Inspection Report Summary
The most recent inspection on October 6, 2025, was a complaint investigation that found no deficiencies. Earlier inspections showed some deficiencies related to personnel documentation, resident care plans, and diet order adherence, with issues such as missing physical exams for staff and residents and incomplete care plans. Prior complaint investigations mostly found no violations, though substantiated complaints included lapses in resident supervision leading to elopements and failures in documenting and investigating resident injuries. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some recurring documentation and care planning issues, but recent investigations indicate improvement in compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 6, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50006041.
Complaint Details
Investigation started on 2025-10-06 with an on-site visit at 11:00 am and was completed the same day. No violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005625.
Complaint Details
Investigation started and completed on 2025-09-22 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Renewal
Capacity: 36
Deficiencies: 4
Date: Sep 3, 2025
Visit Reason
The purpose of this visit was to conduct a re-licensure inspection of the facility, with the onsite visit occurring from 9/3/2025 to 9/8/2025.
Findings
The facility failed to maintain required personnel documentation including physical examinations and training certifications for several staff members. Additionally, the facility did not have a physician's report of physical examination for one resident prior to admission to the memory care unit, and failed to provide adequate care related to diet orders for that resident.
Deficiencies (4)
Personnel files lacked physical examination reports completed within 12 months preceding the date of hire for 2 of 4 sampled staff (Staff A and Staff D).
Personnel files lacked evidence of required training, skills competency determinations, and recertifications for 3 of 4 sampled staff (Staff A, Staff C, Staff D).
Resident #4 did not have a physician's report of physical examination on required forms completed within 30 days prior to admission to the memory care unit.
Facility failed to provide adequate and appropriate care and services for Resident #4, including serving a meal inconsistent with the resident's mechanically soft diet without a physician's order.
Report Facts
Total capacity: 36
Number of sampled staff with missing physical exam: 2
Number of sampled staff lacking training documentation: 3
Number of sampled residents without required physical exam: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiencies related to missing physical exam and training documentation; involved in diet order incident for Resident #4 | |
| Staff D | Named in deficiencies related to missing physical exam and training documentation | |
| Staff C | Named in deficiency related to missing training documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001030 and #GA50000957.
Complaint Details
Investigation of intake #GA50001030 and #GA50000957 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The visit was conducted to investigate intake #GA00239793 with an onsite visit on 10/17/2023 and the investigation completed on 10/20/2023.
Complaint Details
Investigation of intake #GA00239793 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 17, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00234341.
Complaint Details
Investigation of intake #GA00234341 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232934.
Complaint Details
The visit was complaint-related, investigating intake #GA00232934.
Findings
The facility failed to develop individual written care plans within 14 days of admission for 3 of 4 sampled residents, lacking required elements such as care descriptions, preferences, behaviors, physician orders, responsible staff, family involvement, and timely updates.
Deficiencies (1)
Failed to develop resident's individual written care plan within 14 days of admission for 3 of 4 sampled residents, missing required components including care and social needs, preferences, behaviors, physician orders, responsible staff, family involvement, and updates.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed and stated he/she thought the assessment was already the care plan and discussed care plans with legal representatives but failed to document them. | |
| Staff A | Interviewed and stated unawareness of items needed to be considered when developing a written care plan. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00221012, which started on 2022-02-03 and was completed on 2022-02-23.
Complaint Details
Investigation of intake GA00221012 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Date: May 12, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00213723 related to resident supervision and elopement incidents.
Complaint Details
The investigation was triggered by intake #GA00213723 regarding allegations of elopement involving Resident #1 and Resident #2. The complaint was substantiated based on observations, record reviews, and interviews.
Findings
The facility failed to ensure adequate supervision for residents consistent with their needs, resulting in two residents eloping from the facility unnoticed. Resident #1 left the facility on 4/14/2021 and was found a quarter mile away by law enforcement unharmed. Resident #2 was found outside near the sidewalk and returned unharmed. Staff interviews and record reviews confirmed these incidents and identified supervision lapses.
Deficiencies (1)
Facility failed to ensure residents were supervised consistent with their needs, leading to elopement of Resident #1 and Resident #2.
Report Facts
Residents present: 23
Direct care staff on duty: 3
Incident date: Apr 14, 2021
Time Resident #1 last seen: 1345
Time Resident #1 discovered missing: 1400
Time Resident #1 found by law enforcement: 1505
Distance Resident #1 found from facility: 0.25
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208981.
Complaint Details
Investigation began on 2020-10-28 and was completed on 2020-12-18. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206554.
Complaint Details
Investigation of intake #GA00206554 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 1, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205428, which began on 2020-06-26 and was completed on 2020-07-01.
Complaint Details
Investigation of intake #GA00205428 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 21, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205002. The investigation began on 2020-05-18 and was completed on 2020-05-21.
Complaint Details
Investigation of intake #GA00205002 regarding a bruise found on Resident #1's right hip after a seizure. The bruise was not documented or investigated as required by facility protocol, which was found to be insufficient and subsequently revised.
Findings
The facility failed to implement policies and procedures to ensure dignity, respect, and safety of residents, specifically failing to document and investigate a bruise found on Resident #1's right hip after a seizure incident. The facility acknowledged insufficient protocol and revised it to require immediate documentation of bruises or resident changes.
Deficiencies (2)
Failure to implement policies and procedures supporting dignity, respect, choice, independence, and privacy of residents in a safe environment.
Failure to ensure an immediate investigation of the cause of an accident, injury, or death involving a resident was initiated by the administrator or on-site manager for Resident #1.
Report Facts
Investigation dates: 4
Incident date: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Health and Wellness Director | Named in relation to failure to document and investigate bruise on Resident #1 |
| Staff C | Reported seeing bruise on Resident #1 and verbally reported to Staff D | |
| Staff D | Medicine Technician | Responsible for documenting bruise in communication log but failed to do so |
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 7, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The review focused on monitoring COVID-19 cases and assessing infection control processes at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00202773. An onsite visit was made on 2020-02-28, and the investigation was completed on the same day.
Complaint Details
Investigation of complaint #GA00202773 conducted onsite on 2020-02-28.
Findings
The report documents the investigation of a complaint at Sunabella at Savannah, LLC. No specific findings or deficiencies are detailed in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/23/19 initial inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 8
Date: Sep 23, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection of the assisted living facility.
Findings
The facility failed to implement required policies and procedures supporting resident dignity and safety, lacked a complete disaster preparedness plan, did not ensure physical examinations on department forms for residents, failed to conduct admission assessments, did not review or update written care plans quarterly, lacked quarterly medication aide observations, and failed to maintain signed admission agreements and National Sex Offender Registry searches for sampled residents.
Deficiencies (8)
Failed to implement policies, procedures and practices supporting dignity, respect, choice, independence and privacy of residents.
Failed to comply with disaster preparedness requirements; disaster plan did not address loss of utilities and was incomplete.
Failed to ensure physical examinations were completed on Department forms within 30 days prior to admission for 2 of 3 residents.
Failed to obtain admission assessments including family supports, ADL functioning, physical care needs, and behavior impairment for 2 of 3 residents.
Failed to review and modify written care plan quarterly for 1 of 3 residents.
Failed to conduct quarterly medication administration observations for certified medication aide.
Failed to have signed admission agreements in resident files for 3 of 3 sampled residents.
Failed to conduct National Sex Offender Registry searches for 3 of 3 sampled residents.
Report Facts
Residents sampled: 3
Staff CMA file reviewed: 1
Staff CMA hire date: Sep 27, 2018
Resident #1 admission date: Apr 5, 2019
Resident #2 admission date: Aug 7, 2019
Resident #3 admission date: Apr 5, 2019
Change of ownership effective date: Jun 17, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding lack of policies, disaster plan, admission agreements, and NSOR searches | |
| Staff B | Interviewed regarding admission assessments, care plan reviews, and medication administration observations | |
| Staff C | Certified Medication Aide | File reviewed showing no quarterly medication administration observation |
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