Inspection Reports for
Savannah Heights

Complaint investigation regarding bedside commode not being emptied for Resident #40; substantiation status not explicitly stated but deficiency found.

The facility failed to empty the bedside commode for Resident #40 after use on multiple occasions, despite staff awareness and complaints. The Director of Nursing and Administrator were not informed, and the facility policy requires immediate cleaning after use. The deficiency was determined to cause minimal harm affecting a few residents.

The visit was complaint-related involving issues of dignity in care, family and physician notification failures, and Ombudsman notification failures. The complaints were substantiated with findings of minimal harm affecting a few residents.

The facility failed to empty a resident's bedside commode after use, failed to notify family members timely about chest x-rays and hospital readmissions for two residents, and failed to notify the Long Term Care Ombudsman of resident discharges/readmissions for three residents. The facility reported a census of 34 residents and deficiencies were found related to dignity, communication, and documentation.

Complaint #1802590-C resulted in a deficiency. Complaint #1802558-A findings will be sent separately.

The facility was found to have deficiencies related to resident rights and notification of changes, including failure to empty bedside commodes in a dignified manner and failure to notify family members timely about significant changes in residents' conditions. The facility reported a census of 34 residents during the survey.

The facility was found deficient in ensuring safe self-administration of medications, addressing anxiolytic use in care plans with required non-pharmacological interventions, timely response to call lights, documentation of gradual dose reductions and non-pharmacological interventions for psychotropic medications, and offering pneumococcal vaccinations at recommended times.

The facility was found deficient in several areas including resident self-administration of medications, care plan timing and revision, sufficient nursing staff response to call lights, use of psychotropic medications, and influenza and pneumococcal immunizations. The facility reported a census of 32 residents and failed to ensure safe medication self-administration, timely care plan updates, prompt call light responses, proper documentation and use of psychotropic drugs, and adequate vaccination policies and procedures.

The investigation was complaint-driven based on concerns about failure to complete neuro assessments after a fall and inadequate supervision of Resident #1 in her wheelchair. The complaint was substantiated with findings of missed neuro checks and lack of supervision leading to a fall.

The facility failed to complete required neuro assessments for Resident #1 after an unwitnessed fall on 3/23/24 and failed to ensure adequate supervision of the resident in her wheelchair in her room, resulting in a fall. The resident was found on the floor with alarm sounding but no injury was noted. Interviews and record reviews confirmed multiple missed neuro checks and lack of supervision contrary to facility policy.

Complaints #119756-C and #119758-C were substantiated. Facility reported incident #119769-I was substantiated.

The facility was found deficient in quality of care and free of accident hazards/supervision. Specifically, the facility failed to complete neuro assessments after an unwitnessed fall of a resident, and failed to ensure adequate supervision resulting in a fall. Complaints and the incident were substantiated.

The facility was found deficient in multiple areas including failure to timely obtain physician orders for advance directives, failure to provide correct Medicaid/Medicare coverage notices to residents discharged from skilled services, incomplete background checks for employees, failure to document dialysis fistula assessments, and failure to post daily nurse staffing information as required.

The facility was found to have multiple deficiencies including failure to obtain timely physician orders for advance directives, failure to provide correct information to residents being discharged from skilled services, failure to complete background checks for staff, failure to document dialysis assessments, and failure to post nurse staffing information daily. The facility reported a census of 35 residents during the survey.

The complaint investigation found that the facility did not report an injury of unknown origin involving Resident #2 within 24 hours and failed to provide the results of their investigation within five days to the State Survey Agency. The incident involved a mechanical lift failure causing injury to Resident #2. The complaint was substantiated with findings of minimal harm.

The facility failed to report an injury of unknown origin within 24 hours and did not provide investigation results within five days as required. Additionally, the facility failed to provide adequate supervision during a mechanical lift transfer, resulting in Resident #2 being dropped and bruised. Staff education was provided following the incident.

Complaint #108780-C was substantiated. The complaint involved failure to report an injury of unknown origin within required timeframes and failure to provide adequate supervision during resident transfer using a mechanical lift.

The facility failed to report an injury of unknown origin within 24 hours to the State Survey Agency and did not provide the results of their investigation within five days. Additionally, the facility failed to provide adequate supervision using a mechanical lift, resulting in a resident being dropped and bruised during transfer.