Bedside Betrayal: Violations persist at local nursing home seven years after resident’s death

SAVANNAH, Ga. (WTOC) - It’s a choice no one wants to make: whether to put your loved one in a nursing home.

But sometimes, it can’t be avoided.

WTOC Investigates has found over half of Savannah-area nursing homes are rated “below average” or “much below average” by the Centers for Medicare and Medicaid Services (CMS).

Nursing homes in the Savannah area are often cited by the State of Georgia for a litany of violations, one of the most common being patient neglect. Since the beginning of 2024, 120 citations have been issued to area nursing homes.

One of those is Riverview Health and Rehabilitation Center.

A CMS report shows that in February of this year, Riverview was cited nine times, including for an incident in which a nurse threw a mechanical lift pad at a resident, which hit her, and said, “I’m sick of you.”

The report also says Riverview failed to protect two “cognitively impaired” residents from sexual and verbal abuse by another resident, and failed to thoroughly investigate the incident.

CMS also determined the facility had caused, or had the likelihood to cause, serious injury or death to residents.

These violations come years after one woman’s family contends she died because of neglect at the facility.

“My mom was a very loving, caring, supportive woman. That was just her,” says Latifah Bizzard. “She actually passed when Lyrica, my 9-year-old, the little girl was just born. Everyone says that, that knows my mom, they say, ‘She looks so much like your mom.’”

Latifah’s mother, Sara Bizzard, never got to see her grandchildren grow up.

In 2018, Bizzard, who had retired from a career of working with disadvantaged children, fell while going up the stairs at her apartment, breaking her upper arm.

She went to the hospital and was then admitted to Riverview Health and Rehabilitation Center for short-term rehab.

“She ended up leaving the hospital and going to the nursing home where everything just kind of turned for the worse. So that was that,” Latifah says.

Though her family was expecting her to come out of Riverview, Sara Bizzard never made it home.

A lawsuit filed by Sara’s daughter Latifah contends she died due to the negligence of Riverview employees.

Sara ended up back at the hospital during her stay at Riverview with severe sepsis, a urinary tract infection, severe dehydration, and a sacral decubitus ulcer, which is commonly know as a bedsore.

“I got to the hospital, and the wound was bad. It was bad at this point. It was black, it had an awful smell from it, and she was just crying, like, she was in so much pain,” says Bizzard.

Bedsores, like the ones you can see below, are a painful injury caused by prolonged pressure on the skin.

They’re hard to look at, but Brian Krapf, a Savannah attorney specializing in nursing home abuse, says he sees photos of them way too often.

“We see a lot of avoidable pressure ulcers, pressure sores on the backside and on the heels of people who are not turned or repositioned in the beds,” says Krapf. “The pressure sores can ultimately lead to death.”

According to the lawsuit, Bizzard underwent debridement for her wound twice, a procedure that removes damaged or infected tissue, but her condition didn’t improve.

She died less than four months after she was admitted to Riverview to rehab a broken arm.

“I was furious. It was a lot on me. I was already overwhelmed, stressed out, with everything. I was caring for my daughter, my daughter had a trach, my daughter had a G-Tube and it was everything that I was already dealing with my daughter, now I was dealing with it with my mom,” says Latifah Bizzard.

The hardest part to grapple with, she says, is that bedsores are preventable.

“Absolutely preventable with proper nursing care and proper oversight. One of the problems we see over and over and over again in these cases, is short staffing,” says Krapf. “The facilities simply do not have the number of employees necessary to adequately provide care and oversight to all residents as they should.”

“Every time I would go, she was asking me to turn her, and I’d ask ‘How many times have they been in here today, and she’d say, ‘I don’t know, I don’t remember, but I need to be turned,’” says Bizzard.

According to the Agency for Healthcare and Research Quality, around 60,000 patients die as the direct result of bedsores each year, and more than 17,000 lawsuits each year are related to them.

You can view the full details of Latifah Bizzard’s case against Riverview Health and Rehabilitation Center below:

Riverview settled the lawsuit with Bizzard.

“It wasn’t enough. I would have wanted my mom instead of a lawsuit, of course. No money can replace a loved one,” says Bizzard.

Riverview declined to comment on Bizzard’s case, though the facility says after it received the citations in February, “all deficiencies were immediately rectified. Riverview maintains compliance with CMS and DCH guidelines.”

If you’re considering putting your loved one in a nursing home, there are several things Krapf says you should do before deciding.

His number one tip is to tour the facility unannounced so you can see what it’s really like.

You should also head to the Center for Medicare and Medicaid website and use the “Care Compare” function. There, you can see how many “stars” a facility has, and check to see whether they have a history of violations. A five-star rating is the best rating a facility can have.

Inspection reports for Georgia nursing homes are also available on the Georgia Department of Community Health website.

Part 2 of Bedside Betrayal, which will examine staffing shortages in local nursing homes, will air on Thursday, August 31 at 6 p.m. on WTOC.