Inspection Reports for Summer Breeze Senior Living
351 Wilmington Island Rd, Savannah, GA 31410, United States, GA, 31410
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, found no deficiencies. Earlier inspections showed a pattern of some deficiencies related mainly to resident care practices, such as delayed medical notifications after falls, improper resident transfers, and incomplete care plans. Other issues involved staffing, including insufficient nurse coverage and staff certification lapses, as well as occasional concerns about safety measures for residents at risk of eloping. Several complaint investigations were substantiated, particularly those involving resident mishandling and delayed emergency responses, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record suggests some improvement over time, with recent inspections showing no cited deficiencies after prior issues.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
50 residents
Based on a November 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint intake #GA50001518.
Complaint Details
Investigation of intake #GA50001518 was completed with no rule violations found.
Findings
No rule violations were cited as a result of this inspection and investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249602.
Complaint Details
Investigation of intake #GA00249602 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244167.
Complaint Details
Investigation of intake #GA00244167 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240816, involving an on-site visit made on 11/15/2023 with the investigation completed on 11/28/2023.
Complaint Details
Investigation of intake #GA00240816 regarding Resident #2's unwitnessed falls on 11/4/2023, with delayed hospital transport refusal and delayed physician notification.
Findings
The facility failed to implement their developed policies and procedures for one of three sampled residents (Resident #2) who sustained an unwitnessed fall resulting in visible injuries. Staff did not contact emergency services immediately after the fall and delayed notifying the physician until three days later.
Deficiencies (1)
Failure to implement fall response policies and procedures for Resident #2 after an unwitnessed fall resulting in injuries and delayed medical notification.
Report Facts
Date of fall incident: Nov 4, 2023
Date of physician notification: Nov 7, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239139.
Complaint Details
Investigation of intake #GA00239139 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 21, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00235846 with an onsite visit made to the facility on 2023-06-21. The investigation started on 2023-06-21 and was completed on 2023-06-27.
Complaint Details
The visit was complaint-related, investigating intake GA00235846. The investigation was substantiated by the finding that the care plan was not developed within the required timeframe.
Findings
The facility failed to develop the resident's individual care plan within 14 days of admission for 1 of 5 sampled residents (Resident #4). The initial 30 day care plan was developed on 2023-01-25, which was beyond the required timeframe.
Deficiencies (1)
Failure to develop the resident's individual care plan within 14 days of admission for Resident #4.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00234925 and #GA00231831 related to allegations of staff mishandling a resident.
Complaint Details
The visit was complaint-related to allegations of physical abuse and mishandling of Resident #1. The bruising was substantiated as mishandling during transfer. Staff E was terminated. The facility had a two-person assist requirement for Resident #1 which was not followed.
Findings
The facility failed to provide protective care and watchful oversight for Resident #1, resulting in bruising due to improper transfer by staff. Staff E and Staff F were found responsible for mishandling the resident during transfer, and Staff E was terminated. The facility had a plan requiring two staff present during care for Resident #1, which was not followed.
Deficiencies (1)
Failure to provide protective care and watchful oversight resulting in bruising of Resident #1 due to improper transfer by staff.
Report Facts
Date of incident: Apr 26, 2023
Date of inspection: May 16, 2023
Number of sampled residents: 10
Length of bruise: 12
Staff E hire date: Jan 20, 2023
Staff F hire date: Dec 26, 2022
Staff E termination date: May 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named as responsible for improper transfer and terminated employment | |
| Staff F | Named as responsible for improper transfer | |
| Staff C | Interviewed regarding incident and investigation findings | |
| Staff B | Interviewed regarding care requirements for Resident #1 | |
| Staff A | Interviewed regarding oversight requirement and incident details |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00229191, GA00229236, GA00229244 and GA00229319.
Complaint Details
The investigation was related to four intake complaints (GA00229191, GA00229236, GA00229244, GA00229319) and no rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Nov 2, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00228383, GA00228423, and GA00228509. The investigation began on 2022-11-01 and was completed on 2022-11-02.
Complaint Details
Investigation was initiated based on complaint intakes GA00228383, GA00228423, and GA00228509. The complaint was substantiated by findings of no nurse coverage from 10/14/22 to 11/1/22.
Findings
The facility failed to ensure a registered professional nurse (RN) or licensed practical nurse (LPN) was on-site to support care and oversight of the residents, as required for communities with 31 to 60 residents, a minimum of 16 hours per week. Records showed no RN or LPN worked in the facility from 2022-10-14 to 2022-11-01.
Deficiencies (1)
Facility failed to ensure a registered professional nurse (RN) or licensed practical nurse (LPN) was on-site to support care and oversight of the residents, as required for communities with 31 to 60 residents, a minimum of 16 hours per week.
Report Facts
Residents present: 50
Nurse coverage hours required: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and stated the facility did not have a nurse from 10/14/22 to 11/1/22 and they were trying to hire a nurse |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 29, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00227275.
Complaint Details
Investigation of intake GA00227275. Staff interviews and observations confirmed the complaint that there was no nurse or CMA present in the memory care center during certain shifts.
Findings
The facility failed to ensure that the memory care center had at least one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times. Observations and interviews confirmed that Staff B was the only CMA on duty and was providing medication assistance in the Assisted Living section, leaving the memory care center without nursing or CMA coverage.
Deficiencies (1)
Facility failed to ensure that the memory care center had one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times.
Report Facts
Dates CMA on duty alone: 2
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
The purpose of this visit was to conduct a change of ownership inspection starting on 2022-01-10 and completed on 2022-01-21.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Jul 12, 2021
Visit Reason
The visit was conducted to investigate intake #GA00215498 and to perform a compliance inspection at Summer Breeze Senior Living.
Complaint Details
The investigation was initiated due to intake #GA00215498. The complaint involved failure to report a serious injury and staff certification issues. The incident involving Resident #1 was reported late, as confirmed by Staff B during interview.
Findings
The facility failed to ensure that one staff member (Staff D) had current certifications in emergency first aid and CPR, and failed to report a serious injury to the Department within 24 hours for one resident (Resident #1).
Deficiencies (3)
Facility failed to ensure staff had current certification in emergency first aid for 1 of 3 sampled staff (Staff D).
Facility failed to ensure staff hired to provide hands-on personal services received CPR training within the first 60 days of employment for 1 of 3 sampled staff (Staff D).
Facility failed to report to the Department within 24 hours any serious injury to a resident that required medical attention for 1 of 53 residents (Resident #1).
Report Facts
Residents present during inspection: 53
Sampled staff: 3
Date of incident: May 14, 2021
Date of late report: Jun 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in findings related to lack of emergency first aid and CPR certification | |
| Staff G | Interviewed and confirmed Staff D lacked required certifications | |
| Staff B | Interviewed and confirmed late reporting of Resident #1's injury |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 29, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205226.
Complaint Details
Investigation began on 2020-05-26 and was completed on 2020-05-29. No citations were issued.
Findings
No citations were issued as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204115.
Complaint Details
Investigation began on 2020-04-20 and was completed on 2020-04-28. No citations were issued.
Findings
No citations were issued 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
Follow-Up
Deficiencies: 0
Date: Mar 17, 2020
Visit Reason
The purpose of this survey was to conduct a paperwork follow-up to the 12/16/19 inspection.
Findings
Based on a review of documentation submitted by the facility, the violation cited on the inspection has been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 16, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake GA00201347.
Complaint Details
Investigation of intake GA00201347.
Findings
The facility failed to ensure that direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 1 of 3 sampled staff (Staff C).
Deficiencies (1)
Failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 1 of 3 sampled staff (Staff C).
Report Facts
Number of sampled staff without required background check: 1
Number of sampled staff reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct care staff hired 10/3/19 without criminal background check | |
| Staff A | Interviewed and stated Staff C had not had a criminal record check |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 1, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00199720.
Complaint Details
Investigation of complaint #GA00199720 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00198829.
Complaint Details
Investigation of complaint #GA00198829 completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 1, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00197144, with the investigation beginning on 2019-06-10, an onsite visit on 2019-06-11, and completion on 2019-07-01.
Complaint Details
Investigation of complaint #GA00197144 found substantiated failure to timely manage medication procurement, resulting in Resident #1 being without heart medication for approximately three months.
Findings
The facility failed to obtain new prescriptions within 48 hours of receipt of notice or sooner if indicated by the prescribing physician for medication changes for 1 of 1 sampled resident (Resident #1). Resident #1 was without heart medication (Lopressor) from mid-January 2019 until April 2019 due to delayed prescription refills.
Deficiencies (1)
Failure to obtain new prescriptions within 48 hours of receipt of notice or sooner if the prescribing physician indicated an immediate medication change for Resident #1.
Report Facts
Dates medication not available: 3
Date of investigation start: Jun 10, 2019
Date of onsite visit: Jun 11, 2019
Date of investigation completion: Jul 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding Resident #1's medication procurement issues. | |
| Staff C | Interviewed regarding Resident #1's medication procurement issues and pharmacy contact. | |
| Confidential Informant #1 | Interviewed and stated Resident #1 had been without heart medication for one month. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 1/17/19 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaints GA00193758 and GA00193892.
Complaint Details
The investigation was complaint-related, triggered by complaints GA00193758 and GA00193892. The complaint was substantiated by evidence that a visitor was denied access contrary to resident rights.
Findings
The facility failed to permit immediate access to residents by visitors with the resident's consent, violating residents' rights. Specifically, one visitor was improperly denied access and escorted out, which staff later acknowledged as an error.
Deficiencies (1)
Facility must permit immediate access to residents by visitors with the resident's consent; a visitor was denied access and escorted out improperly.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in the finding for escorting a visitor from Resident #1's room and acknowledging the action was an error. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
The purpose of this visit was to investigate complaints GA 00190495 and GA 00191010.
Complaint Details
The visit was complaint-related to investigate complaints GA 00190495 and GA 00191010. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 30, 2018
Visit Reason
The visit was conducted to investigate complaint #GA00190088 with an on-site visit made on 7/30/18 and the investigation completed on 8/2/18.
Complaint Details
Complaint #GA00190088 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 13, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA 00189626.
Complaint Details
The visit was complaint-related, investigating complaint GA 00189626. The complaint involved failure to honor a resident's DNR order during an emergency resuscitation attempt.
Findings
The facility failed to ensure that each resident was provided care and services which were adequate, appropriate, and in compliance with state law and regulations, specifically regarding the accessibility and awareness of a resident's Do Not Resuscitate (DNR) order during an emergency.
Deficiencies (1)
Failure to ensure that care and services were adequate and appropriate for Resident #1, including failure to properly manage and communicate the resident's DNR status during an emergency.
Report Facts
Date of resident admission: Jul 13, 2016
Date of 911 call: Jun 24, 2018
Time CPR started: 1639
Time EMTs arrived: 1649
Time EMTs assumed CPR: 1652
Date of Advance Directive: May 16, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 2, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/7/18 investigation regarding safety devices for residents at risk of eloping.
Findings
The facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping, specifically for 4 of 6 sampled residents with cognitive deficits. Staff pagers were not properly monitored or responded to promptly, and there was no documentation of staff training on pager use.
Deficiencies (1)
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping for 4 of 6 sampled residents with cognitive deficits.
Report Facts
Sampled residents with deficiency: 4
Delay in staff response: 10
Previous citation date: Mar 7, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Did not respond promptly to pager alarm and was unaware exit door was open. | |
| Staff H | Did not respond promptly to pager alarm and pager did not show which door was open. | |
| Staff B | Programmed all staff pagers and acknowledged lack of staff training on pager use. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 9, 2018
Visit Reason
The purpose of the survey was to conduct a paperwork follow-up to the 9/27/17 inspection.
Findings
Based on a review of documentation submitted by the facility, the violation cited on the inspection has been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 20, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00185552 regarding the safety and reporting procedures related to a resident at risk of eloping.
Complaint Details
The investigation was complaint-driven based on complaint #GA00185552. The complaint was substantiated by findings that the facility did not have safety devices on exit doors and delayed reporting the elopement to police.
Findings
The facility failed to utilize appropriate safety devices to prevent elopement of a resident with dementia and failed to report the elopement to local police within the required 30 minutes. Resident #1 was missing overnight and found on the property the next morning.
Deficiencies (2)
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping from the premises.
Failed to call the local police department to report the elopement of a resident within 30 minutes of staff receiving actual knowledge.
Report Facts
Time elapsed before notifying police: 80
Resident missing duration: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding exit doors lacking safety devices and timeline of elopement notification. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 27, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate a self-reported incident #GA00179854.
Findings
The facility failed to obtain a satisfactory fingerprint records check determination for the person hired as Executive Director prior to that person serving in the role, as evidenced by missing documentation and staff interview.
Deficiencies (1)
Failure to obtain a satisfactory fingerprint records check determination for the Executive Director prior to serving in that role.
Report Facts
Date hired for Executive Director: Mar 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in deficiency for failure to have fingerprint records check completed prior to serving |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 6, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00175653.
Complaint Details
Complaint #GA00175653 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 1, 2017
Visit Reason
The visit was conducted to investigate complaint #GA00177972 and to perform a follow-up to the 3/7/17 inspection.
Complaint Details
Complaint #GA00177972 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 1, 2017
Visit Reason
The visit was conducted to investigate complaint #GA00173972 and to perform a follow-up to the 3/7/17 inspection.
Complaint Details
Complaint #GA00173972 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Census: 12
Deficiencies: 6
Date: Mar 7, 2017
Visit Reason
The visit was conducted as a follow-up inspection to the 11/7/16 inspection and to investigate complaint GA 00170818.
Complaint Details
The inspection included investigation of complaint GA 00170818 related to safety and elopement concerns.
Findings
The facility failed to meet multiple requirements including posting directions for keypad locks on exit doors, securing outdoor spaces to prevent undetected egress, having an effective automated alert system for unauthorized exits, maintaining sufficient staffing levels, providing adequate care to residents, timely reporting of resident elopements to authorities, and securing windows to prevent resident elopement.
Deficiencies (6)
Failed to post directions for keypad lock operation on the Memory Care Unit fire exit door.
Memory care courtyard gate was unsecured and could be opened from inside, allowing undetected egress.
Failed to have an effective automated alert system to notify staff of unauthorized entry or exit from the memory care unit.
Insufficient staff on duty at all times to meet resident needs, including during an elopement incident.
Failed to provide adequate and appropriate care and services to Resident #1, who eloped multiple times.
Failed to report resident elopement to local police within 30 minutes as required by the Mattie's Call Act.
Report Facts
Census: 12
Staff to resident ratio: 1
Elopement incidents: 2
Time delay in reporting: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding keypad lock, courtyard gate, window alarms, and elopement incidents | |
| Staff C | Interviewed regarding elopement incidents and staffing shortages | |
| Staff D | Interviewed regarding staffing shortages and elopement incidents | |
| Staff A | Interviewed regarding staffing policies and reporting procedures | |
| Staff E | Mentioned as arriving late to work during staffing shortage | |
| Staff F | Mentioned as working alone in Assisted Living Unit during staffing shortage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 7, 2017
Visit Reason
The visit was conducted to investigate complaint GA 00170818 and to perform a follow-up inspection to the 11/7/16 inspection, with on-site visits made on 1/19/17 and 3/7/17.
Complaint Details
Complaint GA 00170818 was investigated during this visit; citations related to this complaint are included in the follow-up inspection.
Findings
Citations related to the complaint investigation are included in the 3/7/17 follow-up inspection report.
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