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)9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
20151050
2017
2018
2019
2020
2021
2022
2023
2024
2025
Census
Latest occupancy rate125 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
An abbreviated/partial extended survey was conducted to investigate multiple complaint numbers received by the facility.
Findings
Several complaint intakes were investigated; some were unsubstantiated with no deficiencies cited, while others were substantiated but also had no deficiencies cited.
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.
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.
Severity Breakdown
E: 2
Deficiencies (2)
Description
Severity
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.
E
Several sprinkler heads required replacement or adjustment of the escutcheon rings.
E
Employees Mentioned
Name
Title
Context
Staff M
Confirmed findings related to fire sprinkler system deficiencies during facility tour.
Inspection Report Deficiencies: 0Mar 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.
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 SafetyCensus: 90Capacity: 140Deficiencies: 14Jan 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.
Severity Breakdown
F: 3E: 6D: 5
Deficiencies (14)
Description
Severity
Emergency Preparedness Program was not in substantial compliance; staff unable to locate required documentation.
F
Corridors and doors obstructed by cleaning carts, service carts, equipment, and refuse receptacles blocking egress.
E
Emergency lighting unit #17 was not operational after testing.
D
Kitchen hood suppression system service tags expired or incorrect.
E
Fire alarm system lacked month and year of manufacture on alternative supply batteries.
E
Fire alarm pull station obstructed by wheelchairs.
E
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.
D
Portable fire extinguisher in Therapy Kitchen missing Class K in-use placard.
D
Smoke corridor fire door gap exceeded 1/8 inch minimum allowed.
E
Doors in 400-500 corridor, kitchen janitorial closet, and laundry room failed to self-close or latch properly.
E
Electrical panel in rear kitchen blocked by rolling service cart.
D
Fire drills lacked proper documentation of conductance.
F
Fire doors modified with non-approved magnetic release devices; lacked proper maintenance documentation.
F
Oxygen cylinder storage lacked signage denoting full/empty status of cylinders.
D
Report Facts
Census: 90Total Capacity: 140Inspection Date: Jan 29, 2024
Employees Mentioned
Name
Title
Context
Staff M
Confirmed multiple findings during facility tour and observations
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)
Description
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: 40Residents reviewed for abuse: 8Residents reviewed for bed hold policy: 4Residents reviewed for pressure ulcers: 3Residents reviewed for diet: 1Residents reviewed for self-administration of medications: 12Residents attending dialysis: 1Residents affected by dishwasher sanitizing issue: 120Residents 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
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.
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.
Complaint Details
Complaint Intake Numbers GA00240517, GA00241862, and GA00242732 were investigated and found unsubstantiated.
Severity Breakdown
D: 15C: 1F: 2
Deficiencies (19)
Description
Severity
Failed to assess one resident for self-administration of medications.
D
Failed to ensure accurate documentation of code status for one resident.
D
Failed to notify physician of change in skin condition for one resident with fungal rash.
D
Failed to issue Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices to Medicare A recipients.
D
Failed to ensure two residents were free from resident-to-resident abuse in two separate incidents.
D
Failed to report an allegation of abuse to the State Survey Agency in a timely manner.
D
Failed to conduct thorough investigations of resident-to-resident incidents including obtaining witness statements.
D
Failed to provide written bed hold policy to residents or their representatives at time of hospital transfer.
D
Failed to transmit Minimum Data Set (MDS) assessment data to CMS within required timeframe.
D
Failed to ensure accuracy of Minimum Data Set (MDS) assessment related to anticoagulant use.
D
Failed to provide baseline care plan including pressure ulcers for one resident.
D
Failed to invite residents or their representatives to participate in quarterly care plan meetings.
D
Failed to provide pressure ulcer care according to professional standards including documenting orders and treatments.
D
Failed to provide respiratory care per standards including proper storage of respiratory equipment.
D
Failed to communicate with dialysis center prior to and after dialysis treatment for one resident.
D
Failed to include facility name, census, and total number and hours worked by nursing staff on daily nurse staffing document.
C
Failed to ensure resident received diet as ordered by attending physician.
D
Failed to ensure dishwasher rinse temperature met required sanitizing temperature and failed to perform hand hygiene between handling soiled and clean dishes.
F
Failed to ensure laundry aide donned proper personal protective equipment while sorting soiled laundry.
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)
Description
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: 2Therapy sessions missed: 4Physical therapy order frequency: 5Occupational 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
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.
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.
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.
Severity Breakdown
F 0812 SS=F: 1F 0825 SS=D: 1
Deficiencies (2)
Description
Severity
Facility failed to ensure that opened food items in the walk-in freezer and reach-in refrigerator were resealed and labeled with a date.
F 0812 SS=F
Facility failed to provide Physical Therapy Services as ordered for 2 out of 3 residents sampled.
An abbreviated survey was conducted to investigate three complaints (#GA00229056, #GA00229646, and #GA00229802).
Findings
Complaints #GA00229056 and #GA00229802 were found to be unsubstantiated, while complaint #GA00229646 was substantiated. No deficiencies were cited during the survey.
Complaint Details
Complaint #GA00229646 was substantiated; complaints #GA00229056 and #GA00229802 were unsubstantiated.
An abbreviated survey was conducted to investigate complaints #GA00225966, #GA00226076, #GA00226876, and #GA00227477.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints #GA00225966, #GA00226076, #GA00226876, and #GA00227477 were investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report Plan of CorrectionDeficiencies: 0Sep 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.
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.
Severity Breakdown
E: 2
Deficiencies (2)
Description
Severity
Facility failed to maintain unobstructed means of egress; items stored along corridors impeded egress.
E
Multiple patient room doors do not open, close, or latch properly.
E
Employees Mentioned
Name
Title
Context
Staff M confirmed findings related to means of egress and door functionality.
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.
Severity Breakdown
Level D: 1Level E: 1
Deficiencies (2)
Description
Severity
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.
Level D
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.
Level E
Report Facts
Resident census: 105Resident 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 SafetyCensus: 105Capacity: 140Deficiencies: 9Jul 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.
Severity Breakdown
E: 5F: 3D: 1
Deficiencies (9)
Description
Severity
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.
E
Dining room patio gate locked from outside with only one staff member having key.
F
Kitchen hood suppression system is red-tagged due to canister tank size and nozzle coverage.
F
Fire alarm system smoke detector missing in 400 corridor causing panel trouble.
F
Damaged smoke detectors not repaired timely in 400 corridor.
F
Backflow preventer deficiencies found during inspection not repaired; repeated check valve leak noted.
E
Patient room doors do not open/close or latch properly.
E
Wiring junction box cover missing behind dryer in laundry room.
E
Fire drill documentation incorrect and/or not current; multiple dates missing and shifts not marked.
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.
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.
Complaint Details
Complaint GA00216818 was unsubstantiated with no regulatory violations cited. Complaint GA00216765 was substantiated with no regulatory violations cited.
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.
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.
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.
A complaint survey was conducted at PruittHealth of Savannah from July 8, 2020 through July 13, 2020 for complaint numbers GA00200690 and GA00205876.
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.
Complaint Details
Complaint survey conducted for complaint numbers GA00200690 and GA00205876; facility found in compliance.
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 LicensingDeficiencies: 0Dec 12, 2019
Visit Reason
The inspection was conducted as a Licensure Survey for the facility.
Findings
No deficiencies were identified during the Licensure Survey.
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.
An abbreviated survey was conducted from June 13, 2019 through June 18, 2019 to investigate multiple complaints identified by their complaint numbers.
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.
Complaint Details
The survey was conducted to investigate complaints GA00197394, GA00197210, GA00197099, GA00197058, and GA00196966. The facility was found to be in substantial compliance.
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.
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.
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.
Severity Breakdown
E: 2
Deficiencies (2)
Description
Severity
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.
E
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.
E
Report Facts
Resident census: 115Repair 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
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)
Description
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, 2019Date of inspection: May 21, 2019Resident admission dates: Mar 13, 2019Resident admission dates: Mar 23, 2019Resident admission dates: Apr 11, 2019BIMS score: 15Wait 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
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 SafetyCensus: 111Capacity: 120Deficiencies: 4Feb 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.
Severity Breakdown
F: 2D: 2
Deficiencies (4)
Description
Severity
Emergency Preparedness Plan lacked required documentation of cooperation and collaboration with local emergency preparedness officials.
F
Facility failed to provide an NFPA 13 compliant sprinkler system; sprinkler heads obstructed by ceiling fixtures.
D
Doors protecting corridors failed to close fully and latch as required; specific doors blocked or latch not catching.
D
Electrical closets and boiler room were obstructed and lacked proper combustion air supply as required by NFPA 54 and NFPA 70.
F
Report Facts
Census: 111Total Capacity: 120Residents at risk: 25Number of obstructed sprinkler heads: 10Inspection 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
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.
Severity Breakdown
Level D: 6Level E: 1
Deficiencies (7)
Description
Severity
Failed to ensure that two residents transferred to hospital received notice of the facility's bed hold policy prior to transfer.
Level D
Failed to complete a discharge Minimum Data Set assessment for one resident in a timely manner.
Level D
Failed to provide a copy of the Baseline Care Plan to one resident and their responsible party after admission.
Level D
Failed to revise care plans for two residents to reflect hospice services, code status, and noncompliance with fluid restriction and life vest use.
Level D
Failed to develop and implement a discharge plan for one resident.
Level D
Failed to promptly notify the ordering physician of urine culture results that showed resistance to prescribed antibiotic for one resident.
Level D
Failed to properly store, discard, label, and date food items in two unit refrigerators.
Level E
Report Facts
Resident census: 112Number of residents reviewed: 34Date of survey completion: Feb 28, 2019Food expiration date: 48Frozen food expiration date: 14
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)
Description
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: 2Total 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.
An unannounced, abbreviated complaint survey was conducted due to a complaint investigation at Pruitt Health Savannah from February 11 to February 12, 2019.
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.
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.
The inspection was conducted as a result of a complaint investigation #GA00192965 regarding patient rights.
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.
Complaint Details
Complaint investigation #GA00192965 was not substantiated.
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00192723.
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.
An abbreviated survey was conducted to investigate complaint GA00189986.
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.
Complaint Details
Investigation of complaint GA00189986; facility found in substantial compliance.
A revisit survey was conducted to verify correction of deficiencies cited in the April 6, 2018 Complaint Survey GA00186883.
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.
Complaint Details
Complaint Intake Numbers GA00184677 and GA00184864 were investigated and found unsubstantiated with no deficiencies.
An abbreviated survey was conducted to investigate complaint GA00186698 at Pruitt Health - Savannah.
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.
Complaint Details
Investigation of complaint GA00186698; facility found in substantial compliance.
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 SafetyCensus: 114Capacity: 120Deficiencies: 6Feb 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.
Severity Breakdown
D: 5F: 1
Deficiencies (6)
Description
Severity
Failed to maintain fire alarm panel marking, breaker marking, and battery manufacturers date marking.
D
Failed to maintain sprinkler coverage in patient room 100; sprinkler head exceeded maximum permitted distance.
D
Failed to maintain a patient room door (Room 403) so that it latched positively.
D
Facility had a transfer grill in a corridor door to a room containing combustible materials (Data Room).
D
Failed to maintain self-closing smoke compartment doors; one held open by paper wedge and another unable to close completely.
D
Failed to maintain multi-tap power strips in a compliant manner by allowing them to be placed directly on the floor in multiple locations.
F
Report Facts
Census: 114Total Capacity: 120
Employees Mentioned
Name
Title
Context
Staff M
Staff member who confirmed findings during facility tour
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.
An abbreviated survey was conducted to investigate complaint GA00182520 at PruittHealth Savannah.
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.
Complaint Details
Investigation of complaint GA00182520; facility found in substantial compliance.
An abbreviated survey was conducted to investigate complaint GA00181138 at Pruitt Health - Savannah.
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.
Complaint Details
Investigation of complaint GA00181138; facility found in substantial compliance.
The revisit survey was conducted to determine compliance with Federal and State Long Term Care regulations in conjunction with complaint # GA 00178564.
Findings
No deficiencies were cited during the revisit survey and the complaint was found to be unsubstantiated.
Complaint Details
Complaint # GA 00178564 was investigated and found to be unsubstantiated.
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.
Findings
All previously cited deficiencies had been corrected, and the complaint was found to be unsubstantiated with no deficiencies cited during this survey.
Complaint Details
Complaint # GA 00178564 was investigated and found to be unsubstantiated with no deficiencies cited.
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.
Findings
No deficiencies were cited during the abbreviated survey.
Complaint Details
Investigation was complaint-related for complaint #GA00177295; no deficiencies were found.
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Facility failed to provide safe and effective nursing care by writing an order to withhold medication without physician's approval for one resident.
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.
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.
Complaint Details
Complaint Intake Number GA00172651 was investigated in conjunction with this standard survey.
Inspection Report Life SafetyCensus: 107Capacity: 120Deficiencies: 0Mar 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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