SAVANNAH, GA - State inspectors found significant care failures at Signature Healthcare of Savannah during a May 2025 inspection, documenting violations related to medical equipment support, oxygen therapy administration, meal service protocols, and infection control practices.
Wheelchair Support Equipment Denied to Vulnerable Resident
Inspectors observed a critically concerning situation involving a resident with multiple serious medical conditions who was repeatedly denied proper wheelchair support equipment. The resident, identified as having peripheral vascular disease, a right knee contracture, and an ankle ulcer, was observed over multiple days holding his right leg elevated in the air without any supportive device.
The resident had an above-knee amputation of his left leg and required a specialized leg rest attachment for his wheelchair due to his medical conditions. During interviews, the resident stated "he had a leg rest with an attached footrest for the wheelchair and was unable to put it on the wheelchair unassisted, and that staff did not assist him."
Medical protocols require proper positioning and support for residents with vascular conditions and contractures. When extremities are not properly supported, particularly in residents with circulation problems, several serious complications can occur. Blood pooling can worsen in affected limbs, increasing the risk of blood clots and further compromising already impaired circulation. For residents with contractures, unsupported positioning can lead to increased pain, muscle spasms, and progression of joint limitations.
The facility's Director of Nursing confirmed during the inspection that "the resident would be at risk of injury, pain, edema, added pressure, and discomfort by holding his RLE in an elevated position without the supportive device." She also stated that nursing staff were responsible for ensuring the leg rest was properly attached as part of daily resident care services.
The Physical Therapy Director confirmed that the therapy department had previously assessed the resident for the appropriate equipment and had obtained the leg rest from his room, demonstrating that the necessary equipment was available but not being consistently used by nursing staff.
Oxygen Therapy Administered at Incorrect Levels
The inspection revealed systematic failures in oxygen therapy administration, with three residents receiving oxygen at flow rates that did not match their physician's orders. This represents a serious medication error that can have significant health consequences.
Two residents with chronic obstructive pulmonary disease (COPD) were found receiving oxygen at levels significantly higher than prescribed. One resident was receiving 3.5 liters per minute when ordered for 2 liters per minute, while another was receiving 4.5 liters per minute instead of the prescribed 2 liters per minute.
Proper oxygen therapy requires precise dosing because both too little and too much oxygen can be harmful. For patients with COPD, excessive oxygen can suppress their natural breathing drive, potentially leading to carbon dioxide retention and respiratory acidosis. Conversely, insufficient oxygen can result in hypoxemia, causing organ damage and respiratory distress.
A third resident was also receiving 3.5 liters per minute instead of the prescribed 2 liters per minute. "R49 stated her O2 should be set at 2 LPM, and it had been set at 3.5 LPM since she was admitted." This indicates the error had persisted since admission, suggesting systemic problems with medication administration protocols.
The facility's respiratory therapist acknowledged adjusting flow rates without physician orders, stating concerns about oxygen saturation readings. However, changing prescribed oxygen levels without proper authorization violates standard medical protocols and puts residents at risk. When oxygen saturation levels are concerning, the appropriate response is to contact the prescribing physician for order modifications, not to independently adjust therapy levels.
The Director of Nursing confirmed that respiratory therapy staff should not change flow rates without physician orders and stated that nursing staff were responsible for ensuring correct oxygen administration according to physician orders.
Meal Service Failures Affect Resident Choice and Nutrition
The inspection documented significant problems with meal service that denied residents their right to food choices and resulted in incorrect meals being served. Four residents reported they were not offered meal choices when eating in their rooms, contrary to facility policy and regulatory requirements.
Multiple residents described a two-tiered meal system where residents eating in the dining room received menu choices while those eating in their rooms did not. "R106 explained that she only eats in the dining room because when she eats in her room, she does not get to choose what she wants to eat."
This practice violates the principle that all residents, regardless of where they eat, should have equal access to meal choices and preferences. Nutritional autonomy is particularly important for nursing home residents, as food choices often represent one of the few areas where residents can exercise personal preferences and maintain dignity.
The inspection also revealed cases where the actual meals served did not match either the posted menu or the meal tickets. One resident was served ribs, mashed potatoes, and broccoli when the menu indicated a tuna salad hoagie or turkey burger should be available, and his meal ticket showed he should receive a turkey burger meal. On another day, the same resident received a hamburger patty with gravy when his ticket indicated a garlic-baked pork chop meal.
These discrepancies indicate broader systemic problems with meal planning, kitchen operations, and communication between dietary and nursing staff. The Dietary Manager confirmed that residents eating in rooms do not know what meals they will receive and had no explanation for the documented discrepancies between menus, meal tickets, and actual food served.
Infection Control Violations During Medical Procedures
Inspectors documented infection control failures during tracheostomy care, a high-risk medical procedure requiring strict protective protocols. A respiratory technician was observed providing tracheostomy care to a resident on Enhanced Barrier Precautions without wearing the required protective gown.
The facility's own Enhanced Barrier Precautions protocol specifically identifies tracheostomy tubes as indwelling medical devices that create direct pathways for environmental pathogens to enter the body. The protocol requires gowns and gloves during device care for residents with such equipment.
Tracheostomy care involves direct contact with the respiratory tract through an artificial opening in the neck. Proper infection control during these procedures is critical because any contamination can lead to serious respiratory infections, pneumonia, or sepsis. The respiratory tract connection created by a tracheostomy bypasses many of the body's natural defense mechanisms, making residents particularly vulnerable to infection.
The resident's room had appropriate signage indicating Enhanced Barrier Precautions and listing tracheostomy care as requiring gown and glove use. Despite this clear guidance, the respiratory technician failed to follow the posted requirements, wearing only a mask and gloves instead of the required mask, gloves, and gown combination.
Additional Issues Identified
The inspection documented several other areas of concern including incomplete documentation of care plans and inconsistent implementation of established protocols. Staff interviews revealed gaps in understanding of proper procedures and inconsistent application of facility policies across different departments.
The facility's leadership acknowledged the violations during interviews and expressed intentions to retrain staff and improve oversight of care delivery. However, the systemic nature of the problems identified suggests broader issues with quality assurance, staff training, and administrative oversight that require comprehensive remediation efforts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Savannah from 2025-05-15 including all violations, facility responses, and corrective action plans.
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