Inspection Reports for Savannah Square
1 Savannah Square Dr, Savannah, GA 31406, United States, GA, 31406
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 29, 2020 found the facility in compliance with emergency preparedness and infection control regulations related to COVID-19, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily involving medication delivery delays, food safety and sanitation issues, and fire safety code violations such as improperly maintained fire barriers and means of egress doors. Complaint investigations during this period were mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. Prior deficiencies related to infection control, resident care plans, and fire safety were corrected in subsequent follow-up surveys. The facility’s inspection history indicates improvement over time, culminating in clean findings in the most recent surveys.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
18 residents
Based on a September 2020 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 18
Deficiencies: 0
Sep 29, 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 relevant federal regulations and preparedness for 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 related to infection control regulations, having implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Census: 18
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 0
Sep 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on September 9-10, 2020 by Ascellon on behalf of the Georgia Department of Community Health.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 40
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 28, 2020
Visit Reason
A desk review was conducted by the Fire Safety Supervisor to verify compliance with the approved plan of correction and to confirm that citations had been corrected.
Findings
Documentation showed that the facility had complied with the approved plan of correction and that all citations had been corrected.
Inspection Report
Deficiencies: 0
Jul 16, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Savannah Square Health Center following a regulatory survey.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 16, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Number GA00203756.
Findings
The complaint investigation was concluded with the finding that the complaint was unsubstantiated.
Complaint Details
Complaint Number GA00203756 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 0
Jul 16, 2020
Visit Reason
A revisit survey was conducted on 7/16/2020 to investigate Complaint Intake Number GA00203756 and to verify correction of deficiencies cited in the 3/5/2020 Standard Survey.
Findings
All deficiencies cited in the 3/5/2020 Standard Survey were found to be corrected. The complaint investigation was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00203756 was investigated and found to be unsubstantiated.
Inspection Report
Original Licensing
Deficiencies: 3
Mar 5, 2020
Visit Reason
A Licensure Survey was conducted from March 2, 2020 through March 5, 2020 to assess compliance with state and federal regulations for facility licensure.
Findings
The facility was found deficient in pharmacy management due to delayed medication delivery affecting one resident, unsanitary handling of soiled laundry, and multiple food safety violations including expired food items, unclean food preparation equipment, and unsanitary conditions in the kitchen.
Deficiencies (3)
| Description |
|---|
| Failed to ensure timely medication delivery for one of six residents observed (R#2), resulting in a missed dose of Zoloft. |
| Failed to transport soiled laundry in a sanitary manner and maintain cleanliness of two fans in the laundry room. |
| Failed to label and date food items, discard expired food items, secure opened food items, maintain cleanliness of food preparation fans, and clean food preparation equipment (Panini Supreme). |
Report Facts
Residents observed for medication administration: 6
Medication dose missed: 1
Expired food items: 25
Medication delivery days per week: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Interviewed regarding medication administration and pharmacy communication |
| Director of Nursing | Director of Nursing | Interviewed about pharmacy delivery schedule and medication ordering process |
| HK Supervisor | Housekeeper Supervisor | Interviewed and observed regarding laundry sanitation and fan cleanliness |
| HK Aide JJ | Housekeeping Aide | Confirmed staff practices for transporting soiled laundry |
| Executive Chef | Executive Chef | Interviewed and observed regarding kitchen sanitation and food safety violations |
| Administrator | Administrator | Interviewed about laundry sanitation expectations |
| Food and Beverages Director | Food and Beverages Director | Interviewed about kitchen sanitation responsibilities |
Inspection Report
Routine
Census: 25
Deficiencies: 4
Mar 5, 2020
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies including failure to revise a resident's care plan to address repeated refusal of respiratory treatments, failure to ensure timely medication delivery, unsanitary food procurement and preparation practices, and inadequate infection control related to soiled laundry handling and cleanliness of fans in the laundry room.
Severity Breakdown
SS= D: 2
SS= E: 1
SS= F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to revise the care plan for a resident who repeatedly refused respiratory treatments. | SS= D |
| Failure to ensure timely delivery of medication resulting in a resident missing a routine dose of Zoloft. | SS= D |
| Failure to label and date food items properly, discard expired food, secure opened food items, maintain sanitary food preparation environment including cleanliness of fans and food preparation equipment. | SS= F |
| Failure to transport soiled laundry in a sanitary manner and maintain cleanliness of fans in the laundry room. | SS= E |
Report Facts
Resident census: 25
Medication refusals: 20
Medication refusals: 19
Expired food items: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed medication administration and reported medication unavailability for resident #2. |
| Director of Nursing | Director of Nursing (DON) | Confirmed care plan revision responsibilities and medication delivery procedures. |
| Executive Chef | Provided information and observations related to food safety deficiencies. | |
| Housekeeper Supervisor | Housekeeper Supervisor (HK Supervisor) | Provided information and observations related to laundry room infection control deficiencies. |
| HK Aide JJ | Housekeeping Aide | Confirmed staff transported soiled laundry uncovered and described infection control training. |
| Food and Beverages Director | Discussed expectations for kitchen sanitation and cleaning responsibilities. | |
| Administrator | Stated expectations for sanitary laundry processing and infection control. | |
| MDS Coordinator | Confirmed absence of care plan for refusal of care. |
Inspection Report
Life Safety
Census: 25
Capacity: 40
Deficiencies: 1
Mar 3, 2020
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to maintain the two-hour fire barrier between the LHC and the independent living portion of the building, specifically an electrical sleeve that was not properly fire stopped, potentially placing 20 residents at risk in the event of fire.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain the two-hour fire barrier between the LHC and independent living portion due to an electrical sleeve not properly fire stopped as required by NFPA 101. | E |
Report Facts
Census: 25
Total Capacity: 40
Residents at risk: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of fire barrier deficiency during facility tour |
Inspection Report
Abbreviated Survey
Census: 27
Deficiencies: 0
Jan 15, 2020
Visit Reason
An abbreviated complaint survey was conducted to investigate Complaint #GA00202124 at Savannah Square Health Center.
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
Complaint #GA00202124 was investigated and the facility was found to be in substantial compliance.
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 0
Nov 26, 2019
Visit Reason
An abbreviated/partial survey was conducted to investigate complaint GA00199054.
Findings
No deficiencies were cited and the complaint was not substantiated.
Complaint Details
Complaint GA00199054 was investigated and found to be not substantiated.
Report Facts
Facility census: 32
Inspection Report
Abbreviated Survey
Census: 28
Deficiencies: 0
Jun 27, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00197097 at Savannah Square Health Center.
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 GA00197097; facility found in substantial compliance.
Inspection Report
Abbreviated Survey
Census: 27
Deficiencies: 0
May 16, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00195141 at Savannah Square Health Center.
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 GA00195141; facility found in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 9, 2018
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the standard survey on 2018-10-03.
Findings
All deficiencies cited as a result of the standard survey conducted on 2018-10-03 were found to be corrected during the revisit survey on 2018-11-09.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 8, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 29
Deficiencies: 1
Oct 3, 2018
Visit Reason
A standard survey was conducted at Savannah Square Health Center from September 30, 2018 through October 3, 2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain a clean air filter for an oxygen concentrator used by one resident, which posed a risk to respiratory care standards.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain a clean air filter for an oxygen concentrator for one resident (R#6). | SS= D |
Report Facts
Resident census: 29
Census sample: 16
Oxygen order: 3
CPAP setting: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director Of Nursing/ Interim Director Of Nursing (DON) | Interviewed regarding the dirty oxygen concentrator air filter and lack of system to keep filters clean |
Inspection Report
Life Safety
Census: 29
Capacity: 40
Deficiencies: 2
Oct 2, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance due to failure to maintain required fire barriers and smoke compartment separations. Specifically, doors to the laundry and boiler rooms were missing, and there were improperly sealed penetrations in the smoke barrier between two smoke compartments, placing residents at risk in the event of a fire.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain required enclosure of hazardous areas by not having a door installed to the laundry and boiler rooms as required by NFPA 101. | SS=F |
| Failure to maintain required smoke compartment separations due to improperly sealed penetrations in the smoke barrier between two smoke compartments. | SS=F |
Report Facts
Census: 29
Total Capacity: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding missing door and improperly sealed smoke barrier penetrations |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 12, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected. No new deficiencies were reported.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| NFPA 101 Means of Egress Requirements - Other | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Craig Landolt | Named in relation to the follow-up survey and deficiency findings |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 0
Dec 20, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/12/17 Standard Survey.
Findings
All deficiencies cited as a result of the 10/12/17 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Dec 7, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, with all prior issues corrected except for one related to means of egress.
Findings
The facility failed to maintain a door in the required means of egress that complied with NFPA 101 standards, specifically requiring more than the allowed force to release the latch and set the door leaf in motion, posing a risk to residents in case of fire.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Door in the required means of egress required greater than the minimum 15 lbs to release the latch and 50 lbs to set the leaf in motion as required by code. | SS= D |
Report Facts
Force required to release latch: 15
Force required to set door leaf in motion: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings during the tour |
Inspection Report
Routine
Census: 28
Deficiencies: 4
Oct 12, 2017
Visit Reason
The survey was conducted to determine compliance with Federal and State Long Term Care Requirements for Long Term Care Facilities, including a standard Quality Indicator Survey (QIS).
Findings
The facility was found deficient in multiple areas including failure to follow care plans for enteral feeding water flushes, improper technique in gastrostomy tube care, unsafe hot water temperatures in resident rooms, and failure to follow proper infection control procedures during wound care.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow the plan of care for water flushes per physician order for a resident with a gastrostomy tube. | D |
| Failed to use correct technique for gastrostomy tube placement verification, residual checks, and water flush administration as ordered. | D |
| Failed to maintain safe hot water temperatures in three resident rooms, with temperatures exceeding 120 degrees Fahrenheit. | D |
| Failed to ensure licensed nursing staff washed hands prior to donning clean gloves during wound care, risking cross-contamination. | D |
Report Facts
Sample size: 22
Census: 28
Hot water temperature: 125.4
Hot water temperature: 125.1
Hot water temperature: 124.9
Physician order water flush: 100
Physician order feeding volume: 480
Physician order feeding frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in findings related to failure to follow gastrostomy tube care procedures and infection control during wound care |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding expectations for nursing staff and infection control |
| Maintenance Supervisor | Interviewed regarding hot water temperature monitoring and adjustments |
Inspection Report
Life Safety
Census: 28
Capacity: 40
Deficiencies: 12
Oct 10, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including issues with means of egress doors, sprinkler system maintenance, fire barriers, electrical safety, fire safety plan availability, fire drills documentation, generator testing, power cord usage, and oxygen storage signage.
Severity Breakdown
D: 10
E: 2
F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Door in required means of egress required greater than minimum force to release latch and set leaf in motion. | D |
| Failed to maintain required fire sprinkler system; alarm line on dry sprinkler system was closed preventing activation. | D |
| Items stored within 18 inches of sprinkler head deflectors obstructing spray pattern in kitchen storage/pantry. | D |
| Doors required to have approved hold open devices were held open by items or non-compliant wedges. | F |
| Facility failed to maintain required smoke compartments for size and patient capacity. | E |
| Fire two-hour barrier separating nursing home from independent living not properly maintained; penetrations not sealed. | E |
| Open junction boxes above ceiling and in fire alarm closet; flexible cords used instead of permanent wiring; electrical panels blocked. | D |
| Fire safety plan copy not available at nurses station. | D |
| Facility failed to document required quarterly fire drills on all shifts; two drills missing in first quarter of 2017. | D |
| Generator lacked documented load testing for four continuous hours every three years. | D |
| Power strips left on floor in IT closet and Director of Nursing's office, violating proper use of relocatable power taps. | D |
| Oxygen storage closet not properly marked with required caution signage. | D |
Report Facts
Certified beds: 40
Census: 28
Facility square footage: 40323
Fire drills missing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the inspection. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 18, 2017
Visit Reason
The abbreviated survey was conducted to investigate a complaint #GA00169833 and to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the abbreviated survey.
Complaint Details
Complaint #GA00169833 was investigated during the survey; no deficiencies were found.
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