F-F695
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 36377
Residents Affected - Few Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 49 sampled residents (R) (Resident R12) received services to maintain or improve their functional abilities. Specifically,
the facility failed to ensure a supportive footrest/leg rest was secured to Resident R12's wheelchair. This deficient practice had the potential to place Resident R12 at risk of unmet needs and a diminished quality of life.
Findings include:
Review of Resident R12's Annual Minimum Data Set (MDS) assessment, dated 4/2/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status Score (BIMS) of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident had lower extremity impairment on both sides, required maximal assistance for lower body dressing, and was dependent for putting on and taking off footwear. Section M (Skin Conditions) documented that the resident was at risk for developing pressure ulcers and had one stage four pressure ulcer.
Review of Resident R12's Care Plan Report revealed a Focus area, dated 5/20/2024, that the resident has peripheral vascular disease. Interventions included elevating legs when sitting or sleeping, monitoring/documenting for excessive edema, and encouraging the resident to elevate legs.
Review of Resident R12 's clinical record revealed diagnoses including, but not limited to, varicose veins of right lower extremity with ulcer of ankle, non-pressure chronic ulcer of right heel and midfoot with unspecified severity, contracture right knee, hemiplegia and hemipareses following unspecified cerebrovascular disease affecting
the right dominant side, long term use of anticoagulants, acquired absence of left leg above knee, hypertension, and peripheral vascular disease.
Observation on 5/12/2025 at 12:08 pm revealed Resident R12 in a wheelchair, propelling himself in the hallway towards the activity room with his right lower extremity (RLE) highly elevated in the air and extended outward
in an upward position without the support of a leg rest/footrest attachment.
Observation on 5/12/2025 at 1:00 pm revealed Resident R12 sitting in a wheelchair in the activity area and holding his RLE in the air without the support of a leg rest or other supportive device.
In a concurrent observation and interview on 5/12/2025 at 3:00 pm, Resident R12 was observed sitting in a wheelchair
in the hallway and holding his RLE in the air without the support of a leg rest or other supportive device. Resident R12 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.
Observations on 5/13/2025 at 12:01 pm and 3:00 pm, 5/14/2025 at 2:15 pm, and 5/15/2025 at 3:00 pm revealed Resident R12 sitting in a wheelchair, propelling himself in the hallway with his RLE highly elevated in the air, extended outward and dangling in the air without the support of a leg rest or other supportive device.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 In a concurrent observation of Resident R12 and interview on 5/15/2025 at 12:55 pm with the Physical Therapy (PT) Director and the Director of Nursing (DON), both confirmed Resident R12 should not be positioned in his wheelchair Level of Harm - Minimal harm or without the attachment of a supportive device such as a leg rest/footrest due to Resident R12's right ankle ulcer, potential for actual harm contracture, and immobility. The PT Director stated that the therapy department had assessed Resident R12 for a leg rest/footrest, obtained the device from Resident R12's room, and attached it to the wheelchair. The DON stated the Residents Affected - Few 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. The DON further stated she was unaware that Resident R12's wheelchair did not have the leg rest/footrest attached. The DON stated that her expectation was for staff to ensure the resident's leg rest/footrest is attached to the wheelchair daily. She stated that nursing staff were responsible for ensuring that the resident's leg rest/footrest was applied as part of resident care services.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or 36377 potential for actual harm Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Residents Affected - Few Administration, the facility failed to ensure that three of 11 sampled residents (R) (Resident R24, Resident R45, and Resident R49) were administered oxygen (O2) therapy in accordance with the physician's orders. This failure had the potential to place Resident R24, Resident R45, and Resident R49 at risk of respiratory complications and unmet needs.
Findings include:
Review of the facility policy titled Oxygen Administration, dated 2/1/2024, revealed the Preparation section included, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
1. Review of Resident R24's Annual Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that Resident R24 received O2.
Review of Resident R24's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia.
Review of Resident R24 's Clinical Physician Orders revealed an order dated 6/17/2024 for O2 at 2 liters per minute (LPM) via a nasal cannula (NC) continuously.
Observations on 5/12/2025 at 12:35 pm and 2:05 pm revealed Resident R24 receiving O2 by an O2 concentrator via a NC at a flow rate of 3.5 LPM.
2. Review of Resident R45's Quarterly MDS assessment, dated 3/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that Resident R45 received O2.
Review of Resident R45's EMR revealed diagnoses including, but not limited to, COPD.
Review of Resident R45's Clinical Physician Orders revealed an order dated 5/14/2024 for O2 at 2 LPM via NC O2: 90 percent or above. Every shift for shortness of breath.
Observations on 5/12/2024 at 10:01 am and 6:00 pm revealed Resident R45 receiving O2 by an O2 concentrator via a NC with the flow rate set at 4.5 LPM.
In an interview on 5/12/2024 at 1:20 pm, the Respiratory Therapist (RT) confirmed that Resident R45 was receiving O2 at 4.5 LPM. The RT verified increasing the flow rate due to having concerns with the resident's O2 saturation reading of 88 percent. He verified that the physician's order was 2 LPM and adjusted the flow rate to 2 LPM.
In an interview on 5/15/2025 at 10:00 am, the Director of Nursing (DON) confirmed that Resident R24 and Resident R45 were receiving O2 at the wrong flow rate and not per physician orders. She stated that the RT should not be changing the flow rate without a physician's order. She reported being uncertain of which staff could have changed Resident R24 's O2 flow rate.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 50171
Level of Harm - Minimal harm or 3. Review of Resident R49's Admission MDS assessment, dated 4/18/2025, revealed Section C (Cognitive Patterns) potential for actual harm documented a BIMS score of 13 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented that Resident R49 received O2. Residents Affected - Few
Review of Resident R45's EMR revealed diagnoses including, but not limited to, COPD and chronic respiratory failure with hypoxia.
Review of Resident R49's Clinical Physician Orders revealed an order dated 4/18/2025 for O2 at 2 LPM via NC continuously for shortness of breath. O2 saturation to maintain saturation 90 percent or above every shift.
In a concurrent observation and interview on 5/12/2025 at 12:24 pm, Resident R49 was observed receiving O2 at 3.5 LPM via a NC. Resident R49 stated her O2 should be set at 2 LPM, and it had been set at 3.5 LPM since she was admitted .
Observation on 5/12/2025 at 6:10 pm revealed Resident R49 receiving O2 at 3.5 LPM via a NC.
In a concurrent observation and interview on 5/13/2025 at 11:00 am, Licensed Practical Nurse (LPN) DD confirmed that Resident R49's oxygen was set on 3.5 LPM. LPN DD further confirmed the physician's order was for O2 at 2 LPM. LPN DD stated the nurses were responsible for ensuring the O2 flow rate was set correctly.
In an interview on 5/13/2024 at 3:06 pm, the DON stated that she expected nursing staff to ensure each resident's O2 was administered according to the physician's orders.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 49681
Residents Affected - Few Based on observation, resident and staff interviews, and review of the facility policy titled Menus, the facility failed to ensure four of 49 sampled residents (R) (Resident R90, Resident R106, Resident R103, and Resident R72) were offered meal choices. In addition, the facility failed to ensure meal menus were followed for one of 49 sampled R (Resident R72).
Findings include:
Review of the facility policy titled Menus, revised 10/2022, revealed the Procedures section included, . 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of
an item, or a special meal. 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas.
1. Review of Resident R90's Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment).
In an interview on 5/13/2025 at 12:25 pm, Resident R90 stated he was not given a choice of meals, and the only alternative food offered was a peanut butter and jelly sandwich. He stated he gets what the facility gives him for meals.
2. Review of Resident R106's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment).
In an interview on 5/14/25 3:04 pm, Resident R106 stated that she eats in the dining area because she has a choice of food. Resident 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. She stated that the only alternative offered was a peanut butter and jelly sandwich.
3. Review of Resident R103's Quarterly Minimum Data Set (MDS) assessment, dated 3/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment).
In an interview on 5/14/2025 at 3:12 pm, Resident R103 stated she never got to choose what meal she wanted since
she ate in her room, and further stated that if she ate in the dining room, she would be able to make a meal choice.
49675
4. Review of Resident R72's Annual Minimum Data Set (MDS) assessment, dated 3/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803 In an interview on 5/12/2025 at 1:26 pm, Resident R72 stated he never knew what he would be served at mealtimes.
He stated residents who ate in their rooms were not provided a menu choice, and the menu was inaccurate. Level of Harm - Minimal harm or He stated he got what the facility gave him at meals. potential for actual harm
Observation on 5/13/2025 at 1:02 pm revealed Resident R72 sitting in his room, eating lunch. He was served ribs, Residents Affected - Few mashed potatoes, and broccoli. His meal tray ticket indicated he was to receive a turkey burger on a bun, chips, tomato salad, fruit salad, and tea. The menu for the day stated the lunch meal would be a tuna salad hoagie or turkey burger, country tomato salad, creamy cucumber and onion salad, potato chips, macaroni salad, and deluxe fruit salad. Resident R72 stated he was not asked what his choice for the meal was.
Observation on 5/14/2025 at 12:45 pm revealed Resident R72 sitting in his wheelchair, eating lunch. His meal tray had
a hamburger patty with gravy, mashed potatoes with gravy, and carrots. The meal tray ticket indicated he was to receive a garlic-baked pork chop, buttered rice, seasoned okra, dinner roll, and brownie. The menu for the day stated the lunch meal would be sausage jambalaya, Salisbury steak, seasoned okra, sliced parsley carrots, mashed potatoes, cornbread, and a double chocolate brownie. Resident R72 stated he was not asked what his choice for the meal was.
In an interview on 5/14/2025 at 4:45 pm, the Dietary Manager (DM) confirmed that residents who receive lunch in their rooms do not know what meal they will receive, as substitutions are not written on the menus.
She had no explanation for the discrepancies between what meal was posted to be served, what meal was
on the tray tickets, and what was served. The DM confirmed that all residents should have the opportunity to have preferences of foods, and the posted meals should be served.
In an interview on 5/14/2025 at 4:55 pm, the Administrator stated residents should be informed of the menu and offered an alternative. The Administrator further stated that all residents should be given a menu and allowed to choose what foods they wanted for their meals.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or 39786 potential for actual harm Based on observation, staff interviews, and review of the facility's document titled Enhanced Barrier Residents Affected - Some Precautions in Nursing Homes Algorithm, the facility failed to ensure respiratory staff followed infection control practices during tracheostomy care for one of two residents (R) (Resident R13) with a tracheostomy. The deficient practice had the potential to place Resident R13 at risk of respiratory illness and infection due to cross-contamination.
Findings included:
Review of the facility's document titled Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 2022, revealed, The purpose of this algorithm is to outline when to use and how to implement enhanced barrier precautions (EBP). 1. EBP are indicated for the following residents who are: At increased risk of MDRO (multidrug-resistant organism) acquisition (e.g., resident has a wound or indwelling medical device) .
In addition to following Standard Precautions, gowns and gloves should be worn during the following high-contact resident care activities: Device care or use. With implementation, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use . To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves) . Definitions. Indwelling medical device: An indwelling medical device provided a direct pathway for pathogens in the environment to enter the body and cause infection. Examples include, but are not limited to . tracheostomy tubes .
Review of Resident R13's Quarterly Minimum Data Set (MDS) assessment, dated 4/14/2025, revealed Section GG (Functional Abilities and Goals) documented Resident R13 was dependent for activities of daily living (ADLs). Section I (Active Diagnoses) documented diagnoses including debility, cardiorespiratory conditions, aphasia, cerebrovascular accident (CVA), hemiplegia or hemiparesis, and respiratory failure. Section O (Special Treatments, Procedures, and Programs) documented that Resident R13 received oxygen (O2), suctioning, and tracheostomy care.
Observation of Resident R13's room door revealed EBP signage on the door indicating the type of precautions, the required PPE that all healthcare personnel must wear, and the high-contact resident care activities that required the use of a gown and gloves, which included tracheostomy care.
Observation on 5/14/2025 at 10:15 am of Respiratory Nurse Technician LL providing tracheostomy care for Resident R13 revealed Respiratory Nurse Technician LL donned a mask and gloves. Respiratory Nurse Technician LL suctioned Resident R13's tracheostomy, donned sterile gloves, connected the tube, placed a small amount of normal saline, and suctioned two passes. Respiratory Nurse Technician LL removed the tracheostomy collar and discarded it, removed the split gauze, cleaned around the tracheostomy stoma, assessed the stoma, placed new split gauze, placed a new collar, and secured the tracheostomy. The Respiratory Nurse Technician stated he changed the inner cannula twice a day, and the tracheostomy tube was changed once a month.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 115120 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115120 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Savannah Post Acute LLC 815 East 63 Street Savannah, GA 31405
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 In an interview on 5/14/2025 at 11:10 am, Respiratory Nurse Technician LL confirmed Resident R13 was on EBP. He stated he did wear a mask and gloves during Resident R13's tracheostomy care and did not wear a gown. Respiratory Level of Harm - Minimal harm or Nurse Technician LL stated he wore gloves and a mask while providing care to residents on EBP and a potential for actual harm gown for residents on contact isolation-precautions.
Residents Affected - Some In an interview on 5/15/2025 at 9:39 am, Respiratory Nurse Technician KK stated staff should wear gloves, a gown, and a mask when providing tracheostomy care.
In an interview on 5/15/2025 at 10:55 am, the Director of Nursing (DON) stated she expected staff to wear gloves and a gown while providing care to a resident on EBP, and to wear gloves, a gown, and a mask while providing tracheostomy care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 115120