Inspection Report
Follow-Up
Deficiencies: 0
Jul 2, 2025
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected and to review the Emergency Preparedness Program compliance.
Findings
The Emergency Preparedness Program was found to be in substantial compliance with LTC 42 CFR & 483.73, and all previously cited deficiencies were corrected.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Jun 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 15, 2025 Standard Survey.
Findings
All deficiencies cited in the prior May 15, 2025 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Jun 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 15, 2025, standard survey.
Findings
All deficiencies cited in the previous May 15, 2025, standard survey were found to be corrected during the revisit survey.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Latisha Bolden | Named in relation to the revisit survey and statement of deficiencies. |
Inspection Report
Life Safety
Census: 109
Capacity: 121
Deficiencies: 7
May 19, 2025
Visit Reason
A Life Safety Code Survey was 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 requirements, including broken or missing self-closing door arms, unsealed openings in fire barriers, blocked and unmaintained fire extinguishers, smoke doors not closing properly, non-functioning HVAC in certain areas, and missing receptacle covers.
Severity Breakdown
SS= D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to repair broken or missing self-closing arms on doors affecting smoke compartments and upstairs offices. | SS= D |
| Failed to enclose an opening in the ceiling of the second story maintenance office presenting a fire hazard. | SS= D |
| Failed to ensure all portable fire extinguishers were not blocked, maintained, and tagged to show they are in service. | SS= D |
| Failed to construct smoke barriers to required fire resistance rating and properly seal penetrations. | SS= D |
| Failed to ensure smoke door closed completely when magnet released it due to door hinge issues. | SS= D |
| Failed to maintain HVAC system in kitchen and laundry room resulting in non-functioning air conditioning. | SS= D |
| Failed to ensure all electrical receptacles had covers, with one missing cover found in maintenance office. | SS= D |
Report Facts
Census: 109
Total Capacity: 121
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Routine
Census: 111
Deficiencies: 12
May 15, 2025
Visit Reason
A standard routine survey was conducted at Signature Healthcare of Savannah from May 12, 2025 through May 15, 2025, including investigation of multiple complaint intakes, some substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to protect resident dignity related to incontinent care, failure to provide meal choice for residents eating in their rooms, failure to timely report abuse allegations, failure to provide written bed hold notices, inaccurate MDS coding for PASRR Level II, failure to follow oxygen therapy orders, failure to update care plans for infection control and oxygen therapy, failure to provide therapeutic positioning devices, failure to provide nutritional meals according to diagnosis, and failure to follow infection control practices during tracheostomy care.
Complaint Details
Multiple complaint intakes were investigated in conjunction with the standard survey. Some complaints were substantiated with deficiencies, including GA00254031, GA00245811, GA00251775, and others.
Severity Breakdown
SS=D: 11
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to protect dignity related to incontinent care by providing smaller briefs causing leakage. | SS=D |
| Facility failed to provide meal choice of same nutritional value to residents eating in their rooms. | SS=D |
| Facility failed to report allegations of abuse in a timely manner. | SS=D |
| Facility failed to provide written bed hold notice to resident upon hospital transfer. | SS=D |
| Facility failed to accurately code PASRR Level II status on MDS for one resident. | SS=D |
| Facility failed to refer one resident with serious mental disorder for PASRR Level II assessment on admission. | SS=D |
| Facility failed to ensure care plans for oxygen therapy reflected physician orders and failed to initiate oxygen interventions for residents. | SS=D |
| Facility failed to revise care plan to include Enhanced Barrier Precautions and MRSA in urine for resident with indwelling catheter. | SS=D |
| Facility failed to provide therapeutic supported device equipment (leg rest/footrest) for resident with leg contracture and pressure wound. | SS=D |
| Facility failed to ensure oxygen therapy was administered according to physician orders for three residents. | SS=D |
| Facility failed to provide nutritional meals according to resident diagnosis and failed to provide menus allowing meal preference choices. | SS=D |
| Facility failed to follow infection control practices during tracheostomy care for resident with trach on Enhanced Barrier Precautions. | SS=E |
Report Facts
Resident census: 111
Sample size: 53
Residents on regular meal diet: 78
Residents on puree diet: 13
Residents on mechanical diet: 15
Residents on special diets: 18
Oxygen flowrate: 2
Observed oxygen flowrate: 3.5
Observed oxygen flowrate: 4.5
Blood glucose levels: 537
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Certified Nurse Assistant | Named in incontinent care deficiency interview |
| Administrator | Named in multiple interviews related to deficiencies | |
| ADON | Assistant Director of Nursing | Named in abuse reporting deficiency interview |
| LPN BB | Licensed Practical Nurse | Named in bed hold notice deficiency interview |
| MDS Coordinator | Named in PASRR and oxygen care plan deficiencies | |
| Food Service Manager | Named in meal choice deficiency interview | |
| RT LL | Respiratory Therapist | Named in trach care infection control deficiency |
| RT KK | Respiratory Therapist | Named in trach care infection control deficiency |
| LPN EEE | Licensed Practical Nurse | Named in nutritional meal deficiency interview |
| RD GGG | Registered Dietitian | Named in nutritional meal deficiency interview |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Jan 7, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00251364 and GA00253322.
Findings
The complaints GA00251364 and GA00253322 were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints GA00251364 and GA00253322 were investigated and found to be unsubstantiated.
Report Facts
Complaints investigated: 2
Census: 112
Inspection Report
Deficiencies: 0
Nov 12, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Signature Healthcare of Savannah, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Nov 12, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 23, 2024, Complaint Survey.
Findings
All deficiencies cited as a result of the September 23, 2024, Complaint Survey were found to be corrected.
Complaint Details
The revisit survey followed a complaint survey conducted on September 23, 2024, and confirmed correction of all cited deficiencies.
Report Facts
Census: 106
Inspection Report
Annual Inspection
Deficiencies: 1
Sep 23, 2024
Visit Reason
A State Licensure survey was conducted at Savannah Post Acute LLC from September 18, 2024, through September 23, 2024, to assess compliance with state health regulations.
Findings
The facility failed to develop a care plan for one of four sampled residents with a history of wandering and exit-seeking behaviors, increasing the risk that the resident would not receive appropriate treatment or care. Interviews and record reviews confirmed delays in care planning and assessment for elopement risks.
Deficiencies (1)
| Description |
|---|
| Failure to develop a care plan for a resident with wandering and exit-seeking behaviors. |
Report Facts
Number of sampled residents: 4
Date of Quarterly Minimum Data Set (MDS) Assessment: Sep 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GGG | Licensed Practical Nurse | Documented resident's wandering and exit-seeking behavior on 8/18/2024 |
| NN | Licensed Practical Nurse | Documented visitor intervention and resident elopement on 9/15/2024 |
| FF | Registered Nurse | Documented resident found outside facility with no injuries on 9/15/2024 |
| PP | Licensed Practical Nurse | Stated staff used care plan as guidance during interview on 9/23/2024 |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Sep 23, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Number GA00250687, which was substantiated with deficiencies related to resident care and safety.
Findings
The facility failed to develop a care plan for a resident with wandering and exit-seeking behaviors and failed to provide adequate supervision to prevent elopement when the resident exited the facility unnoticed for over one hour. Multiple staff interviews and record reviews confirmed delays in assessment and inadequate door security.
Complaint Details
Complaint Number GA00250687 was substantiated. The investigation revealed that the resident (R1) with cognitive impairment and wandering behavior eloped from the facility on 9/15/2024 due to inadequate care planning and supervision. The resident was outside the facility for over one hour without staff awareness. The front exit door was found to have a latch malfunction and was not secured properly at the time of the incident.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop a care plan for a resident with wandering and exit-seeking behaviors. | SS= D |
| Failure to provide protective oversight and supervision to prevent elopement when a resident exited the facility and was unaccounted for over one hour. | SS= D |
Report Facts
Census: 102
Dates of key events: Sep 15, 2024
Dates of assessments: Sep 17, 2024
Dates of survey: Sep 18, 2024
Dates of survey: Sep 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GGG | Licensed Practical Nurse (LPN) | Documented resident's wandering and exit-seeking behavior on 8/18/2024 |
| NN | Licensed Practical Nurse (LPN) | Documented visitor pushing resident back into facility on 9/15/2024 |
| FF | Registered Nurse (RN) | Documented resident found outside facility with no injuries on 9/15/2024 and informed Director of Nursing |
| PP | Licensed Practical Nurse (LPN) | On duty during elopement incident and reported family member's observation on 9/15/2024 |
| MM | Receptionist | Documented resident exiting front door unnoticed on 9/15/2024 |
| FFF | Certified Nursing Assistant (CNA) | Worked on hall where resident resided on 9/15/2024 and observed resident's agitation |
| KK | Licensed Practical Nurse (LPN) | Worked on 9/15/2024 and noted resident's confusion and ambulation |
| EEE | Certified Nursing Assistant (CNA) | Stated she had not completed elopement training |
| LL | Receptionist | Reported front exit door delay and staffing coverage at reception |
| HH | Assistant Maintenance Director | Observed front exit door not latching and reported staff had not brought issue to attention |
| II | Maintenance Director II | Activated switch on front exit door to restore proper latching |
| CC | Nurse Practitioner (NP) | Wrote order for resident's departure alert system on 9/15/2024 |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 5, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Follow-Up Survey.
Inspection Report
Deficiencies: 0
Jun 20, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Signature Healthcare of Savannah, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Jun 20, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the 4/12/2024 Recertification Survey.
Findings
All deficiencies cited as a result of the 4/12/2024 Recertification Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Jun 4, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to ensure proper inspection, testing, and maintenance of the fire sprinkler system, specifically in the 100 Hall between Room 108 and the Activity Room, where fire stopping material was improperly used to hold sprinkler head escutcheons in place. These findings were confirmed by staff at the time of discovery.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper inspection, testing, and maintenance of the fire sprinkler system; fire stopping material used to hold sprinkler head escutcheons in place. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire sprinkler system during facility tour. |
Inspection Report
Routine
Census: 109
Deficiencies: 8
Apr 12, 2024
Visit Reason
A State Licensure survey was conducted at Savannah Post Acute LLC from April 8, 2024, through April 12, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including incomplete grievance investigations, failure to report and investigate abuse and misappropriation of resident property, inadequate posting of abuse reporting information, lack of competency documentation for Certified Medication Aides, infection control lapses during a COVID-19 outbreak, unsecured medications at bedside, incomplete and unimplemented care plans for several residents, failure to provide scheduled baths/showers, and unsanitary kitchen and dumpster conditions.
Deficiencies (8)
| Description |
|---|
| Facility failed to thoroughly complete resident grievance forms and ensure timely resolution and resident satisfaction for 42 of 101 grievance forms reviewed. |
| Facility failed to report misappropriation of property to the State Survey Agency and failed to thoroughly investigate abuse allegations for four residents. |
| Facility failed to post complete abuse reporting information accessible to residents and visitors. |
| Facility failed to provide evidence that three of four Certified Medication Aides completed medication administration competency skills checklist before administering medications. |
| Facility failed to ensure infection control practices were followed during COVID-19 outbreak, including mask changes and closing of transmission-based precaution room doors; failed to designate qualified Infection Control Preventionist for two of last 12 months and failed to ensure adequate time for ICP duties. |
| Three residents had unsecured and unauthorized medications or medicated treatment products at bedside without assessment for self-administration. |
| Facility failed to develop or implement comprehensive, person-centered care plans for contracture management, oxygen therapy, dialysis care, and failed to provide scheduled assistance with activities of daily living including baths/showers. |
| Facility failed to ensure kitchen walls, floors, and equipment were clean and free of rust, debris, and grease buildup; used expired quaternary test strips; and failed to maintain outdoor garbage and refuse area free of litter for two dumpsters. |
Report Facts
Resident grievances incomplete: 42
Residents tested positive for COVID-19: 31
Staff tested positive for COVID-19: 11
Facility census: 109
Residents sampled: 54
Residents with unsecured medications: 3
Grievance forms reviewed: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Reported helping residents write grievances and submitting complaints to Administrator | |
| Administrator | Confirmed issues with grievance process and lack of reporting abuse and misappropriation | |
| Social Services Director | Spoke to resident about abuse allegation, failed to document or notify Administrator or DON | |
| Director of Nursing | Unaware of missing money allegations and abuse reports, confirmed expectations for reporting | |
| Certified Medication Aide PP | CMA | Reported no skills competency checklist completed |
| Certified Medication Aide JJJ | CMA | Reported no medication administration skills checkoff completed |
| Food Service Manager | Confirmed kitchen cleanliness issues and dumpster conditions | |
| Vice President of Clinical Operations | Observed and confirmed kitchen cleanliness issues | |
| Director of Nursing | Confirmed lack of care plans, missing dialysis communication forms, and infection control program deficiencies |
Inspection Report
Routine
Census: 109
Deficiencies: 16
Apr 12, 2024
Visit Reason
A standard survey was conducted at Savannah Post Acute LLC from April 8, 2024, through April 12, 2024, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsecured medications at bedside, incomplete grievance resolution documentation, incomplete abuse reporting and investigations, inadequate care plans, insufficient bathing assistance, delayed antibiotic administration, unclean oxygen equipment, poor infection control practices during a COVID-19 outbreak, inadequate antibiotic stewardship, and insufficient infection preventionist staffing.
Complaint Details
Multiple complaint intake numbers were investigated. Some complaints were substantiated with deficiencies, others were unsubstantiated or substantiated without deficiencies.
Severity Breakdown
Level D: 9
Level E: 1
Level F: 5
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure three residents had secured and authorized medications at bedside. | Level D |
| Failed to thoroughly complete resident grievance forms and ensure timely resolution for 42 of 101 grievances reviewed. | Level E |
| Failed to post complete abuse reporting information accessible to residents and visitors. | Level D |
| Failed to report misappropriation of property to State Survey Agency for two residents. | Level D |
| Failed to thoroughly investigate abuse allegations for four residents. | Level D |
| Failed to develop or implement comprehensive care plans for three residents including contracture management, oxygen therapy, and dialysis care. | Level D |
| Failed to provide adequate bathing assistance to one resident, resulting in unmet needs. | Level D |
| Failed to transcribe and administer antibiotic medication timely for one resident. | Level D |
| Failed to provide respiratory care consistent with standards for four residents including unclean oxygen equipment, missing orders, and undocumented tracheostomy care. | Level D |
| Failed to ensure adequate nursing staff for the first quarter of 2024. | Level F |
| Failed to provide evidence that three of four Certified Medication Aides completed medication administration competency skills checklist. | Level F |
| Failed to maintain kitchen cleanliness and use unexpired sanitizing test strips. | Level F |
| Failed to maintain outdoor garbage area free of litter and debris. | Level F |
| Failed to ensure infection control practices during COVID-19 outbreak including mask changes and closing isolation room doors. | Level F |
| Failed to provide evidence of periodic review and follow-up of antibiotic prescribing practices for 12 months. | Level F |
| Failed to designate a qualified Infection Control Preventionist and ensure adequate time for ICP duties for six of last 12 months. | Level F |
Report Facts
Residents present: 109
Grievance forms reviewed: 101
Incomplete grievance forms: 42
PBJ Staffing Rating: 1
Medication administration competency checklists missing: 3
Expired sanitizing test strips: 1
COVID-19 positive residents: 31
COVID-19 positive staff: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LL | Licensed Practical Nurse | Reported medication order transcription delay for R49 |
| FFF | Licensed Practical Nurse | Confirmed unsecured medications in resident rooms R30, R32, R71 |
| DON | Director of Nursing | Confirmed multiple deficiencies including care plans, infection control, and staffing |
| SSA | Social Service Assistant | Documented grievances but failed to report missing resident money to State Agency |
| Administrator | Facility Administrator | Acknowledged deficiencies in grievance process, infection control, and antibiotic stewardship |
| RA AA | Restorative Aide | Reported no restorative services provided to R11 |
| LPN CC | Licensed Practical Nurse Restorative Nurse | Oversaw restorative nursing program, confirmed discontinuation of R11 restorative services |
| FSM | Food Service Manager | Confirmed kitchen cleanliness issues and expired sanitizing strips |
| District Manager | District Manager | Confirmed dumpster area cleanliness issues |
| ICP | Infection Control Preventionist | Newly employed, unable to provide infection control tracking data |
Inspection Report
Life Safety
Census: 108
Capacity: 120
Deficiencies: 3
Apr 10, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper placement of kitchen hood suppression nozzles, failure to properly inspect, test, and maintain the fire sprinkler system, and improper use of power strips in patient care areas. Multiple deficiencies affecting the fire suppression system and electrical equipment were observed and confirmed during the tour.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Improper hood suppression nozzle placement over cooking equipment affecting the kitchen hood suppression system. | D |
| Failure to ensure proper inspection, testing, and maintenance of the fire sprinkler system, including use of fire stopping material to hold sprinkler escutcheons, painted and lint-loaded sprinkler heads, and external loading on sprinkler piping. | E |
| Failure to adhere to manufacturer recommendations for surge power strips, including piggybacking and not mounting power strips off the floor in patient care areas. | D |
Report Facts
Census: 108
Total Capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 0
Jan 30, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00243242.
Findings
The complaint GA00243242 was unsubstantiated and no deficiencies were cited related to this complaint.
Complaint Details
Complaint GA00243242 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Nov 22, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00225539, #GA00226262, and #GA00227898.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00225539, #GA00226262, and #GA00227898 were investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Jul 25, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Signature Healthcare of Savannah, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Jul 25, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the May 19, 2022 Recertification Survey.
Findings
All deficiencies cited in the May 19, 2022 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Census: 109
Deficiencies: 3
May 19, 2022
Visit Reason
A Licensure Survey was conducted from 5/17/2022 through 5/19/2022 to assess compliance with licensure requirements and identify any deficiencies.
Findings
The facility failed to ensure treatment orders for one resident with pressure ulcers were transcribed and implemented as ordered by the physician. Additionally, the facility did not maintain clean privacy curtains and bathroom walls in good repair in several rooms, and failed to develop a pneumococcal vaccine policy or provide documentation that three sampled residents were offered or received the vaccine.
Deficiencies (3)
| Description |
|---|
| Failed to ensure treatment orders for one resident (#71) with pressure ulcers were transcribed and implemented as ordered by the physician. |
| Failed to maintain clean privacy curtains in rooms 102, 107, and 111, and failed to ensure bathroom walls were in good repair in rooms 106, 107, and 110. |
| Failed to develop a pneumococcal vaccine policy and failed to provide documentation that three sampled residents (#77, #24, and #79) were offered and/or received the pneumococcal vaccine. |
Report Facts
Facility census: 109
Residents with pressure ulcers: 10
Sampled residents for pneumococcal vaccine: 5
Residents without vaccine documentation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Named in interview regarding transcription and implementation of physician orders |
| Treatment Nurse | Named in wound care observation and interview about order transcription | |
| Director of Nursing (DON) | Interviewed regarding chart checks and order transcription responsibilities | |
| Plant Operations Manager | Interviewed regarding maintenance and repair issues | |
| House Keeping Manager | Interviewed regarding cleaning and privacy curtain inspections | |
| Administrator | Interviewed regarding maintenance reporting and department responsibilities | |
| Infection Control Prevention Coordinator (ICPC) | Interviewed regarding vaccine documentation |
Inspection Report
Renewal
Census: 109
Deficiencies: 3
May 19, 2022
Visit Reason
A Licensure Survey was conducted from 5/17/2022 through 5/19/2022 to assess compliance with state regulations and licensing requirements for Signature Healthcare of Savannah.
Findings
The facility was found deficient in nursing care related to failure to transcribe and implement wound care treatment orders for one resident, environmental sanitation issues including unclean privacy curtains and bathroom wall damage in multiple rooms, and failure to develop pneumococcal vaccine policies and provide vaccine documentation for three residents.
Deficiencies (3)
| Description |
|---|
| Failure to ensure treatment orders for one resident (#71) with pressure ulcers were transcribed and implemented as ordered by the physician. |
| Failure to maintain clean privacy curtains in rooms 102, 107, and 111 and failure to ensure bathroom walls were in good repair in rooms 106, 107, and 110. |
| Failure to develop a pneumococcal vaccine policy and procedure and failure to provide documentation that three sampled residents (#77, #24, and #79) were offered and/or received the pneumococcal vaccine. |
Report Facts
Facility census: 109
Residents with pressure ulcers: 10
Residents sampled for pneumococcal vaccine documentation: 5
Residents without vaccine documentation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding transcription and implementation of physician orders |
| Infection Control Prevention Coordinator (ICPC) | Interviewed regarding pneumococcal vaccine documentation | |
| Director of Nursing (DON) | Interviewed regarding chart checks and order transcription responsibilities | |
| Plant Operations Manager | Interviewed regarding maintenance and repair processes | |
| House Keeping Manager | Interviewed regarding cleaning and privacy curtain inspection procedures | |
| Administrator | Interviewed regarding maintenance reporting and department responsibilities |
Inspection Report
Life Safety
Census: 109
Capacity: 120
Deficiencies: 0
May 17, 2022
Visit Reason
A 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 to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
May 4, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated Survey investigating complaints #GA00222943 and #GA00223615.
Findings
The complaints were unsubstantiated with no regulatory violations cited. The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
Complaints #GA00222943 and #GA00223615 were investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Total census: 112
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 3, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by their numbers.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00218152, #GA00218238, #GA00220124, #GA00221118, #GA00221701, and #GA00221919 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 25, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00214586.
Findings
The complaint was not substantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00214586 was investigated and found to be not substantiated.
Inspection Report
Deficiencies: 0
Nov 17, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 100
Deficiencies: 0
Nov 17, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the September 23, 2020 Complaint Survey.
Findings
All deficiencies cited as a result of the September 23, 2020 Complaint Survey were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey on September 23, 2020. All cited deficiencies were corrected.
Report Facts
Census: 100
Inspection Report
Re-Inspection
Census: 100
Deficiencies: 0
Nov 17, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the September 23, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Report Facts
Census: 100
Inspection Report
Routine
Census: 99
Deficiencies: 0
Oct 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with the relevant regulations, and no deficiencies were cited during this survey.
Report Facts
Total census: 99
Inspection Report
Renewal
Deficiencies: 1
Sep 23, 2020
Visit Reason
A Licensure Survey was conducted from 9/21/2020 through 9/23/2020 to assess compliance with licensure requirements at Signature Healthcare of Savannah.
Findings
The facility failed to obtain a treatment order upon admission for a resident with sutures, resulting in inadequate wound care and subsequent infection. Interviews with staff and family confirmed lack of wound care orders and failure to notify the physician for treatment instructions.
Deficiencies (1)
| Description |
|---|
| Failure to obtain a treatment order upon admission for a resident with sutures, leading to inadequate wound care and infection. |
Report Facts
Staples on resident's forehead: 24
Dates of licensure survey: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Wound Care Nurse | Interviewed regarding wound care and noted no cleaning or dressing applied to sutures |
| DD | Licensed Practical Nurse | Interviewed about protocol for obtaining wound treatment orders on admission |
| EE | Licensed Practical Nurse | Interviewed about protocol for obtaining wound treatment orders on admission |
| HH | Physician Assistant | Interviewed from neurology office regarding wound care order clarification |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 23, 2020
Visit Reason
An abbreviated partial survey was conducted to investigate complaints GA00207060 and GA00207664. Complaint GA00207664 was substantiated with a deficiency, while complaint GA00207060 was partially substantiated without deficiencies.
Findings
The facility failed to obtain a treatment order upon admission for a resident with sutures, resulting in inadequate wound care and subsequent infection after discharge. Interviews with staff and family confirmed lack of wound treatment orders and failure to notify the physician for clarification.
Complaint Details
Complaint GA00207664 was substantiated with a deficiency related to wound care treatment orders. Complaint GA00207060 was partially substantiated without deficiencies.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to obtain a treatment order upon admission for a resident with sutures, leading to inadequate wound care and infection. | Level D |
Report Facts
Staples on resident's forehead: 24
Brief Mental Status (BIMS) score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Wound Care Nurse | Interviewed regarding wound care and treatment orders for resident R 'A' |
| DD | Licensed Practical Nurse | Interviewed about procedures for obtaining wound treatment orders on admission |
| EE | Licensed Practical Nurse | Interviewed about procedures for obtaining wound treatment orders on admission |
| HH | Physician Assistant | Interviewed from neurology office regarding wound care treatment orders |
| Director of Nursing | Director of Nursing | Interviewed about expectations for obtaining wound care orders |
| Administrator | Administrator | Interviewed about expectations for nursing staff regarding wound orders |
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 1
Sep 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on September 21 and 22, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH) to assess compliance with COVID-19 testing and infection control regulations.
Findings
The facility was found not in substantial compliance with 42 CFR §483.80 infection control regulation due to failure to receive COVID-19 test results for staff within the required 48-hour timeframe and failure to contact the state health department regarding delays in test result turnaround times.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain COVID-19 test results within 48 hours for four of five staff tested and failure to contact the state health department about delays in test results. | E |
Report Facts
Census: 96
Staff tested: 5
Staff with delayed test results: 4
County positivity rate: 10.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding COVID-19 test result turnaround times and communication with state health department | |
| Staff Development Coordinator (SDC) | Interviewed about COVID-19 test result turnaround times | |
| Director of Nursing (DON) | Interviewed about communication with corporate and state regarding test result delays | |
| Business Office Manager | Interviewed about delays in receiving COVID-19 test results |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 28, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a Covid-19 Focused Infection Control Survey investigating complaints #GA00205286, GA00205773, and GA00206109.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints #GA00205286, GA00205773, and GA00206109 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Jul 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
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 for COVID-19 preparation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00201973 and #GA00202542.
Findings
The complaints were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00201973 and #GA00202542 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 0
Nov 14, 2019
Visit Reason
A revisit survey was conducted from 11/12/19 through 11/14/19 to verify correction of deficiencies cited in the Standard Survey of 8/8/19.
Findings
All deficiencies cited as a result of the Standard Survey of 8/8/19 were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 14, 2019
Visit Reason
An abbreviated/partial extended survey was conducted from 11/12/19 to 11/14/19 to investigate complaint GA00199687 and included revisits from prior surveys conducted in August and July 2019.
Findings
The allegations from complaint GA00199687 were determined to be unsubstantiated. The survey included a revisit from previous standard and abbreviated surveys.
Complaint Details
The complaint GA00199687 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 0
Nov 14, 2019
Visit Reason
A revisit survey was conducted from 11/12/19 through 11/14/19 to verify correction of deficiencies cited during the Complaint Survey of 7/18/19.
Findings
All deficiencies cited as a result of the Complaint Survey of 7/18/19 were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted to confirm correction of deficiencies identified in the complaint survey dated 7/18/19.
Report Facts
Census: 105
Inspection Report
Follow-Up
Deficiencies: 0
Oct 1, 2019
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 during this follow-up visit.
Inspection Report
Routine
Census: 105
Deficiencies: 6
Aug 8, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and facility policies related to resident rights, assessments, accident prevention, medication use, and infection control.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident dignity during feeding, timely and accurate quarterly assessments, proper transfer procedures, appropriate use of psychotropic medications, and infection control practices. Actual harm was identified due to a resident fall during improper transfer. Infection control lapses included staff eating while feeding residents and using phones during care.
Severity Breakdown
SS= D: 5
SS= G: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Staff failed to ensure dignity for residents during feeding by standing while feeding and eating while feeding a resident. | SS= D |
| Quarterly Minimum Data Set (MDS) assessment was not completed in a timely manner for one resident. | SS= D |
| Facility failed to accurately assess one resident's MDS, documenting restraint use without physician order. | SS= D |
| Resident was transferred without required two-person assist using mechanical lift, resulting in fall and fracture requiring surgery. | SS= G |
| Facility failed to ensure one resident had proper diagnosis for prescribed psychotropic medications. | SS= D |
| Facility failed to maintain infection control measures; staff observed eating and using phone while feeding resident. | SS= D |
Report Facts
Resident census: 105
Fall risk score: 16
MDS assessments reviewed: 35
Residents assessed for feeding dependency: 20
Residents reviewed for unnecessary medications: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in fall incident transferring resident without assistance causing fracture |
| CNA FF | Certified Nursing Assistant | Observed eating and using phone while feeding resident, violating infection control |
| CNA GG | Certified Nursing Assistant | Observed standing while feeding resident, violating dignity policy |
| LPN HH | Licensed Practical Nurse | Observed and corrected CNA FF for eating and phone use during feeding |
| RN JJ | Registered Nurse | Made data entry error on MDS assessment regarding restraint use |
| Pharmacist AA | Pharmacist | Reviewed medications and noted improper diagnoses for psychotropic drugs |
| Director of Nursing | Director of Nursing | Provided expectations on feeding dignity, infection control, and medication order accuracy |
| Administrator | Facility Administrator | Provided expectations on resident dignity and infection control during feeding |
| Infection Control Preventionist | Infection Control Preventionist | Commented on infection control risks of staff eating and phone use during feeding |
Inspection Report
Routine
Census: 20
Deficiencies: 2
Aug 8, 2019
Visit Reason
The inspection was conducted to assess compliance with pharmacy management, medication administration, and infection control regulations at Signature Healthcare of Savannah.
Findings
The facility failed to ensure proper diagnosis documentation for psychotropic medications for one resident and failed to maintain infection control measures during feeding assistance for another resident, including staff eating and using a phone while feeding residents.
Deficiencies (2)
| Description |
|---|
| Failure to ensure one of five residents reviewed for unnecessary medications had a proper diagnosis for prescribed psychotropic medications. |
| Failure to ensure infection control preventive measures were maintained for one of 20 residents requiring feeding assistance, including staff eating and using a phone while feeding. |
Report Facts
Residents reviewed for unnecessary medications: 5
Residents assessed for feeding assistance: 20
Observation time: 12.42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and infection control expectations |
| Pharmacist AA | Pharmacist | Interviewed regarding medication diagnosis review and communication |
| CNA FF | Certified Nursing Assistant | Observed eating while feeding resident and using phone; interviewed about infection control training |
| LPN HH | Licensed Practical Nurse | Observed and confirmed CNA FF's behavior during feeding |
| Administrator | Administrator | Interviewed regarding infection control policies and expectations |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding awareness of infection control incident |
Inspection Report
Life Safety
Census: 106
Capacity: 120
Deficiencies: 1
Aug 7, 2019
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 segregate full and empty oxygen cylinders in storage closets, which could place 6 residents at risk in the event of fire. Observations and staff interviews confirmed the cylinders were mixed together in multiple locations.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep full and empty oxygen cylinders segregated as required by NFPA 99 Chapter 11. | SS= D |
Report Facts
Residents at risk: 6
Census: 106
Total capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of mixed oxygen cylinders during tour of facility |
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 3
Jul 18, 2019
Visit Reason
An abbreviated survey was conducted from July 16, 2019 through July 18, 2019 to investigate complaint GA00197711 at Signature Healthcare of Savannah.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Deficiencies included failure to follow care plans for weekly skin checks for three residents, failure to develop care plans for behaviors for two residents with known behaviors, and incomplete and inaccurate documentation of skin checks, wounds, and skin tears for three residents.
Complaint Details
The survey was conducted to investigate complaint GA00197711. The facility was not found to be in substantial compliance with Medicare/Medicaid regulations.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow care plan for weekly skin checks for three residents and failed to develop care plans for behaviors for two residents with known behaviors. | SS=E |
| Failed to provide necessary behavioral health services to address known behaviors for two residents. | SS=D |
| Failed to maintain complete and accurate medical records for three residents by not documenting weekly skin checks, wounds, skin tears, and reddened areas. | SS=E |
Report Facts
Resident census: 107
Days between weekly skin checks for Resident #2: 21
Days without weekly skin checks for Resident #5: 27
BIMS score for Resident #4: 7
BIMS score for Resident #5: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Interviewed regarding Resident #4's skin picking behavior and lack of documentation. |
| LPN LL | Licensed Practical Nurse | Interviewed regarding Resident #4's wounds and skin prep treatment. |
| CNA DD | Certified Nursing Assistant | Reported Resident #4's skin picking behavior and observed wounds. |
| DON | Director of Nursing | Interviewed about documentation practices, behaviors, and care planning for Residents #4 and #5. |
| UM II | LPN Unit Manager | Interviewed about Resident #5's behaviors and care planning. |
| LPN GG | Licensed Practical Nurse | Completed Admission Assessment for Resident #3 and interviewed about documentation of skin tears and bruising. |
| LPN AA | Licensed Practical Nurse | Interviewed about documentation practices for skin tears and bruising. |
| RN FF | Registered Nurse | Interviewed about documentation of new injuries during weekly skin checks. |
| CNA MM | Certified Nursing Assistant | Interviewed about documentation practices and training on injury reporting system. |
| UM JJ | Unit Manager | Interviewed about staff training and challenges with new EMR wound reporting system. |
| Administrator | Phone interview regarding Resident #5's x-ray report and documentation practices. |
Inspection Report
Routine
Deficiencies: 2
Jul 18, 2019
Visit Reason
The inspection visit was conducted to assess compliance with nursing care plans, specifically focusing on weekly skin checks and care planning for resident behaviors.
Findings
The facility failed to follow the care plan for weekly skin checks for three of five residents and failed to develop care plans for behaviors for two of five residents with known behaviors. Documentation and care planning deficiencies were noted, including missed weekly skin evaluations and lack of behavior care plans.
Deficiencies (2)
| Description |
|---|
| Failed to follow the care plan for weekly skin checks for three residents (R#2, R#4, R#5). |
| Failed to develop a care plan for behaviors for two residents (R#4, R#5) with known behaviors. |
Report Facts
Days between weekly skin checks: 21
Days without weekly skin checks: 27
BIMS score: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | CNA | Interviewed regarding R#4's skin picking behavior. |
| HH | Licensed Practical Nurse (LPN) | Interviewed about R#4's skin picking behavior and documentation practices. |
| UM II | LPN Unit Manager | Interviewed about R#5's attention-seeking behaviors and care planning. |
| Director of Nursing (DON) | Interviewed about documentation and care planning for R#5's behaviors and pain complaints. |
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 0
Jun 11, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00196549 and GA00196822 at Signature Healthcare of 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 complaints GA00196549 and GA00196822; facility found in substantial compliance.
Report Facts
Resident census: 103
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 30, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint numbers GA00194343 and GA00194346.
Findings
No health care deficiencies were cited during the complaint survey.
Complaint Details
The survey was complaint-related, investigating complaint numbers GA00194343 and GA00194346, with no deficiencies found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 18, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00190568 and GA00191100.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaints GA00190568 and GA00191100 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Jul 31, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted June 4, 2018 through June 7, 2018.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during the revisit survey conducted on July 30 and July 31, 2018.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 26, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 112
Deficiencies: 10
Jun 7, 2018
Visit Reason
A standard routine survey was conducted to assess compliance with Medicare/Medicaid regulations and other federal requirements for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including management of resident funds, Medicaid/Medicare coverage notices, safe and homelike environment, ADL care, drug regimen review, psychotropic medication use, drug storage, food preferences, medical record documentation, and infection control practices.
Severity Breakdown
SS=B: 2
SS=D: 5
SS=E: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to have petty cash available for resident withdrawal after posted banking hours, limiting resident access to personal funds. | SS=B |
| Failed to issue required Medicaid/Medicare coverage and liability notices to residents discharged from Medicare Part A services. | SS=B |
| Failed to provide a sanitary homelike dining environment by not promptly cleaning a urine spill in the dining room during meal service. | SS=D |
| Failed to ensure consistent provision of nail and denture care for a totally dependent resident. | SS=D |
| Consultant pharmacist failed to recommend evaluation of continued use of a PRN psychotropic medication (Xanax) beyond 14 days. | SS=D |
| Failed to address use of PRN psychotropic medication beyond 14 days without documented rationale and evaluation. | SS=D |
| Failed to secure all drugs and biologicals in locked storage with restricted access; keys were left in medication room door lock. | SS=E |
| Failed to honor resident food consistency preferences and physician diet order for a regular consistency diet, serving mechanical soft diet instead. | SS=D |
| Failed to maintain complete and accurately documented medical record; medication administration was not documented on the MAR. | SS=D |
| Failed to follow infection control procedures during meal service; staff touched rims of glasses while filling beverages and failed to sanitize hands between resident care activities. | SS=E |
Report Facts
Resident census: 112
Resident trust fund accounts: 73
Residents interviewed at council meeting: 15
Doses of Xanax administered: 16
Glasses on tray: 24
Facility census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Left keys in medication room door lock, compromising drug storage security |
| RN CC | Registered Nurse | Verified expectations for medication documentation and infection control |
| Business Office Manager | Interviewed regarding resident trust fund access and petty cash availability | |
| Receptionist KK | Interviewed regarding resident access to funds after hours | |
| Social Services Director | Interviewed regarding Medicaid/Medicare coverage notices issuance | |
| Director of Nursing | Director of Nursing | Provided expectations on nail care, medication review, and medication documentation |
| Certified Dietary Manager | Interviewed regarding resident diet orders and preferences | |
| Chaplain | Observed touching rims of glasses during beverage service | |
| Certified Nursing Assistant LL | Observed failing to sanitize hands between resident care activities |
Inspection Report
Routine
Census: 51
Deficiencies: 3
Jun 7, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care and infection control standards at Signature Healthcare of Savannah.
Findings
The facility failed to consistently provide nail and denture care for one resident who was totally dependent on staff for activities of daily living. Additionally, staff failed to follow infection control procedures during meal service, including not sanitizing hands and touching the rims of glasses, potentially affecting multiple residents.
Deficiencies (3)
| Description |
|---|
| Failure to ensure consistent nail and denture care for a resident dependent on staff for ADLs. |
| Failure to follow infection control procedures by staff failing to sanitize hands and touching rims of glasses during meal service. |
| Certified Nursing Assistant observed feeding a resident without washing or sanitizing hands after touching contaminated objects. |
Report Facts
Sample size: 51
Residents potentially affected: 111
Glasses touched: 24
Residents present during infection control observation: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Interviewed regarding nail care and denture cleaning practices |
| DON | Director of Nursing | Interviewed regarding expectations for nail and oral care |
| Chaplain | Observed touching rims of glasses while filling drinks | |
| CNA LL | Certified Nursing Assistant | Observed feeding resident without hand hygiene between residents |
| RNP FF | Registered Nurse Practitioner | Interviewed regarding proper technique for filling glasses and staff training |
| Registered Nurse Staff Development/Infection Control Coordinator | Registered Nurse | Interviewed regarding hand hygiene and infection control practices |
Inspection Report
Annual Inspection
Census: 112
Capacity: 120
Deficiencies: 8
Jun 6, 2018
Visit Reason
The inspection was conducted as an annual Life Safety Code Survey and Emergency Preparedness Plan review to assess compliance with Medicare/Medicaid participation requirements and NFPA standards.
Findings
The facility was found not in substantial compliance with emergency preparedness training requirements and multiple Life Safety Code standards including means of egress, corridor access, fire alarm system installation, sprinkler system installation, smoke barrier integrity, utilities safety, and electrical equipment use. Several deficiencies were identified that could place residents and staff at risk in the event of fire or emergency.
Severity Breakdown
F: 4
E: 2
D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to maintain an emergency preparedness training program for staff as required by Appendix Z. | F |
| Resident room doors failed to positively latch as required by NFPA 101. | E |
| Facility failed to provide approved corridor access from habitable rooms lacking automatic smoke detection system as required by NFPA 101. | D |
| Fire alarm panel was not properly marked and batteries were not dated as required by NFPA 101 and NFPA 72. | F |
| Two pendent sprinkler heads in the Activity Room were spaced less than six feet apart, violating NFPA 101 and NFPA 13. | D |
| Penetration in the smoke barrier at Cypress Hall was not properly sealed as required by NFPA 101. | F |
| Power strips were found on the floor in the dietary director's office, violating NFPA 101 requirements. | D |
| Power strip was found beneath a patient bed in room 114 within the patient care area, violating NFPA 99 and S&C letter 14-46-LSC. | D |
Report Facts
Residents at risk due to door latching deficiency: 25
Residents at risk due to corridor access deficiency: 1
Residents at risk due to sprinkler system deficiency: 12
Staff at risk due to power strip on floor: 1
Residents at risk due to power strip in patient care area: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 3, 2018
Visit Reason
An abbreviated survey was conducted at Signature Health of Savannah on 5/3/18 to investigate Complaint Intake Number GA00188423.
Findings
Based on findings, no deficiencies were cited during the abbreviated survey.
Complaint Details
Investigation was complaint-related under Complaint Intake Number GA00188423; no deficiencies were found.
Report Facts
Complaint Intake Number: GA00188423
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 15, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00181822 and GA00181896 at Signature Health Care.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaints GA00181822 and GA00181896; facility found in substantial compliance.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 17, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00180345 at Signature Health and Rehabilitation.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Complaint GA00180345 was investigated during the abbreviated survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 24, 2017
Visit Reason
A complaint (GA00180035) was investigated to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.
Findings
No deficiencies were cited during the investigation.
Complaint Details
Complaint GA00180035 was investigated and found to have no deficiencies.
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 0
Jul 20, 2017
Visit Reason
A standard survey was conducted at Signature Healthcare of Savannah from July 17, 2017 through July 20, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 99
Capacity: 110
Deficiencies: 0
Jul 18, 2017
Visit Reason
A 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 and related standards during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2017
Visit Reason
A complaint survey was conducted to investigate complaint #GA00167341 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Signature Healthcare of Savannah.
Complaint Details
Complaint #GA00167341 was investigated and found to have no deficiencies cited.
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