Inspection Reports for Protected: Oaks at Savannah
7410 Skidaway Rd, Savannah, GA 31406, United States, GA, 31406
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
Moderate
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 19, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00215770 and #GA00216021, involving resident safety and exploitation concerns.
Findings
The facility failed to ensure adequate supervision and safety for Resident #1 who wandered off the premises and was found three blocks away, and failed to protect Resident #3 from financial exploitation by Staff G. Additionally, the facility did not report the exploitation incident to the Department as required.
Complaint Details
The investigation was initiated due to complaints regarding Resident #1 wandering off the facility and an allegation of financial exploitation involving Staff G and Resident #3. Resident #1 was found by a neighbor after wandering off and was transported to the hospital with no injuries. Staff G admitted to taking $50.00 from Resident #3 but the incident was not reported to the Department.
Severity Breakdown
SS=J: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 received adequate care and supervision, resulting in the resident wandering off the facility and being found three blocks away. | SS=J |
| Failure to ensure Resident #3 was free from exploitation when Staff G took $50.00 from the resident. | SS=D |
| Failure to report exploitation of Resident #3 to the Department as required by law. | SS=D |
Report Facts
Date of incident: Jul 5, 2021
Amount stolen: 50
Number of sampled residents with deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Involved in supervision and reporting of Resident #1 wandering incident and handling Staff G exploitation case | |
| Staff G | Employee who took $50.00 from Resident #3 and was reprimanded | |
| Staff H | Reported Resident #1's wandering behavior and need for monitoring | |
| Staff J | Observed Resident #1's behavior changes on day of incident | |
| Staff N | Noted Resident #1's confusion during shift on day of incident | |
| Staff O | Observed Resident #1 leaving front porch on day of incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212408.
Findings
No rule violations were found as a result of this inspection.
Complaint Details
Investigation was started and completed on 3/19/2021 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 9, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208979. The investigation began on 2020-11-02 and was completed on 2020-11-09 with an on-site visit made on 2020-11-09.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00208979 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 21, 2020
Visit Reason
The visit was conducted to investigate intake #GA00206267.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2020-07-20 and was completed on 2020-07-21. No rule violations were found.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Jul 16, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205582, which began on 2020-06-24 and was completed on 2020-07-16.
Findings
The facility failed to maintain the required minimum on-site staff to resident ratios during waking and non-waking hours, resulting in inadequate care and delayed responses to emergency call pendants. Multiple interviews and record reviews confirmed understaffing, with residents experiencing delayed assistance and inadequate care.
Complaint Details
Investigation was complaint-driven based on intake #GA00205582. The complaint was substantiated by findings of understaffing and inadequate resident care.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain minimum on-site staff to resident ratio of one awake direct care staff per 15 residents during waking hours and one per 25 residents during non-waking hours. | SS= D |
| Failed to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations. | SS= D |
Report Facts
Facility census: 55
Staff scheduled: 2
Resident pendant calls: 9
Resident pendant calls: 9
Response time: 33
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 25, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205853. The investigation began on 2020-06-15 and was completed on 2020-06-25.
Findings
The facility failed to implement policies and procedures supporting residents' dignity, respect, and safety, including medication administration and resident care. Specific findings include failure to follow physician orders for medication administration for Resident #2, inadequate monitoring and intervention for Resident #1's worsening leg wounds, and failure to ensure residents were free from neglect.
Complaint Details
The investigation was complaint-driven, intake #GA00205853. The facility was found to have failed in multiple areas including medication administration errors and neglect of residents' health conditions.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement policies supporting dignity, respect, choice, independence, and privacy of residents. | D |
| Failure to follow physician orders regarding medication administration for Resident #2, including holding Humalog insulin without doctor orders. | D |
| Failure to maintain awareness of Resident #1's health status and intervene appropriately for worsening leg wounds. | D |
| Failure to ensure Resident #2 was free from neglect related to medication administration. | D |
Report Facts
Medication doses not administered: 2
Blood sugar readings: 106
Blood sugar readings: 210
Blood sugar readings: 116
Blood sugar readings: 144
Medication orders: 20
Medication orders: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication administration errors and resident care issues. | |
| Staff E | Noted holding of Humalog doses without doctor orders; signed medication orders for Resident #1. | |
| Staff B | Certified Medication Aide (CMA) | Provided care and documented observations related to Resident #1's leg condition. |
| NN | Retired RN | Interviewed regarding Resident #1's wound care and physician communications. |
| MM | Visited Resident #1, observed wounds, and called ambulance for emergency care. | |
| OO | RN | Provided wound care for Resident #1. |
| Staff F | RN | Filling in to pass medication; noted absence of prescribed creme for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 11, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204549 and #GA00205007. The investigation began on 2020-05-04 and was completed on 2020-05-11.
Findings
The facility failed to review and update a written care plan quarterly for one sampled resident and failed to ensure residents were treated with dignity, kindness, consideration, respect, and privacy. A photograph of a resident with a possible black eye was sent to a personal friend outside the facility.
Complaint Details
The investigation was initiated based on intake #GA00204549 and #GA00205007. A photograph of a resident with what appeared to be a black eye was sent by a staff member to a personal friend who was not affiliated with the facility or regulatory bodies.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to review a written care plan at least quarterly and modify it as changes in the resident's needs occurred for 1 of 3 sampled residents. | D |
| Facility failed to ensure each resident was treated with dignity, kindness, consideration and respect and be given privacy in the provision of assisted living care for 1 of 3 sampled residents. | D |
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Original Licensing
Deficiencies: 1
Jan 22, 2020
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to maintain the interior free of unsafe conditions posing a safety risk to residents, specifically a broken hallway window in the memory care unit that was temporarily covered with cardboard and duct tape, which could be easily peeled back by residents.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The bottom half of a hallway window in the memory care unit was broken and covered with cardboard and duct tape, posing a safety risk due to falling glass shards and easy access by residents. | D |
Report Facts
Glass shards fallen: 4
Time window broken: 30
Date of inspection: Jan 22, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Interviewed regarding the broken window and safety risk. |
| Staff B | Maintenance Director | Interviewed regarding the broken window and plans to cover it with plywood. |
| Staff C | Observed and revealed the broken window during inspection. |
Inspection Report
Routine
Deficiencies: 1
Dec 3, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
The facility failed to ensure that the written care plan (ISP) was reviewed at least quarterly and modified as changes in the resident's needs occurred for 1 of 2 residents sampled (Resident #2).
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure that the written care plan (ISP) was reviewed at least quarterly and modified as changes in the resident's needs occur for Resident #2. | D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00189565.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00189565 was investigated and found to have no rule violations; the investigation was closed on 2018-07-31.
Inspection Report
Complaint Investigation
Deficiencies: 14
Jun 4, 2018
Visit Reason
The purpose of this visit was to investigate complaints #GA00188795 and #GA00188859 regarding staff training deficiencies and resident care issues.
Findings
The facility failed to ensure staff received required training within the first 60 days and six months of employment on multiple dementia care topics for sampled staff. Additionally, the facility failed to provide adequate care and services to residents, including failure to properly respond to a resident fall resulting in a pelvic fracture and failure to protect a resident from abuse by staff.
Complaint Details
The visit was complaint-driven to investigate allegations of inadequate staff training and resident care issues, including a resident fall with delayed hospital transfer and an incident of physical abuse involving a resident and staff.
Severity Breakdown
SS= D: 12
SS= K: 1
SS= J: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure staff had current certification in emergency first aid training within the first 60 days of employment for 1 of 2 sampled staff (Staff D). | SS= D |
| Failure to ensure staff received training specific to assigned job duties such as assisting residents with transferring using a mechanical lift for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff assigned to the unit received training within the first six months of employment on the nature of Alzheimer's Disease and other dementias for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on common behavior problems and recommended behavior management techniques for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on communication skills that facilitate better resident-staff relations for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on positive therapeutic interventions and activities for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on the role of the family in caring for residents with dementia for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on environmental modifications that can avoid problematic behavior for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on development of comprehensive and individual service plans for 2 of 8 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on new developments in dementia care for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on skills for recognizing physical or cognitive changes warranting medical attention for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to ensure staff received training on skills for maintaining the safety of residents with dementia for 2 of 2 sampled staff (Staff C and Staff D). | SS= D |
| Failure to provide adequate, appropriate care and services in compliance with state law for 1 of 2 sampled residents (Resident #2) after a fall resulting in a pelvic fracture and delayed hospital transfer. | SS= K |
| Failure to ensure each resident had the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation for 1 of 2 sampled residents (Resident #1) involving physical abuse by staff. | SS= J |
Report Facts
Sampled staff: 2
Sampled residents: 2
Incident dates: May 13, 2018
Incident dates: May 20, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in multiple training deficiencies and involved in resident abuse incident. | |
| Staff D | Named in multiple training deficiencies and assisted in resident care. | |
| Staff A | Provided interviews confirming lack of staff training and observations of resident conditions. | |
| Staff B | Referenced in instructions regarding hospital transfer and staff training. | |
| Staff F | Provided interview about resident fall events. | |
| Staff H | Registered Nurse (RN) | On duty during resident fall incident and involved in care and communication with Hospice. |
| Staff KK | Witnessed resident abuse incident. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187565.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00187565 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2018
Visit Reason
The purpose of this visit was to investigate self reported incident GA00185865.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of self reported incident GA00185865 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 16, 2018
Visit Reason
The purpose of this visit was to investigate complaints #GA001184005, #GA00183521, and #GA00182829. An on-site visit was made on 01/16/2018 and the investigation was completed on 01/17/2018.
Findings
The facility failed to ensure adequate and appropriate care for Resident #10, who was locked out of the facility overnight and found lying on the floor in the mechanical room the next morning. The resident did not receive dinner or evening medications and was not accounted for during the night shift.
Complaint Details
The investigation was complaint-driven based on complaints #GA001184005, #GA00183521, and #GA00182829. The complaint was substantiated by findings related to Resident #10's care and safety.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate and appropriate care and services in compliance with state law, evidenced by Resident #10 being locked out overnight, missing dinner and medications, and found lying on the floor. | J |
Report Facts
Temperature high: 91
Temperature low: 75
Number of sampled residents with deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed and stated the resident went outside and could not get back in |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 16, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2017
Visit Reason
The visit was conducted to investigate a self-reported incident #GA00174924 at the facility.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was complaint-related, triggered by a self-reported incident. The investigation was closed with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00171982.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00171982 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2016
Visit Reason
The purpose of this visit was to investigate complaint #GA00169356.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00169356 was investigated and found to have no violations.
Loading inspection reports...
