Inspection Reports for Buckingham South
5450 Abercorn St, Savannah, GA 31405, GA, 31405
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 21, 2025, identified deficiencies related to cleanliness and maintenance issues, including stained carpet, broken furniture, missing ceiling tiles, and rusty air conditioning vents. Earlier inspections showed a mixed pattern, with prior deficiencies involving resident safety, staff performance, medication documentation, and policy compliance, while several complaint investigations found no violations. Main themes of deficiencies included environmental maintenance and safety concerns, as well as past issues with staff conduct and resident care. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving staff misconduct and safety lapses, but no fines or enforcement actions were listed in the available reports. The facility’s inspection history shows some recurring issues with maintenance and care, with recent findings indicating ongoing challenges in maintaining a clean and safe environment.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 21, 2025
Visit Reason
The visit was conducted to investigate intake #GA50004923, with the investigation beginning on 2025-08-21 and ending on 2025-08-25.
Complaint Details
The investigation was initiated based on intake #GA50004923. The complaint involved concerns about cleanliness, safety hazards including hoarding behavior by Resident #1, and maintenance issues such as missing ceiling tiles and rusty air conditioning vents. Resident #1 was described as a hoarder, with family awareness, and the accumulation of belongings posed potential fire hazards.
Findings
The facility failed to maintain the interior of the assisted living community in a clean and safe condition, posing health and safety risks. Specific issues included stained carpet, broken furniture, unsanitary conditions related to a resident's cat, missing ceiling tiles, and rusty, dusty air conditioning vents.
Deficiencies (3)
Interior of the assisted living community was not kept clean or in good repair, including stained carpet, broken furniture, and unsanitary conditions in Resident #1's room.
Several ceiling tiles or grids were missing in the laundry room and office.
Several air conditioning vents on the second and fourth floors were rusty and dusty.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding inability to keep Resident #1's room clean and described the condition of the room. | |
| Staff A | Interviewed about Resident #1's hoarding behavior, family awareness, and potential fire hazards from accumulated belongings. | |
| AB | Interviewed about removal of ceiling tiles and difficulty hiring contractors to replace them. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004354, with the investigation beginning on 2025-07-16 and ending on 2025-07-23. An onsite visit was made on 2025-07-23.
Complaint Details
Investigation of intake #GA50004354 was conducted from 2025-07-16 to 2025-07-23, with no citations issued.
Findings
No citations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection at the facility.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250056 with an onsite visit made on 10/24/2024.
Complaint Details
Investigation was initiated based on intake #GA00250056. The investigation was conducted and completed on 10/24/2024.
Findings
The facility failed to ensure that each sleeping room for residents had a secondary exit such as a door or window usable for escape, specifically for 1 of 5 sampled residents (Resident #4). Resident #4's room on the third floor lacked a secondary exit and similar rooms on other floors were used for storage.
Deficiencies (1)
Each sleeping room must have a secondary exit that could be a door or window usable for escape; Resident #4's room lacked this secondary exit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249034 with an onsite visit made on 2024-08-22.
Complaint Details
Investigation started on 2024-08-21 and completed on 2024-08-23 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation completed on 2024-08-23.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248036.
Complaint Details
Investigation of intake #GA00248036 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244587.
Complaint Details
Investigation of intake #GA00244587 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 28, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00229679, with an onsite visit conducted on 2/28/2023 and investigation completed on 3/3/2023.
Complaint Details
The investigation was initiated due to intake #GA00229679 involving allegations of staff misconduct including misappropriation of resident property (eating resident's food), failure to follow doctor's orders for use of PTBL, inadequate feeding assistance, and disrespectful treatment of Resident #1. The complaint was substantiated based on video evidence and interviews.
Findings
The facility failed to ensure proper staff performance and resident care, including a staff member eating a resident's food, failure to use a portable total body lift (PTBL) during transfers, inadequate feeding assistance, improper infection control practices, and lack of dignity and respect toward Resident #1. Video evidence and interviews confirmed these deficiencies.
Deficiencies (7)
Staff was caught on video eating Resident #1's food and putting an unwashed fork back on the plate.
Failure to use portable total body lift (PTBL) during transfers of Resident #1 as ordered by hospice.
Failure to provide sufficient and unhurried assistance with feeding Resident #1 who required total assistance.
Failure to protect foods from spoilage and contamination while being prepared and served.
Failure to ensure staff demonstrated understanding and use of proper infection control practices.
Failure to provide adequate and appropriate care and services in compliance with state laws and regulations for Resident #1.
Failure to treat Resident #1 with dignity, kindness, consideration, and respect, including staff laughing at resident's pain and making disrespectful comments.
Report Facts
Incident report date: Nov 14, 2022
Resident admission date: May 16, 2022
Resident death date: Oct 4, 2022
Video incident dates: Sep 19, 2022
Video incident dates: Sep 23, 2022
Time of video incident: 837
Time of video incident: 1141
Time of video incident: 1131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Identified as staff caught on video eating resident's food and failing to use PTBL during transfers | |
| Staff A | Interviewed staff who reviewed video footage and discussed disciplinary actions | |
| Staff D | Interviewed staff who identified Staff E on video footage | |
| Staff B | Referenced by Staff A regarding termination of Staff E | |
| Staff C | Instructed staff on use of PTBL and posted reminders | |
| Staff H | Staff seen laughing at resident's pain on video | |
| Staff I | Staff seen laughing at resident's pain on video | |
| Staff G | Person spoken to by hospice caregiver complaining about resident | |
| AB | Person who declined to answer questions without legal counsel |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00225025. An on-site visit was made on 7/5/22 and the investigation was completed on 7/7/22.
Complaint Details
Investigation was related to intake GA00225025 regarding medication administration documentation for Resident #1. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to ensure that staff updated the Medication Administration Record (MAR) each time medication was offered or taken for 1 of 4 sampled residents (Resident #1). Specifically, the 6/10/22 8:00 p.m. medications were administered but not initialed on the MAR.
Deficiencies (1)
Failure to update the Medication Administration Record (MAR) each time medication was offered or taken for Resident #1.
Report Facts
Residents sampled: 4
Medications not initialed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Interviewed staff who administered medications but forgot to initial MAR | |
| Staff B | Interviewed staff who did not notice the medications were not initialed |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223468 and GA00223610 and conduct the compliance inspection.
Complaint Details
Investigation of intake #GA00223468 and GA00223610; no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 4, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00212090 and GA00212324, with an on-site visit made on 2021-02-22. The investigation began on 2021-02-18 and was completed on 2021-03-04.
Complaint Details
The investigation was complaint-driven based on intake numbers GA00212090 and GA00212324. The complaint involved concerns about Staff B accepting $60,000 from Resident #1 and serving as the resident's legal surrogate and healthcare agent, which is against facility policy.
Findings
The facility failed to implement policies prohibiting staff from accepting gifts or financial benefits from residents, as Staff B accepted $60,000 from Resident #1. Additionally, the facility failed to ensure that no staff member or governing body member served as the legal surrogate or representative for a resident, as Staff B was named as the legal agent and healthcare agent for Resident #1, contrary to facility policy.
Deficiencies (2)
Facility failed to implement policies prohibiting employees from accepting tips, gifts, loans, or gratuities from residents or their families; Staff B accepted $60,000 from Resident #1.
Facility failed to ensure no member of the governing body, administration, or staff served as legal surrogate or representative of a resident; Staff B was named as Agent and Healthcare Agent for Resident #1.
Report Facts
Amount accepted by staff: 60000
Dates of investigation: Investigation began 2021-02-18, on-site visit 2021-02-22, completed 2021-03-04
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named as primary contact/responsible party for Resident #1, accepted $60,000 from Resident #1, named as legal agent and healthcare agent, reprimanded by facility, declined interview on attorney advice. | |
| Staff A | Stated facility policy prohibits staff from accepting gifts and acting as power of attorney or agent for residents; stated Staff B was reprimanded. | |
| II | Interviewed on 2/18/21 expressing concern about Resident #1 writing checks to Staff B. | |
| JJ | Interviewed on 2/22/21 stating Staff B accepted $60,000 from Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 4, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00209855.
Complaint Details
Investigation of intake #GA00209855 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 24, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207206.
Complaint Details
Investigation of intake #GA00207206 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00206677 and GA00206691.
Complaint Details
Investigation of complaint intakes GA00206677 and GA00206691 was conducted from 2020-07-24 to 2020-07-30 with no violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00196541.
Complaint Details
Investigation of complaint #GA00196541 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate complaint #GA00193446.
Complaint Details
Investigation of complaint #GA00193446 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 10, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00180173 regarding resident safety and staffing at Buckingham South.
Complaint Details
The complaint investigation substantiated that Resident #1 wandered off the facility multiple times, including incidents on 09-19-2017 and 09-20-2017, resulting in injury. The facility failed to maintain adequate staffing and did not report the elopement to authorities within the required timeframe.
Findings
The facility failed to maintain adequate staffing ratios to meet residents' health and safety needs, resulting in Resident #1 wandering off the property multiple times and sustaining skin tears. Additionally, the facility failed to report the elopement to local police within the required 30 minutes as mandated by the Mattie's Call Act.
Deficiencies (3)
Failed to staff above the minimum on-site staff to resident ratio to meet residents' ongoing health, safety, and care needs.
Failed to provide adequate and appropriate care and services in compliance with state law for Resident #1 who wandered off and sustained injuries.
Failed to report the elopement of Resident #1 to the local police department within 30 minutes as required by the Mattie's Call Act.
Report Facts
Date of incident: Sep 20, 2017
Date of incident: Sep 19, 2017
Staff to resident ratio: 15
Staff to resident ratio: 25
Timeframe for reporting elopement: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding Resident #1 wandering and injury; no full name provided | ||
| Staff C interviewed regarding Resident #1 wandering; no full name provided | ||
| Confidential Witness AA interviewed about Resident #1 wandering; no full name provided | ||
| Confidential Witness BB interviewed about Resident #1 wandering; no full name provided |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 10, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00171250, with the investigation starting on 2017-02-06 and completing on 2017-02-09.
Complaint Details
Complaint #GA00171250 was investigated and found to have no violations.
Findings
No violations were cited as a result of this complaint investigation.
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