Inspection Reports for
Signature HealthCARE of Savannah

The facility failed to implement a care plan to monitor for adverse effects from anticoagulant medication for one resident and failed to ensure proper administration timing of phenytoin with a high-protein supplement for another resident, both posing potential risks of medical complications.

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.

The facility was found deficient in multiple areas including failure to provide correct size briefs, timely abuse reporting, accurate PASRR assessments, complete and implemented care plans for oxygen therapy, proper wheelchair support for a resident, incorrect oxygen flow rates, inaccurate meal menus and lack of meal choices, and inadequate infection control practices during tracheostomy care.

The facility was found deficient in multiple areas including failure to provide correct size briefs, timely abuse reporting, written bed hold notices, accurate PASRR assessments, complete and implemented care plans for oxygen therapy, proper wheelchair support for a resident, correct oxygen flow rates, adherence to meal menus and resident meal choices, and infection control practices during tracheostomy care.

Multiple complaint intakes were investigated in conjunction with the standard survey. Some complaints were substantiated with deficiencies, including GA00254031, GA00245811, GA00251775, and others.

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.

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.

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.

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.

The complaint investigation revealed that resident R1, with a history of wandering and exit-seeking behaviors, eloped from the facility on 9/15/2024. The resident was found outside near a school by a visitor and was returned to the facility with no injuries. The facility failed to have care plan interventions for wandering or elopement prior to the incident and did not provide adequate supervision or secure the front exit door, which was found to be malfunctioning. Staff interviews confirmed delays in assessment and care planning, and that the resident was unaccounted for for at least one hour.

The facility failed to develop a care plan addressing wandering and elopement for one resident (R1) prior to an elopement incident on 9/15/2024. The resident exited the facility unnoticed due to inadequate supervision and a malfunctioning front exit door, resulting in the resident being unaccounted for over one hour. Staff interviews and record reviews confirmed delays in assessment and care planning for elopement risks.

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.

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.

Multiple complaint intake numbers were investigated. Some complaints were substantiated with deficiencies, others were unsubstantiated or substantiated without deficiencies.

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.

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.

The facility was found deficient in multiple areas including medication self-administration policies, resident grievance resolution, abuse reporting and investigation, care planning, assistance with activities of daily living, respiratory care, dialysis communication, infection prevention and control, staffing adequacy, medication administration competency, kitchen sanitation, garbage disposal, and antibiotic stewardship.

The facility was found deficient in multiple areas including failure to secure medications at bedside, incomplete grievance investigations, inadequate abuse reporting and investigation, incomplete care plans for residents, failure to provide adequate assistance with activities of daily living, lapses in respiratory care and oxygen therapy, inadequate dialysis communication, insufficient staffing levels, lack of competency verification for medication aides, unsanitary kitchen conditions, improper garbage disposal, and ineffective infection prevention and control practices during a COVID-19 outbreak.

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.

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.

The facility was found deficient in multiple areas including failure to obtain a concurring physician's signature on POLST forms, maintaining a safe and clean environment with stained privacy curtains and damaged bathroom walls, failure to transcribe and implement wound care orders, improper feeding tube management, and lack of pneumococcal vaccine policies and documentation.

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.

Complaint GA00207664 was substantiated with a deficiency related to wound care treatment orders. Complaint GA00207060 was partially substantiated without deficiencies.

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.

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.

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.

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.

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.

The survey was conducted to investigate complaint GA00197711. The facility was not found to be in substantial compliance with Medicare/Medicaid regulations.

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.

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.

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.

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.

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.