Savannah Heights

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF689Apr 1, 2026

  Based on record review, staff interviews, and the facility policy, the facility failed to ensure the chair/bed alarms worked properly one resident (Resident #3) and failed to implement new interventions in an effort to limit falls for 3 of 3 residents (Resident#1, Resident #2, and Resident #3) reviewed for supervision related to re-occurring falls The facility reported a census of 30 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident used a manual wheelchair and walker and independent with mobility. The MDS revealed medical diagnoses for acute respiratory failure, anxiety disorder, and depression. […]

• No harm, potential for more than minimal, isolatedF550Aug 25, 2025

  Based on staff interviews, record review, and the facility policy, the facility failed to care for a resident in a dignified manner by not emptying her bedside commode after providing toileting assistance for 1 of 3 residents reviewed for dignity. The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated Resident #40 dependent with toileting hygiene and chair/bed to chair transfer. The MDS revealed Resident #40 occasionally incontinent of bladder and always continent of bowel. […]

• No harm, potential for more than minimal, isolatedF580Aug 25, 2025

  Based on clinical record review, facility policy review, resident family and staff interview, the facility failed to notify a family member prior to a chest x-ray being performed and failed to notify the physician a resident returned to the facility after hospitalization in a timely manner for 2 of 2 residents (Resident #18 and Resident #8) reviewed for notifications. The facility reported a census of 34 residents. Findings include: 1. The Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #18 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS listed a medical diagnosis of traumatic brain injury. […]

• No harm, potential for more than minimal, isolatedF628Aug 25, 2025

  Based on staff interview, clinical record review, and facility policy review, the facility failed to provide notification of resident discharge/readmission status to a Long Term Care Ombudsman for 3 of 3 residents (Resident #2, Resident #8, and Resident #38) reviewed for discharge process. The facility reported a census of 34 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 7/25/25, revealed Resident #2 was unresponsive, or unable to complete Brief Interview for Mental Status (BIMS). Resident #2 required full dependance on staff assistance for care needs. The list of diagnoses included anoxic brain damage, quadriplegia (loss of movement to all extremities), and epilepsy. […]

• No harm, potential for more than minimal, isolatedF554Aug 29, 2024

  Based on observation, clinical record review, and staff interview, the facility failed to ensure only residents able to safely self-administer medications had access to medications for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 32 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 6/7/24, listed diagnoses for Resident #5 included traumatic brain dysfunction, anxiety, and morbid obesity and listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. A 4/8/21 Care Plan entry stated the resident had impaired thought processes due to traumatic brain injury. […]