Harborview Satilla

In the surveyor’s words

From the most serious findings on record at Harborview Satilla, in the surveyor’s own words.

• Actual harm, isolatedF656Feb 12, 2026

  Based on staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, Facility A failed to implement the comprehensive care plan for one of 63 sampled Residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture.Findings include:Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023 under the Policy section revealed, It is the policy of this facility to develop and implement comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents' medical, nursing, mental, and psychosocial needs and all… […]

• Actual harm, isolatedF689Feb 12, 2026

  Based on staff interviews, record review, and review of the facility's policy titled, Safe Resident Handling/Transfer, Facility A failed to ensure safe transfer to a shower chair for one of 68 sampled residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture.Review of the facility's policy titled, Safe Resident Handling/Transfer, dated 1/1/2026, under the Policy section stated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk of injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards… […]

• Actual harm, isolatedF656Apr 22, 2025

  Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plan the facility failed to ensure the care plan was followed for two person assistance toileting for one Resident ((R) R1) of three residents which resulted in R1 having a fall. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma. […]

• Actual harm, isolatedF689Apr 22, 2025

  Based on medical record review, staff interviews and review of the facility policy Accidents and supervision, the facility failed to ensure that one resident (R1) of three residents was provided with enough staff to complete perineal care of residents while in bed. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma. Findings include: Review of the facility policy, Accidents and Supervision dated 3/1/2022, revealed Policy: the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observations, staff interviews, record review, and review of facility's policy titled, Date Marketing for Food Safety Policy, Facility A failed to ensure food was stored, sealed, and labeled correctly. This deficient practice affected the facility kitchen and had the potential to cause food contamination and foodborne illness among all residents consuming facility-prepared food. Facility A had 75 sampled residents that received an oral diet from the kitchen.Findings include:A review of the facility's policy titled, Date Marketing for Food Safety Policy, dated 1/1/2026, revealed that the facility adheres to a date marketing system to ensure the safety of ready-to-eat, time/temperature control for safety food.During an observation and walk through of the kitchen on 2/10/2026 at… […]