Inspection Report Summary
The most recent inspection on March 25, 2025 found no deficiencies related to a substantiated complaint investigation. Earlier inspections showed a mixed pattern with several deficiencies cited in January and October 2024, primarily involving fire safety maintenance issues and failure to provide ordered therapies and proper food handling. Prior complaints were mostly unsubstantiated or substantiated without deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has addressed many prior deficiencies through follow-up surveys, indicating some improvement in compliance over time. Complaint investigations have been frequent but rarely resulted in citations, reflecting ongoing monitoring without major enforcement actions.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
15.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
132 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 132
Deficiencies: 1
Date: Dec 22, 2025
Visit Reason
The inspection was conducted to assess compliance with the Resident Assessment Instrument (RAI) Manual requirements, specifically focusing on the completion of Discharge Minimum Data Set (MDS) assessments for residents.
Findings
The facility failed to complete a Discharge MDS assessment within the required 14-day timeframe for one of 36 residents reviewed. Additionally, 36 MDS assessments were found to be late. Interviews with MDS Coordinators confirmed delays in completing assessments despite efforts including remote employees.
Deficiencies (1)
Failure to complete a Discharge Minimum Data Set (MDS) assessment within the required 14-day timeframe for one resident.
Report Facts
Residents reviewed for MDS completions: 36
Facility census: 132
Late MDS assessments: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Registered Nurse (RN) MDS Coordinator | Interviewed regarding delayed discharge MDS assessment for resident R2 |
| GG | Registered Nurse (RN) MDS Coordinator | Interviewed confirming 36 late MDS assessments and MDS department responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 20, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide written bed hold policies and transfer notices to residents or their representatives during emergent hospital transfers, and to assess medication administration practices.
Complaint Details
The complaint investigation revealed that the facility did not provide written transfer/discharge notices or bed hold policies to residents or their representatives during emergent hospital transfers. Interviews with staff confirmed lack of awareness and failure to provide required notices. Medication administration errors were also observed during the investigation.
Findings
The facility failed to provide written bed hold policies and transfer notices to seven of seven residents reviewed for emergent hospital transfers, potentially affecting residents' knowledge and rights. Additionally, medication administration errors were identified, including improper use of insulin pens and administration of medications not ordered, resulting in a 13.64% medication error rate.
Deficiencies (2)
Failure to provide written bed hold policy and transfer notices to residents or their representatives for emergent hospital transfers.
Medication administration errors including failure to prime insulin pens and administration of medications not ordered.
Report Facts
Residents reviewed for emergent hospital transfer: 7
Medication administration error rate: 13.64
Medication administration opportunities: 44
Medication errors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated she had never filled out a transfer/discharge notice and was not aware one needed to be provided. |
| Administrator | Facility Administrator | Acknowledged the facility had not been providing written transfer and discharge notices. |
| Social Worker | Social Worker | Stated she had not been providing written transfer/discharge notices and was unaware of the requirement until shown the policy. |
| Interim Director of Health Services | Interim Director of Health Services (IDHS) | Confirmed no transfer forms were used for hospital transfers. |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Observed administering medications incorrectly and confirmed forgetting to prime insulin pen. |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Observed administering insulin pen without priming. |
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Observed administering medications late and confirmed delay due to workload. |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Observed administering two allergy medications to a resident and planned to contact APRN about the issue. |
| Director of Health Services | Director of Health Services (DHS) | Stated expectation that insulin pens be primed before each use and medications administered within one hour before or after scheduled time. |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, care plan development, and medication administration practices at Pruitthealth - Savannah nursing home.
Findings
The facility failed to provide written bed hold policies and transfer notices to residents or their representatives for hospital transfers, failed to conduct timely care plan conferences for one resident, and had a medication administration error rate of 13.64%, including improper insulin pen use and administration of medications not ordered.
Deficiencies (3)
Failed to ensure written bed hold policy and transfer notices were provided to residents or their representatives for hospital transfers.
Failed to review and revise residents' care plans quarterly, resulting in no care plan conference for one resident since 6/25/2024.
Medication administration error rate of 13.64% due to improper insulin pen use and administration of medications not ordered.
Report Facts
Residents reviewed for hospital transfer notices: 7
Sample size of residents: 28
Medication administration error rate: 13.64
Medication administration opportunities: 44
Medication administration errors: 6
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Stated she had never filled out a transfer/discharge notice and was not aware one needed to be provided. | |
| Administrator | Acknowledged the facility had not been providing written transfer and discharge notices to residents or their representatives. | |
| Social Worker | Stated she had not been providing written transfer/discharge notices and was unaware they were needed until shown the policy. | |
| Interim Director of Health Services (IDHS) | Confirmed no transfer forms were used except for 30-day discharge forms, which were not used for hospital transfers. | |
| Director of Health Services (DHS) | Stated expectation that insulin pens be primed before each use and medications administered within one hour before or after scheduled time. | |
| Minimum Data Set Coordinator (MDSC) | Confirmed last care conference for resident R27 was held on 6/25/2024 and noted delays due to staff turnover. | |
| Licensed Practical Nurse (LPN) 5 | Observed administering medications and confirmed discrepancies between calcium supplements. | |
| Licensed Practical Nurse (LPN) 3 | Observed administering insulin pen without priming and admitted forgetting to prime. | |
| Licensed Practical Nurse (LPN) 6 | Observed administering medications late due to being called to attend to a resident in distress. | |
| Licensed Practical Nurse (LPN) 7 | Observed administering two allergy medications to resident R31 and confirmed contacting APRN about medication duplication. |
Inspection Report
Abbreviated Survey
Census: 125
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00254368 and GA00254318.
Complaint Details
Complaint GA00254368 was unsubstantiated. Complaint GA00254318 was substantiated.
Findings
Complaint GA00254368 was unsubstantiated, while complaint GA00254318 was substantiated. No deficiencies were cited related to either complaint.
Inspection Report
Abbreviated Survey
Census: 127
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint numbers received by the facility.
Complaint Details
Complaint Intakes GA00253924, GA00253326, GA00252148, GA00250649, GA00249536, and GA00248312 were unsubstantiated with no deficiencies cited. Complaint Intakes GA00252209, GA00252061, GA00254121, and GA00247541 were substantiated with no deficiencies cited.
Findings
Several complaint intakes were investigated; some were unsubstantiated with no deficiencies cited, while others were substantiated but also had no deficiencies cited.
Report Facts
Complaint Intakes Investigated: 9
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 15, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, with some exceptions noted related to fire sprinkler system maintenance.
Findings
The facility failed to ensure proper inspection, testing, and maintenance of the fire sprinkler system, including a yellow service tag indicating required service on the sprinkler riser near the Therapy Room and several sprinkler heads requiring replacement or adjustment of escutcheon rings. These findings were confirmed by Staff M during the tour.
Deficiencies (2)
Failure to ensure proper inspection, testing, and maintenance of the fire sprinkler system, including a yellow service tag indicating service is required on the sprinkler riser adjacent to the Therapy Room.
Several sprinkler heads required replacement or adjustment of the escutcheon rings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire sprinkler system deficiencies during facility tour. |
Inspection Report
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - SAVANNAH, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 18, 2024 Recertification Survey.
Findings
All deficiencies cited in the January 18, 2024 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 90
Capacity: 140
Deficiencies: 14
Date: Jan 29, 2024
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness, means of egress obstructions, emergency lighting failures, kitchen hood suppression system maintenance, fire alarm system installation and maintenance, sprinkler system inspection and maintenance, portable fire extinguisher maintenance, smoke barrier and door deficiencies, electrical panel access, fire drill documentation, and gas cylinder storage signage.
Deficiencies (14)
Emergency Preparedness Program was not in substantial compliance; staff unable to locate required documentation.
Corridors and doors obstructed by cleaning carts, service carts, equipment, and refuse receptacles blocking egress.
Emergency lighting unit #17 was not operational after testing.
Kitchen hood suppression system service tags expired or incorrect.
Fire alarm system lacked month and year of manufacture on alternative supply batteries.
Fire alarm pull station obstructed by wheelchairs.
Fire sprinkler system had sprinkler heads loaded with paint, corrosion, external loading on piping, service required tags, obstructed FDC, and sprinkler heads needing replacement or escutcheon adjustment.
Portable fire extinguisher in Therapy Kitchen missing Class K in-use placard.
Smoke corridor fire door gap exceeded 1/8 inch minimum allowed.
Doors in 400-500 corridor, kitchen janitorial closet, and laundry room failed to self-close or latch properly.
Electrical panel in rear kitchen blocked by rolling service cart.
Fire drills lacked proper documentation of conductance.
Fire doors modified with non-approved magnetic release devices; lacked proper maintenance documentation.
Oxygen cylinder storage lacked signage denoting full/empty status of cylinders.
Report Facts
Census: 90
Total Capacity: 140
Inspection Date: Jan 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and observations |
Inspection Report
Routine
Deficiencies: 20
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to evaluate compliance with healthcare regulations including medication administration, resident rights, skin condition management, abuse prevention, care planning, dietary services, respiratory care, dialysis services, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medication, inaccurate documentation of code status, failure to notify physicians of skin condition changes, failure to issue Medicare non-coverage notices, resident-to-resident abuse incidents, delayed abuse reporting, incomplete abuse investigations, failure to provide written bed hold notices, untimely MDS data transmission, inaccurate MDS assessments, incomplete baseline and comprehensive care plans, failure to provide scheduled showers, failure to implement dental and skin treatments, improper respiratory equipment storage, failure to communicate with dialysis centers, inadequate dishwasher sanitization, and failure to ensure therapeutic diets were provided as ordered.
Deficiencies (20)
Facility failed to assess one resident for self-administration of medication, leaving medications at bedside without proper orders.
Failed to ensure accurate documentation of resident code status, resulting in conflicting orders for resuscitation.
Failed to notify physician of a resident's change in skin condition (fungal rash) requiring treatment.
Failed to issue Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices to Medicare A residents when therapy or skilled nursing services ended.
Failed to prevent resident-to-resident abuse incidents involving physical altercations between residents.
Failed to timely report an allegation of abuse to the State Survey Agency.
Failed to conduct thorough investigations of resident-to-resident abuse incidents, including lack of witness interviews and documentation.
Failed to provide written bed hold policy to residents or their representatives upon hospital transfer.
Failed to transmit Minimum Data Set (MDS) assessment data to the State within required timeframe.
Failed to ensure accurate MDS assessment related to anticoagulant use.
Failed to develop baseline care plan addressing pressure ulcers within 48 hours of admission.
Failed to invite residents or their representatives to participate in quarterly care plan meetings.
Failed to provide pressure ulcer care according to professional standards including transcription of orders, weekly assessments, baseline care plan, and treatment documentation.
Failed to provide appropriate treatment and care for skin conditions including fungal rash and dental abscess.
Failed to provide off-loading of pressure ulcer with heel boot as recommended by wound consultant.
Failed to communicate with dialysis center prior to and after resident dialysis treatments.
Failed to post daily nurse staffing information including facility name, census, and total hours worked by staff.
Failed to ensure dishwasher rinse temperature met required standards and failed to perform hand hygiene between handling soiled and clean dishes.
Failed to ensure resident received diet as ordered by attending physician, specifically failure to provide double portions of protein.
Failed to ensure laundry aide donned proper personal protective equipment while sorting soiled laundry.
Report Facts
Residents reviewed: 40
Residents affected: 125
Residents affected: 120
Residents affected: 126
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 8 | LPN | Named in medication self-administration finding |
| Director of Health Services | DHS | Interviewed regarding multiple findings including medication, skin condition, abuse, care planning, wound care, dialysis communication, respiratory care |
| Certified Nursing Assistant 5 | CNA | Named in skin condition and shower care findings |
| Licensed Practical Nurse 7 | LPN | Named in skin condition and shower care findings |
| Certified Nursing Assistant 6 | CNA | Named in skin condition and shower care findings |
| Private Duty Certified Nursing Aide | PDCNA | Named in skin condition findings |
| Minimum Data Set Coordinator 3 | MDSC | Named in multiple findings including MDS transmission, care planning, respiratory care |
| Corporate Nurse | Nurse | Named in multiple findings including NOMNC policy, wound care, abuse investigations |
| Certified Nursing Assistant 1 | CNA | Witnessed resident-to-resident abuse |
| Certified Nursing Assistant 2 | CNA | Witnessed resident-to-resident abuse |
| Licensed Practical Nurse 2 | LPN | Witnessed resident-to-resident abuse |
| Certified Nursing Assistant 3 | CNA | Witnessed resident-to-resident abuse |
| Licensed Practical Nurse 1 | LPN | Assessed resident after abuse incident |
| Licensed Practical Nurse 3 | LPN | Witnessed resident-to-resident abuse |
| Social Service Director 2 | SSD | Named in care plan meeting findings |
| Dietary Manager | DM | Named in diet order findings |
| Dietary Aide 1 | DA | Named in dishwasher sanitization findings |
| Wound Nurse 1 | WN | Named in wound care findings |
| Wound Nurse Practitioner | WNP | Named in wound care findings |
| Assistant Director of Health Services | ADHS | Named in multiple findings including shower care, wound care, dishwasher sanitization |
Inspection Report
Routine
Deficiencies: 20
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with healthcare facility regulations including medication administration, resident rights, skin condition management, abuse prevention, care planning, dietary services, respiratory care, dialysis care, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medication, inaccurate documentation of code status, failure to notify physicians of skin condition changes, failure to issue Medicare non-coverage notices, resident-to-resident abuse incidents, delayed abuse reporting, incomplete abuse investigations, failure to provide written bed hold notices, untimely MDS data transmission, inaccurate MDS assessments, incomplete baseline and comprehensive care plans, failure to provide scheduled showers, failure to implement dental and skin treatments, improper respiratory equipment storage, failure to communicate with dialysis centers, inadequate dishwasher sanitization, and failure to ensure therapeutic diets were provided as ordered.
Deficiencies (20)
Facility failed to assess one resident for self-administration of medications, leaving medications at bedside without proper orders.
Failed to ensure accurate documentation of resident code status, resulting in conflicting orders for resuscitation.
Failed to notify physician of a resident's fungal rash requiring treatment, delaying necessary care.
Failed to issue Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices to Medicare A residents ending therapy or skilled nursing services.
Failed to protect residents from resident-to-resident abuse in two separate incidents involving physical altercations.
Failed to timely report an allegation of abuse to the State Survey Agency.
Failed to conduct thorough investigations of resident-to-resident abuse incidents, including lack of witness interviews and documentation.
Failed to provide written bed hold notices to residents or their representatives upon hospital transfer.
Failed to transmit Minimum Data Set (MDS) data to CMS within required timeframe for one resident.
Failed to ensure accurate MDS assessment related to anticoagulant use for one resident.
Failed to develop a baseline care plan including pressure ulcer care for one resident within 48 hours of admission.
Failed to include dialysis-related care plan interventions and dietary needs for one resident receiving dialysis.
Failed to ensure showers were provided per schedule for one resident with partial assistance needs.
Failed to implement dental orders and provide treatment for fungal rash for two residents.
Failed to transcribe physician treatment orders, conduct weekly pressure ulcer assessments, develop baseline care plan, and document treatments for pressure ulcers for one resident.
Failed to follow wound nurse practitioner recommendations and provide ordered pressure ulcer care for two residents.
Failed to store respiratory equipment properly, exposing equipment to contamination for one resident.
Failed to communicate with dialysis center prior to and after dialysis treatment for one resident.
Failed to ensure dishwasher rinse temperature met required sanitizing temperature and failed to perform hand hygiene between handling soiled and clean dishes.
Failed to ensure therapeutic diet with double protein portions was provided as ordered for one resident.
Report Facts
Residents reviewed: 40
Residents affected: 3
Residents affected: 6
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dishwasher rinse temperature: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 8 | LPN | Named in medication self-administration deficiency |
| Director of Health Services | DHS | Interviewed regarding multiple deficiencies including medication, skin care, abuse, and care planning |
| Certified Nursing Assistant 5 | CNA | Observed and interviewed regarding skin care and resident abuse incidents |
| Licensed Practical Nurse 7 | LPN | Interviewed regarding skin care and abuse incidents |
| Certified Nursing Assistant 6 | CNA | Interviewed regarding skin care and resident hygiene |
| Private Duty Certified Nursing Aide | PDCNA | Interviewed regarding skin condition observations |
| Minimum Data Set Coordinator 3 | MDSC | Interviewed regarding MDS transmission and care planning |
| Corporate Nurse | Nurse | Interviewed regarding NOMNC policy and wound care documentation |
| Certified Nursing Assistant 1 | CNA | Witnessed resident abuse incident |
| Certified Nursing Assistant 2 | CNA | Witnessed resident abuse incident |
| Licensed Practical Nurse 2 | LPN | Witnessed resident abuse incident |
| Certified Nursing Assistant 3 | CNA | Witnessed resident abuse incident |
| Licensed Practical Nurse 1 | LPN | Assessed resident after abuse incident |
| Licensed Practical Nurse 3 | LPN | Witnessed resident abuse incident |
| Social Service Director 2 | SSD | Interviewed regarding care plan meetings |
| Dietary Manager | DM | Interviewed regarding diet order communication and dishwasher practices |
| Dietary Aide 1 | DA | Observed dishwasher temperature and hand hygiene practices |
| Wound Nurse 1 | WN | Interviewed regarding wound care and documentation |
| Wound Nurse Practitioner | WNP | Consultant providing wound care recommendations |
| Assistant Director of Health Services | ADHS | Interviewed regarding shower schedule and dishwasher practices |
| Minimum Data Set Coordinator 1 | MDSC | Interviewed regarding care plan meetings |
Inspection Report
Routine
Deficiencies: 13
Date: Jan 18, 2024
Visit Reason
A State Licensure survey was conducted at Pruitthealth Savannah from January 15, 2024 through January 18, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to notify physicians of significant changes in residents' health, failure to issue required Medicare notices, inadequate abuse investigations, failure to provide written bed hold policies, inadequate pressure ulcer care, failure to provide ordered diets, failure to assess self-administration of medications, failure to communicate with dialysis centers, improper use of personal protective equipment by laundry staff, and failure to maintain proper dishwasher sanitizing temperatures and hand hygiene.
Deficiencies (13)
Failure to notify physician of a change in skin condition for one resident and failure to issue Medicare Non-Coverage Notices and Skilled Nursing Facility Advanced Beneficiary Notices to Medicare A recipients.
Failure to report an allegation of abuse in a timely manner and incomplete investigations of resident-to-resident incidents.
Failure to provide written bed hold policy to residents or responsible parties at time of hospital transfer.
Failure to provide pressure ulcer care according to professional standards including failure to transcribe physician orders, conduct assessments, develop baseline care plans, and document treatments.
Failure to ensure one resident received diet as ordered by attending physician.
Failure to assess one resident for self-administration of medications and leaving medications unattended at bedside.
Failure to include dialysis care plan interventions and failure to communicate with dialysis center prior to and after dialysis treatments.
Laundry aide failed to don proper personal protective equipment while sorting soiled resident clothing and linens.
Dishwasher rinse temperature was below required 180 degrees Fahrenheit and staff failed to perform hand hygiene between handling soiled and clean dishes.
Failure to provide showers per schedule for one resident with a stage IV pressure ulcer.
Failure to follow wound care consultant recommendations and to document verbal and telephone orders for wound care treatments for one resident.
Failure to off-load right heel with heel boot at all times except when ambulating as recommended by wound care consultant.
Failure to assess and treat pressure ulcers for one resident from admission until consultant visit.
Report Facts
Residents sampled: 40
Residents reviewed for abuse: 8
Residents reviewed for bed hold policy: 4
Residents reviewed for pressure ulcers: 3
Residents reviewed for diet: 1
Residents reviewed for self-administration of medications: 12
Residents attending dialysis: 1
Residents affected by dishwasher sanitizing issue: 120
Residents identified as NPO: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 5 | CNA | Provided incontinent care and applied skin cream to resident R103 |
| Director of Health Services | DHS | Reviewed resident records and confirmed expectations for physician notification and care plans |
| Licensed Practical Nurse 7 | LPN | Unaware of resident R103's excoriated rash and shower orders |
| Consultant Wound Nurse Practitioner | WNP | Evaluated resident R103 and R329's wounds and ordered treatments |
| Private Duty Certified Nursing Aide | PDCNA | Reported resident R103's skin condition |
| Minimum Data Set Coordinator 3 | MDSC | Confirmed lack of NOMNC issuance and care plan omissions |
| Corporate Nurse | Nurse | Confirmed policies and expectations for orders and investigations |
| Administrator | Administrator | Confirmed late reporting of abuse allegations and lack of witness statements |
| Dietary Manager | DM | Confirmed diet order communication failures and dishwasher issues |
| Laundry Aide 1 | LA | Observed not wearing proper PPE while sorting soiled laundry |
| Dietary Aide 1 | DA | Observed running dishwasher at improper temperature and poor hand hygiene |
| Certified Nursing Assistant 6 | CNA | Assigned to resident R103 and unaware of heel boot use recommendations |
| Licensed Practical Nurse 8 | LPN | Confirmed medications left unattended at bedside for resident R109 |
| Wound Nurse 1 | WN | Responsible for wound care and assessments for residents R103 and R329 |
Inspection Report
Routine
Census: 126
Deficiencies: 19
Date: Jan 18, 2024
Visit Reason
A standard survey was conducted at Pruitthealth Savannah from January 15, 2024, through January 18, 2024, including investigation of three complaint intake numbers which were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00240517, GA00241862, and GA00242732 were investigated and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with multiple deficiencies including medication self-administration, advanced directives documentation, physician notification of skin condition changes, issuance of Medicare non-coverage notices, resident-to-resident abuse, bed hold policy notification, MDS transmission and accuracy, care planning, pressure ulcer care, respiratory equipment storage, dialysis communication, nurse staffing posting, dietary order implementation, dishwashing sanitation, and infection control in laundry.
Deficiencies (19)
Failed to assess one resident for self-administration of medications.
Failed to ensure accurate documentation of code status for one resident.
Failed to notify physician of change in skin condition for one resident with fungal rash.
Failed to issue Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices to Medicare A recipients.
Failed to ensure two residents were free from resident-to-resident abuse in two separate incidents.
Failed to report an allegation of abuse to the State Survey Agency in a timely manner.
Failed to conduct thorough investigations of resident-to-resident incidents including obtaining witness statements.
Failed to provide written bed hold policy to residents or their representatives at time of hospital transfer.
Failed to transmit Minimum Data Set (MDS) assessment data to CMS within required timeframe.
Failed to ensure accuracy of Minimum Data Set (MDS) assessment related to anticoagulant use.
Failed to provide baseline care plan including pressure ulcers for one resident.
Failed to invite residents or their representatives to participate in quarterly care plan meetings.
Failed to provide pressure ulcer care according to professional standards including documenting orders and treatments.
Failed to provide respiratory care per standards including proper storage of respiratory equipment.
Failed to communicate with dialysis center prior to and after dialysis treatment for one resident.
Failed to include facility name, census, and total number and hours worked by nursing staff on daily nurse staffing document.
Failed to ensure resident received diet as ordered by attending physician.
Failed to ensure dishwasher rinse temperature met required sanitizing temperature and failed to perform hand hygiene between handling soiled and clean dishes.
Failed to ensure laundry aide donned proper personal protective equipment while sorting soiled laundry.
Report Facts
Residents present: 126
Deficiencies cited: 18
Dishwasher rinse temperature: 108
Dishwasher rinse temperature required: 180
MDS transmission delay: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Confirmed medications at bedside without order |
| Director of Health Services | Director of Health Services | Provided multiple policy and compliance clarifications |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Observed resident skin condition and care |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Provided care and described resident skin condition |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Unaware of resident skin condition and treatments |
| Wound Nurse 1 | Wound Nurse | Described wound care and assessments |
| Consultant Wound Nurse Practitioner | Wound Nurse Practitioner | Evaluated resident wounds and ordered treatments |
| Private Duty Certified Nursing Aide | Certified Nursing Aide | Provided resident care and described skin condition |
| Minimum Data Set Coordinator 3 | MDS Coordinator | Reviewed MDS assessments and care plans |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Witnessed resident-to-resident abuse incident |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Witnessed resident-to-resident abuse incident |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Witnessed resident-to-resident abuse incident |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Assessed resident after abuse incident |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident |
| Administrator | Facility Administrator | Confirmed abuse incidents and investigation deficiencies |
| Minimum Data Set Coordinator 1 | MDS Coordinator | Set up care conferences and confirmed missed meetings |
| Dietary Manager | Dietary Manager | Confirmed diet order discrepancies and meal tray issues |
| Dietary Aide 1 | Dietary Aide | Observed dishwasher temperature and hand hygiene issues |
| Laundry Aide 1 | Laundry Aide | Observed sorting soiled laundry without PPE |
| Certified Nursing Assistant 8 | Certified Nursing Assistant | Observed meal tray passing and diet slip |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 22, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - SAVANNAH following a regulatory inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Date: Dec 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 23, 2023 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on October 23, 2023. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the October 23, 2023 Complaint Survey were found to be corrected.
Report Facts
Census: 127
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth Savannah from October 16, 2023 through October 26, 2023 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies including failure to provide ordered physical therapy services for 2 of 3 sampled residents, and failure to ensure opened food items in the kitchen were properly resealed and dated.
Deficiencies (2)
Facility failed to provide Physical Therapy Services as ordered for 2 out of 3 Residents sampled (R21 and R23).
Facility failed to ensure that opened items were resealed and labeled with a date in the walk-in freezer and reach-in refrigerator in the kitchen.
Report Facts
Therapy sessions missed: 2
Therapy sessions missed: 4
Physical therapy order frequency: 5
Occupational therapy order frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Staff Physical Therapist Manager | Reported issues with residents missing therapy appointments due to lack of staff assistance |
| EE | Dietary Manager | Reported that all opened items in dietary must be resealed and dated |
| AA | Facility Administrator | Acknowledged issues with therapy attendance and kitchen food labeling; confirmed corrective actions |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
An abbreviated/partial extended survey was conducted from October 16 to October 23, 2023, investigating multiple complaint intake numbers to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Numbers GA00235006, GA00236870, GA00230949, GA00234951, GA00232935, GA00231533 were substantiated with no deficiencies. Complaint Intake Numbers GA00231908 and GA00231441 were substantiated with deficiencies. Complaint Intake Numbers GA00239804, GA00239524, GA00236912, GA00236239, GA00230939, and GA00231510 were unsubstantiated.
Findings
The survey found the facility was not in substantial compliance with regulations, citing deficiencies including failure to ensure opened food items were resealed and dated in the kitchen, and failure to provide ordered physical therapy services for two residents. Some complaints were substantiated with deficiencies, while others were not.
Deficiencies (2)
Facility failed to ensure that opened food items in the walk-in freezer and reach-in refrigerator were resealed and labeled with a date.
Facility failed to provide Physical Therapy Services as ordered for 2 out of 3 residents sampled.
Report Facts
Resident census: 114
Residents sampled for therapy deficiency: 3
Therapy sessions missed: 2
Therapy sessions missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Staff Physical Therapist Manager (PTM) | Reported issues with residents missing therapy appointments due to staff not assisting them. |
| EE | Dietary Manager | Interviewed regarding failure to reseal and date opened food items. |
| AA | Facility Administrator | Acknowledged food storage issues and therapy scheduling improvements. |
Inspection Report
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
The inspection was conducted to assess compliance with food procurement, storage, preparation, distribution, and serving standards in the facility's kitchen.
Findings
The facility failed to ensure that opened food items in the walk-in freezer and reach-in refrigerator were resealed and labeled with dates. Observations and staff interviews confirmed multiple opened items without proper sealing or dating, though the issue was corrected during the inspection.
Deficiencies (1)
Failed to ensure that opened items were resealed and labeled with a date in the walk-in freezer and reach-in refrigerator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager EE | Interviewed regarding food storage and labeling practices. | |
| Facility Administrator AA | Interviewed and acknowledged the labeling issue and corrective actions. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
An abbreviated survey was conducted to investigate three complaints (#GA00229056, #GA00229646, and #GA00229802).
Complaint Details
Complaint #GA00229646 was substantiated; complaints #GA00229056 and #GA00229802 were unsubstantiated.
Findings
Complaints #GA00229056 and #GA00229802 were found to be unsubstantiated, while complaint #GA00229646 was substantiated. No deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 12, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00225966, #GA00226076, #GA00226876, and #GA00227477.
Complaint Details
Complaints #GA00225966, #GA00226076, #GA00226876, and #GA00227477 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - SAVANNAH, indicating a regulatory inspection was conducted.
Findings
The document contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/5/22 through 7/7/22 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 22, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to maintain unobstructed means of egress and patient room doors that open, close, and latch properly. Observations and staff interviews confirmed items stored along corridors impeded egress and several patient room doors required significant force to operate or did not latch properly.
Deficiencies (2)
Facility failed to maintain unobstructed means of egress; items stored along corridors impeded egress.
Multiple patient room doors do not open, close, or latch properly.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings related to means of egress and door functionality. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 7, 2022
Visit Reason
The inspection was conducted due to complaints related to COVID-19 infection prevention and control practices, specifically regarding failure to notify residents and families of positive COVID-19 cases and failure to conduct outbreak testing in accordance with CDC and CMS requirements.
Complaint Details
The complaint investigation found that the facility did not notify residents, families, and representatives timely about a positive COVID-19 staff case and failed to conduct required outbreak testing. The Infection Control Preventionist was unaware of the positive case initially and did not document county transmission rates. The Director of Health Services initiated testing after being informed, and the Administrator admitted to dropping the ball during his absence.
Findings
The facility failed to notify residents, families, and representatives by the required time following a positive COVID-19 staff case on 6/26/22, and failed to conduct outbreak testing for all staff and residents as required. The facility also did not maintain proper testing logs or documentation of community transmission levels.
Deficiencies (2)
Failed to notify residents, families, and representatives by 5:00 PM the next calendar day following a positive COVID-19 staff case on 6/26/22.
Failed to conduct outbreak testing for all staff and residents after a positive COVID-19 staff case on 6/26/22 and did not maintain testing logs or community transmission documentation.
Report Facts
Census: 105
Census: 101
Date of positive staff COVID-19 test: Jun 26, 2022
Notification deadline: Jun 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Described notification process and admitted to dropping the ball on notification | |
| Infection Control Preventionist (ICP) | Responsible for infection control activities; unaware of positive staff case initially and did not document transmission rates | |
| Director of Health Services (DHS) | Started testing after being informed of positive staff case; noted ICP was on performance improvement plan |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 7/5/22 through 7/7/22 to assess compliance for facility licensure renewal.
Findings
No deficiencies were cited during the Licensure Survey conducted from 7/5/22 through 7/7/22.
Inspection Report
Routine
Census: 105
Deficiencies: 2
Date: Jul 7, 2022
Visit Reason
A standard survey was conducted at Pruitthealth-Savannah from July 5, 2022 to July 7, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to notify residents, families, and representatives timely about a COVID-19 positive staff member and failing to conduct outbreak testing and maintain proper documentation as required by CDC and CMS guidelines.
Deficiencies (2)
Failure to notify residents, families, and representatives by 5 p.m. the next calendar day following a staff member testing positive for COVID-19 on 6/26/22.
Failure to conduct outbreak testing for all staff and residents after a staff member tested positive for COVID-19 on 6/26/22 and failure to maintain testing logs, line listing forms, or community transmission level logs.
Report Facts
Resident census: 105
Resident census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Described notification process and confirmed failure to notify residents and families about COVID-19 positive staff on 6/26/22 | |
| Infection Control Prevention (ICP) | Unaware of positive staff member on 6/26/22 and did not document county transmission findings | |
| Director of Health Services | Revealed ICP did not notify her about positive staff member or outbreak testing; ICP was on performance improvement plan |
Inspection Report
Life Safety
Census: 105
Capacity: 140
Deficiencies: 9
Date: Jul 7, 2022
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements including obstructed means of egress, locked patio gate, improperly maintained kitchen hood suppression system, missing smoke detectors, backflow preventer deficiencies, malfunctioning patient room doors, uncovered junction box, and incomplete fire drill documentation.
Deficiencies (9)
Failed to maintain unobstructed means of egress; patient room privacy curtains prevent door latching; items stored in corridors; kitchen egress blocked; patient room doors difficult to open/close.
Dining room patio gate locked from outside with only one staff member having key.
Kitchen hood suppression system is red-tagged due to canister tank size and nozzle coverage.
Fire alarm system smoke detector missing in 400 corridor causing panel trouble.
Damaged smoke detectors not repaired timely in 400 corridor.
Backflow preventer deficiencies found during inspection not repaired; repeated check valve leak noted.
Patient room doors do not open/close or latch properly.
Wiring junction box cover missing behind dryer in laundry room.
Fire drill documentation incorrect and/or not current; multiple dates missing and shifts not marked.
Report Facts
Census: 105
Total Capacity: 140
Inspection Date: Jul 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the inspection |
Inspection Report
Original Licensing
Capacity: 140
Deficiencies: 0
Date: May 10, 2022
Visit Reason
A walk-through licensure survey was conducted to assess the addition of 20 beds for the 500 Hall at Pruitthealth Savannah.
Findings
The facility was found to be in compliance with state requirements, and the bed capacity increased from 120 beds to 140 beds.
Report Facts
Bed capacity increase: 20
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Sep 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Investigations GA00216818 and GA00216765 were initiated due to complaints and conducted to assess compliance with infection control regulations and emergency preparedness related to COVID-19.
Complaint Details
Complaint GA00216818 was unsubstantiated with no regulatory violations cited. Complaint GA00216765 was substantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control. Complaint GA00216818 was unsubstantiated with no regulatory violations cited, and complaint GA00216765 was substantiated with no regulatory violations cited.
Report Facts
Total census: 96
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00216194 and #GA00216217.
Complaint Details
Complaints #GA00216194 and #GA00216217 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00216194 and #GA00216217 were unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00214423 on 6/16/2021.
Complaint Details
Complaint #GA00205723 was substantiated with no deficiency cited.
Findings
Complaint #GA00205723 was substantiated but no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 6, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00214154.
Complaint Details
Complaint #GA00214154 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00211450 and #GA00211452.
Complaint Details
Complaints #GA00211450 and #GA00211452 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaints #GA00211450 and #GA00211452 were unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00209853.
Complaint Details
Complaint #GA00209853 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209588.
Complaint Details
Complaint #GA00209588 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Routine
Census: 102
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 102
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00207828 and GA00207842.
Complaint Details
Complaints GA00207828 and GA00207842 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00206855, GA00206920, and GA00207465.
Complaint Details
Complaints #GA00206855, GA00206920, and GA00207465 were unsubstantiated.
Findings
The complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 110
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, having implemented recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A complaint survey was conducted at PruittHealth of Savannah from July 8, 2020 through July 13, 2020 for complaint numbers GA00200690 and GA00205876.
Complaint Details
Complaint survey conducted for complaint numbers GA00200690 and GA00205876; facility found in compliance.
Findings
The facility was found to be in compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements Long Term Care Facilities.
Inspection Report
Routine
Census: 106
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services on June 16-17, 2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Report Facts
Total census: 106
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as a Licensure Survey for the facility.
Findings
No deficiencies were identified during the Licensure Survey.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: Jul 10, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the Abbreviated/Partial Extended Survey conducted from May 21, 2019 through May 24, 2019.
Findings
All deficiencies resulting from the prior survey were found to be corrected.
Report Facts
Resident Census: 112
Inspection Report
Abbreviated Survey
Census: 108
Deficiencies: 0
Date: Jun 18, 2019
Visit Reason
An abbreviated survey was conducted from June 13, 2019 through June 18, 2019 to investigate multiple complaints identified by their complaint numbers.
Complaint Details
The survey was conducted to investigate complaints GA00197394, GA00197210, GA00197099, GA00197058, and GA00196966. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Resident census: 108
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Date: May 24, 2019
Visit Reason
A partial/abbreviated survey was conducted from May 21, 2019 through May 24, 2019 to investigate complaint GA00196409 regarding the malfunctioning handicapped accessible doors at the main entry of the facility.
Complaint Details
The visit was triggered by complaint GA00196409 concerning the malfunctioning handicapped accessible doors at the main entry. The complaint was substantiated as the doors were found not to be functioning properly, affecting residents' ability to enter the building independently.
Findings
The facility failed to ensure the handicapped accessible doors at the main entry were functioning properly, resulting in residents unable to re-enter the building without assistance. Multiple staff and residents confirmed the doors had been malfunctioning intermittently for at least a year, with repairs made in April 2019 that only lasted a few days. There was no call system outside for residents to request assistance, and staff monitoring and reporting of the door malfunction was inadequate.
Deficiencies (2)
Failure to ensure the resident environment remained free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically the malfunctioning handicapped accessible doors preventing residents from re-entering the facility independently.
Failure to maintain the handicapped access doors in safe operating condition, resulting in failure of the automatic doors to open for residents unable to open doors manually.
Report Facts
Resident census: 115
Repair date: Apr 18, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Courtesy Desk Clerk | Aware the handicapped access pad was not working properly and opened doors for residents when needed |
| BB | Maintenance Director | Provided repair invoices and admitted failure to monitor handicapped access doors daily |
| HH | Occupational Therapist | Reported resident families complained about the doors but did not report the problem |
| JJ | Transport Services Staff | Confirmed the handicapped access doors had not worked properly for months and assisted residents |
| LL | Transport Staff | Confirmed the doors worked sporadically since March 2019 |
Inspection Report
Routine
Deficiencies: 1
Date: May 21, 2019
Visit Reason
The inspection was conducted to assess the safety and functionality of the handicapped accessible feature at the main entry doors of the facility, following concerns that the doors were not working properly and residents were unable to re-enter the building without assistance.
Findings
The facility failed to ensure that the handicapped accessible doors at the main entry were functioning properly, resulting in residents in wheelchairs being unable to enter without assistance. Multiple interviews and observations confirmed the doors were intermittently working, with no signage or call bell outside for assistance, and staff were not consistently monitoring or reporting the issue.
Deficiencies (1)
The facility failed to ensure that the handicapped accessible feature for the double doors at the main entry were functioning properly, preventing residents unable to physically open the doors from re-entering without assistance.
Report Facts
Date of repair work: Apr 18, 2019
Date of inspection: May 21, 2019
Resident admission dates: Mar 13, 2019
Resident admission dates: Mar 23, 2019
Resident admission dates: Apr 11, 2019
BIMS score: 15
Wait time for assistance: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD BB | Maintenance Director | Interviewed regarding door repairs and monitoring |
| CD AA | Courtesy Desk clerk | Interviewed about door functionality and resident assistance |
| OT HH | Occupational Therapist | Interviewed about family complaints regarding door accessibility |
| Administrator | Interviewed about staff responsibilities and door issues | |
| Director of Nursing | DON | Interviewed about complaints and staff reports related to door accessibility |
Inspection Report
Re-Inspection
Census: 115
Deficiencies: 0
Date: Apr 25, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/28/19 Annual Recertification Survey.
Findings
All deficiencies cited in the previous annual recertification survey were found to be corrected during this revisit survey.
Report Facts
Census: 115
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 23, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 111
Capacity: 120
Deficiencies: 4
Date: Feb 28, 2019
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to perform a Life Safety Code Survey related to fire safety and compliance with NFPA standards.
Findings
The facility's Emergency Preparedness Plan was not in substantial compliance with Appendix Z requirements for local cooperation and collaboration. The Life Safety Code Survey identified multiple deficiencies including noncompliant sprinkler system installation, doors that did not close or latch properly, and inadequate maintenance of electrical closets and boiler room combustion air supply, all posing risks to residents.
Deficiencies (4)
Emergency Preparedness Plan lacked required documentation of cooperation and collaboration with local emergency preparedness officials.
Facility failed to provide an NFPA 13 compliant sprinkler system; sprinkler heads obstructed by ceiling fixtures.
Doors protecting corridors failed to close fully and latch as required; specific doors blocked or latch not catching.
Electrical closets and boiler room were obstructed and lacked proper combustion air supply as required by NFPA 54 and NFPA 70.
Report Facts
Census: 111
Total Capacity: 120
Residents at risk: 25
Number of obstructed sprinkler heads: 10
Inspection date: Feb 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, sprinkler system, door deficiencies, and electrical room issues |
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 7
Date: Feb 28, 2019
Visit Reason
A standard survey was conducted at Pruitt Health Savannah from 2/25/19 through 2/28/19 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide bed-hold policy notices upon transfer, incomplete discharge Minimum Data Set assessments, failure to provide baseline care plan copies, failure to revise care plans timely, lack of discharge planning, failure to notify physician of lab results, and improper storage and labeling of resident food items.
Deficiencies (7)
Failed to ensure that two residents transferred to hospital received notice of the facility's bed hold policy prior to transfer.
Failed to complete a discharge Minimum Data Set assessment for one resident in a timely manner.
Failed to provide a copy of the Baseline Care Plan to one resident and their responsible party after admission.
Failed to revise care plans for two residents to reflect hospice services, code status, and noncompliance with fluid restriction and life vest use.
Failed to develop and implement a discharge plan for one resident.
Failed to promptly notify the ordering physician of urine culture results that showed resistance to prescribed antibiotic for one resident.
Failed to properly store, discard, label, and date food items in two unit refrigerators.
Report Facts
Resident census: 112
Number of residents reviewed: 34
Date of survey completion: Feb 28, 2019
Food expiration date: 48
Frozen food expiration date: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Social Service Director | Interviewed regarding bed-hold policy notification |
| BB | Financial Officer | Interviewed regarding bed-hold payment communication |
| LL | Registered Nurse MDS Coordinator | Interviewed regarding discharge MDS completion |
| CC | Nurse Navigator | Interviewed regarding baseline care plan provision |
| KK | Minimum Data Set Coordinator | Interviewed regarding care plan revisions and discharge planning |
| MM | Licensed Practical Nurse Unit Manager | Interviewed regarding lab result communication and refrigerator monitoring |
| II | Licensed Practical Nurse | Interviewed regarding personal food items in refrigerator |
| DD | Certified Nursing Assistant | Interviewed regarding resident noncompliance with fluid restriction and life vest |
| FF | Licensed Practical Nurse | Interviewed regarding resident noncompliance with fluid restriction and life vest |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 28, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically focusing on the revision and updating of person-centered care plans for residents.
Findings
The facility failed to revise or update the care plans for two residents to reflect significant changes including hospice admission, code status, and noncompliance with fluid restriction and life vest use. Interviews and record reviews confirmed these deficiencies.
Deficiencies (1)
Failure to revise the person-centered plan of care for two residents to reflect hospice services, code status, and noncompliance with care including fluid restriction and life vest use.
Report Facts
Residents with deficient care plans: 2
Total residents reviewed: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Registered Nurse (RN), Minimum Data Set (MDS) Coordinator | Confirmed policy on care plan updates and hospice admission documentation. |
| CC | Registered Nurse (RN) | Obtained diet refusal form from resident R81. |
| DD | Certified Nursing Assistant (CNA) | Provided observations on resident R81's noncompliance with fluid restriction and life vest use. |
| FF | Licensed Practical Nurse (LPN) | Reported resident R81's history of removing life vest and battery. |
| DON | Director of Nursing | Stated expectations for staff to revise care plans per resident needs. |
| RD | Registered Dietician | Commented on importance of fluid restriction orders in care plans. |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Feb 12, 2019
Visit Reason
An unannounced, abbreviated complaint survey was conducted due to a complaint investigation at Pruitt Health Savannah from February 11 to February 12, 2019.
Complaint Details
The complaint was related to missing clothing items, dental appointment scheduling, call light responsiveness, and assistance with transfer intentions. The complainant was not a family member or legal representative. The investigation found no substantiated issues.
Findings
The survey found no regulatory citations or concerns regarding resident safety and care. Observations, record reviews, and interviews indicated positive staff-resident interactions and no evidence supporting the complaint allegations.
Report Facts
Facility census: 112
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation #GA00192965 regarding patient rights.
Complaint Details
Complaint investigation #GA00192965 was not substantiated.
Findings
The facility was found to be in compliance with the applicable rules and regulations. The allegation was not substantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 13, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00192723.
Complaint Details
The complaint was substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 24, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegations identified as GA#00191316.
Complaint Details
Investigation of complaint GA#00191316; all allegations unsubstantiated.
Findings
All allegations related to GA#00191316 were found to be unsubstantiated during the survey.
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 0
Date: Jul 25, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00189986.
Complaint Details
Investigation of complaint GA00189986; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Re-Inspection
Census: 115
Deficiencies: 0
Date: Jun 4, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 6, 2018 Complaint Survey GA00186883.
Complaint Details
Complaint Intake Numbers GA00184677 and GA00184864 were investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the April 6, 2018 complaint survey were found to be corrected. The complaint investigations GA00184677 and GA00184864 were found unsubstantiated with no deficiencies.
Report Facts
Census: 115
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00186698 at Pruitt Health - Savannah.
Complaint Details
Investigation of complaint GA00186698; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 114
Capacity: 120
Deficiencies: 6
Date: Feb 8, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance with life safety requirements including fire alarm system labeling, sprinkler coverage, corridor door latching, transfer grills in corridor doors, smoke barrier door maintenance, and improper use of multi-tap power strips.
Deficiencies (6)
Failed to maintain fire alarm panel marking, breaker marking, and battery manufacturers date marking.
Failed to maintain sprinkler coverage in patient room 100; sprinkler head exceeded maximum permitted distance.
Failed to maintain a patient room door (Room 403) so that it latched positively.
Facility had a transfer grill in a corridor door to a room containing combustible materials (Data Room).
Failed to maintain self-closing smoke compartment doors; one held open by paper wedge and another unable to close completely.
Failed to maintain multi-tap power strips in a compliant manner by allowing them to be placed directly on the floor in multiple locations.
Report Facts
Census: 114
Total Capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 5, 2018
Visit Reason
A Revisit Survey was conducted at Pruitthealth Savannah from 2/5/18 through 2/8/18 to verify correction of deficiencies cited during the standard survey of 2/8/18.
Findings
All deficiencies cited as a result of the standard survey of 2/8/18 were found to be corrected on 3/25/18.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 4, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00182520 at PruittHealth Savannah.
Complaint Details
Investigation of complaint GA00182520; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 25, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00181138 at Pruitt Health - Savannah.
Complaint Details
Investigation of complaint GA00181138; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 23, 2017
Visit Reason
The revisit survey was conducted to determine compliance with Federal and State Long Term Care regulations in conjunction with complaint # GA 00178564.
Complaint Details
Complaint # GA 00178564 was investigated and found to be unsubstantiated.
Findings
No deficiencies were cited during the revisit survey and the complaint was found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 23, 2017
Visit Reason
A revisit survey was conducted in conjunction with a complaint survey to determine if previously cited deficiencies had been corrected and to investigate Complaint # GA 00178564.
Complaint Details
Complaint # GA 00178564 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All previously cited deficiencies had been corrected, and the complaint was found to be unsubstantiated with no deficiencies cited during this survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 24, 2017
Visit Reason
The abbreviated survey was conducted on July 24 and 25, 2017, by a Registered Nurse to investigate a complaint #GA00177295 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Investigation was complaint-related for complaint #GA00177295; no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Jun 30, 2017
Visit Reason
An Abbreviated Survey was conducted at Pruitt Health-Savannah on 6/29/17 and 6/30/2017 to investigate complaint GA00176398 regarding the facility's compliance with Federal and State Long Term Care regulations.
Complaint Details
The investigation was triggered by complaint GA00176398. It was substantiated that the Director of Nursing issued an unauthorized order to hold Synthroid medication without physician approval, which was a misinterpretation of lab results.
Findings
The facility failed to provide safe and effective nursing care by writing an order to withhold medication (Synthroid) without physician approval for one resident (R#1). The Director of Nursing misinterpreted lab results and issued an unauthorized order to hold Synthroid for four days, which the physician did not authorize and was unaware of until his rounds on 6/13/2017.
Deficiencies (1)
Facility failed to provide safe and effective nursing care by writing an order to withhold medication without physician's approval for one resident.
Report Facts
Census sample: 111
TSH lab result: 31.9
Synthroid dose: 100
Synthroid dose: 112
Days medication withheld: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Signed the unauthorized order to hold Synthroid and misinterpreted lab results | |
| Administrator | Interviewed and confirmed the policy that orders must be physician-approved and that the order should not have been written without physician consent | |
| Physician | Unaware of the hold order, did not authorize it, and clarified medication orders during rounds |
Inspection Report
Routine
Census: 107
Deficiencies: 0
Date: Mar 23, 2017
Visit Reason
A standard survey was conducted at Pruitthealth - Savannah from March 20, 2017 through March 23, 2017. In addition, Complaint Intake Number GA00172651 was investigated in conjunction with this standard survey.
Complaint Details
Complaint Intake Number GA00172651 was investigated in conjunction with this standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 107
Capacity: 120
Deficiencies: 0
Date: Mar 21, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements for participation in Medicare/Medicaid and related fire safety standards.
Report Facts
Total square footage: 56053
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