Lawsuit against Savannah Court senior home alleges wrongful death

The facility near Lake Oconee has been the subject of an AJC investigation into the state’s oversight of assisted living and personal care homes
A couple of the houses that are part of the Savannah Court of Lake Oconee assisted living home are seen on Monday, Dec. 11, 2023, in Greensboro, GA. The facility has a troubled history, and the state's efforts to regulate and shut down the home.
Miguel Martinez /

Credit: Miguel Martinez

Credit: Miguel Martinez

A couple of the houses that are part of the Savannah Court of Lake Oconee assisted living home are seen on Monday, Dec. 11, 2023, in Greensboro, GA. The facility has a troubled history, and the state's efforts to regulate and shut down the home. Miguel Martinez /

A wrongful death lawsuit has been filed against Savannah Court of Lake Oconee, a Greensboro assisted living facility that has been the subject of a series of Atlanta Journal-Constitution investigations examining the state’s lackluster oversight of assisted living and personal care homes.

The suit, which was filed in the State Court of Gwinnett County last month, alleges Savannah Court failed to render appropriate care to Aljean Almand. The 94-year-old resident died on April 26, 2022, ten days after, what the suit describes as, an avoidable fall that caused her to fracture both of her shins.

“Aljean Almand passed away as a direct and proximate result of Defendants’ negligence,” the complaint, which was filed by Almand’s son Keith Almand, and grandson Kevin Jones, the executor of the estate, states.

According to the suit, Almand was admitted to Savannah Court on Feb. 17, 2022. It is alleged that the facility didn’t perform any physical or care needs assessment in advance of her admission and had no care plan or individual service plan. While there was a medication log for April, there were allegedly no logs kept in February or March, as is required by law.

The communication record additionally only had three entries for Almand. One mentioned a wound that had not been mentioned elsewhere. While the log stated that the sore looked “healthy,” hospital records from a week later described the wound as an ulcer that went down to the bone.

The spotty and inconsistent record-keeping was compounded, according to the suit, on April 16, 2022, when Almand fell.

According to the medication log, that night Almand was not given her doctor-prescribed dose of Alprazolam, a psychotropic medication used to minimize panic attacks. The log specifically noted the facility had run out of the medicine. Later that evening Almand, according to the suit, needed to go the bathroom but was unable to get help. Agitated without the proper medicine she attempted to get out of bed and go on her own. In the process, she fell. According to a police report of the incident, her bone was sticking out of the skin when she was found.

Almand was taken to the hospital and upon release on April 22 she went to Abbey Hospice. She died four days later on April 26.

The suit alleges Savannah Court failed to exercise reasonable care; failed to hire and train appropriate personnel; retained unfit and unqualified staff; repeatedly failed to establish appropriate corporate budgeting policies that in turn “deprived residents of adequate staffing, supplies, care and caused neglect.”

Almand and Jones declined, via their attorney Kate Hughes, to speak with The Atlanta Journal-Constitution.

“Based on my investigation of this facility I suspect this is just the tip of the iceberg,” said Hughes, an Atlanta-based attorney who specializes in nursing home and assisted living cases.

The suit was filed on January 28, weeks after the AJC published an investigation into the 72-bed facility. The story detailed how Savannah Court received over 70 violations from state Department of Community Health (DCH) regulators since 2021. The state cited the home for two incidents that resulted in deaths in April 2022 — the same month Almand fell and subsequently died.

Despite being reported to the state in April, Almand’s fall was not documented in a July 2022 inspection report that came as a result of the other April deaths.

“There were 11 citations, but none connected directly to the complaint,” David Graves, a DCH spokesperson, wrote in an email.

When asked how the state determines what incidents to investigate, Graves said there is a review and triage system to determine whether or not an on-site visit is needed.

“Facility-reported incidents are reviewed and may trigger an on-site visit based on the facility’s documented response and corrective action,” said Graves. He did not explain why Almand’s incident was not part of the report.

The incident’s lack of documentation in the report raises questions about the public’s ability to know the true volume of incidents, and potential violations, within the state’s assisted living and personal care homes.

“It’s the Wild West,” Richard Mollot, executive director of the Long Term Care Community Coalition, a New York-based nonprofit, said about the sector when discussing the AJC’s original findings around Savannah Court.

Savannah Court, and its parent company Senior Living Management, did not respond to a request for comment on the suit, or questions as to why the facility admitted Almand to begin with. According to the complaint, Almand had a history of lower extremity paralysis and couldn’t move around easily on her own. State law requires personal care home residents to be ambulatory when admitted.

Senior Living Management, a Florida-based company, operates a total of 17 senior care homes across the Sunshine State, Louisiana, and Georgia. It has a total of four facilities in Georgia.

While it can be challenging to track lawsuits because Senior Living Management operates under a cluster of different LLCs, the AJC was able to identify several complaints filed in court against the company, and its various Georgia properties, in recent years.

Three suits allege scenarios similar to Almand’s, where falls allegedly resulted in much more severe health conditions and eventually deaths.

A 2021 wrongful death suit filed against Savannah Court of Camilla was scheduled to go to trial in January but the two sides settled in October. Another suit filed in March 2022 against Savannah Grand of Columbus moved to arbitration in May 2022 and is still pending. An August 2023 suit against Savannah Court of Lake Oconee, which is still pending, alleges a resident was left on the floor for 45 minutes after falling out of a wheelchair. Like Almand’s case, the suit alleges the facility kept no documentation of the resident’s various ailments, health conditions, and medical needs as is required by law.

In August the state sent Savannah Court of Lake Oconee a license revocation notice. The two sides, however, subsequently entertained a “settlement agreement” that would have allowed the facility to stay open. In October, as those discussions were playing out, the AJC found that a resident was sexually assaulted by another resident. A hearing ended up proceeding in the state’s administrative court after the AJC published that first investigation; A closure decision, however, won’t come for at least another month.