for care of Resident #1 and suspension during investigation | |
| Staff C | Named in investigation for care of Resident #1 and suspension during investigation | |
| Staff A | Took photograph of Resident #1's injury and provided interview | |
| Staff D | Provided interview regarding training on handling combative residents | |
| Staff G | Provided interview regarding training on handling combative residents | |
| Staff H | Provided interview regarding training on handling combative residents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210718.
Complaint Details
Investigation started on 2021-01-08 and was completed on 2021-01-25. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210332.
Complaint Details
Investigation started on 2021-01-04 and was completed on 2021-01-08. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 18, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00209406. An on-site visit was made on 11/18/2020, with the investigation beginning on 11/16/2020 and completed on 11/25/2020.
Complaint Details
Investigation of intake #GA00209406 regarding Resident #1's care plan and behavioral management. The complaint was substantiated based on findings of inadequate care planning and staff guidance.
Findings
The facility failed to develop a written care plan that was modified as changes in the resident's needs occurred for one resident sampled. Resident #1 exhibited verbal and physical aggression, confusion, and behavioral issues, with no documentation on how staff should address these behaviors or recent hospitalizations related to behavior changes.
Deficiencies (1)
Failed to develop a written care plan that was modified as changes in the resident's needs occurred for Resident #1.
Report Facts
Dates of hospital treatment: Resident #1 treated at hospitals on 10/18/20, 7/29/20-8/5/20, and 6/26/20-7/8/20.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Described Resident #1's behavior and recommended a behavior/mental health long term facility. | |
| Staff A | Interviewed on 11/25/20 and stated the 9/14/20 care plan was the most recent. | |
| Staff B | Completed the 9/14/20 quarterly care plan for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208660. The investigation began on 2020-10-19 and was completed on 2020-10-27.
Complaint Details
Investigation of intake #GA00208660 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 Cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 11, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00203306. An onsite visit was made on 3/11/20, and the investigation was completed on 3/17/20.
Complaint Details
Investigation of complaint #GA00203306 regarding allegations of inappropriate touching by Staff C of Resident #1. The allegation was not reported to the Department as required. Staff interviews confirmed failure to report.
Findings
The facility failed to ensure allegations of abuse, including inappropriate touching of a resident, were reported to the Department as required by the Long Term Care Resident Abuse Reporting Act. Review of records and interviews confirmed the incident was not reported.
Deficiencies (1)
Facility failed to report allegations of rape, assault, battery, abuse, neglect, or exploitation of a resident to the Department as required.
Report Facts
Dates of investigation: Mar 11, 2020
Dates of investigation: Mar 17, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Reported allegation of inappropriate touching to Staff A | |
| Staff A | Did not report the incident to the Department | |
| Staff C | Alleged perpetrator of inappropriate touching |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 30, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00201521.
Complaint Details
Investigation of complaint #GA00201521 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 12, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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