Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewood At Tybee Island Of Journey Llc, The during CMS and state inspections, most recent first.
An active raccoon infestation was found in resident rooms, the hallway, dining area, walls, and attic ceiling, with one raccoon falling through a ceiling tile into a resident room and another found in the hallway. Residents reported fear, hearing movement in the ceiling, and seeing a hole left exposed above the bed area, while staff confirmed multiple raccoons had been captured and that the issue had been ongoing. Residents with anxiety, depression, insomnia, weakness, and cognitive deficits were affected by the disturbance and unsafe conditions.
Administration failed to manage a known raccoon infestation after staff observed a live raccoon in the attic and later a raccoon fell through a resident’s ceiling. A resident was found in bed with a hole in the ceiling above her room, exposed insulation, and she reported that the raccoon had fallen through the wet ceiling tile and showed a photo of the animal in her room. The DNS and ED acknowledged the infestation, ceiling openings, and that the issue had been known to the facility, while the survey determined the situation posed Immediate Jeopardy.
Surveyors found expired, unlabeled, and undated food items in dry storage, the reach-in freezer, the reach-in refrigerator, and the walk-in freezer, with the DM confirming the findings. They also observed mold-like buildup and brown residue in the ice machine, and during meal tray assembly, wet plates were taken from the plate warmer and used for service. The RD confirmed the wet nesting issue and staff stated the plate warmer had not been plugged in.
Open dumpsters and a cluttered refuse area were observed with broken dumpster lids, exposed trash, and discarded bulk furniture around the dumpster enclosure. The DM confirmed the dumpsters should have been secured and the ED stated the damaged dumpsters contributed to raccoons and cats being present; a CMA reported raccoons were seen going into the open dumpsters regularly.
Infection control practices were not maintained in a resident bathroom, a shower room, and the laundry area. A resident bathroom had a brown smeared substance on the floor and unbagged, unlabeled urinals and bedpans stored on a shelf above the toilet; the DON confirmed the items needed bagging and labeling and the floor needed cleaning. In the shower room, a soiled washcloth and dirty razor were left out, and in the laundry room, the door had large gaps, the floor was dirty with wet linens and towels, a fan was coated with debris and blowing toward resident clothing, and the washer chemical dispenser pumps were detached, with staff estimating detergent amounts.
Unsafe Water Temperatures in Resident Rooms and Shower Area: Water in multiple resident room sinks and a common shower room exceeded the facility's stated limit of 120 F and was found to be uncomfortably hot to the touch. The facility had no active maintenance staff, and a housekeeper was directed to check temperatures despite not being responsible for that duty. Residents with dementia, Alzheimer's disease, schizoaffective disorder, bipolar disorder, and other cognitive impairment were identified as potentially at risk.
Unclean resident rooms and unresolved environmental hazards: PTAC filters in two rooms had thick gray fuzzy debris, and one room also had debris under the PTAC, an unknown bagged item by the sink, unidentified clothing items in an unlabeled bag on the floor, and a light bulb base hanging from the bathroom ceiling. A resident with a BIMS score of 14 said the room contained items from a prior occupant, the clothing was not his, the light had been like that for a while, and the room was not cleaned routinely; the ED confirmed the conditions.
The facility failed to provide written information about the right to accept or refuse treatment and to formulate an advance directive for two residents, and it failed to keep code status orders consistent with resident wishes and documentation. One resident with heart failure, COPD, and respiratory failure had a full code order in the chart despite a DNR POLST and stated she wanted to be DNR; another resident with diabetes, bronchitis, and dysphagia had conflicting DNR/full code documentation across the EMR, care plan, POLST, and code status lists, with staff confirming the records were mixed up.
A resident with severe cognitive impairment, CKD, DM2, mood disturbance, and anxiety was discharged to a sister facility, but the record lacked a transfer/discharge summary, the basis for the discharge, the resident's status at discharge, and documentation that required information was sent to the receiving provider. The DON/DNS stated staff did not document the transfer because they viewed it as going across the street and were unsure whether the ombudsman was notified.
The facility failed to submit PASARR Level II referrals for two residents with documented qualifying psychiatric diagnoses. One resident had schizophrenia, bipolar disorder, anxiety, and depression, and no Level II submission was found despite the diagnosis being present at admission. The other resident had schizophrenia disorder and bipolar disorder, but was not listed on the PASARR Level II tracking list and no Level II had been submitted; staff interviews confirmed the omission.
Care plans were not revised to match advance directives for two residents. One resident's EMR and care plan banner showed DNR while the POLST was full code, and another resident had an active physician order for full code but a POLST for DNR, with the care plan still reflecting full code interventions. The MDS Coordinator and DON confirmed the mismatches between the code status documents and the care plans.
A resident with major depressive disorder, recurrent anxiety disorder, and COPD remained on Buspirone 5 mg BID despite a consultant pharmacist’s recommendation for a GDR. The resident was cognitively intact, and the MAR showed the medication was administered as ordered each day while the DON/DNS stated she was not aware of the pharmacy recommendation and was responsible for monitoring GDRs.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
The facility did not ensure licensed nurse coverage on one wing during an evening shift, resulting in no nurse on that wing after about 6:00 PM. Two nurses from the day shift reported that no relief nurse arrived, notified the scheduler, DON, and Administrator, stayed several extra hours, then secured the medication cart keys and left. The scheduler confirmed that no licensed nurses were assigned for that shift and that the DON did not come in. Several cognitively intact residents reported that no nurse was available to administer medications, including a diabetic resident who stated he did not receive his medicine until the next day, and a grievance documented that some residents did not receive their scheduled evening doses.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to the failure to safeguard residents from harm by others.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as observed and documented by surveyors.
The facility did not manage its operations to ensure effective and efficient use of resources, as observed by surveyors during their review.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Certified Medication Aides (CMAs) administered medications, including narcotics, without documented annual competency check-offs, and were not certified to give controlled substances. Multiple staff, including RNs and consultants, were unaware that CMAs were administering narcotics, despite facility policy prohibiting this practice. This resulted in unqualified staff administering medications to residents.
A deficiency was identified when clean clothes and linens were found uncovered and coated with dust and debris in the laundry area, with a fan blowing contaminated air onto them. The ceiling, pipes, and equipment were not being cleaned as required, PPE was inadequate and dirty, and there was no proper biohazard container. Staff interviews revealed a lack of awareness and documentation regarding proper laundry sanitation practices.
A resident was taken outside by two CNAs while wearing a hospital gown that was pulled up, leaving the resident's lower body exposed to public view, including construction workers and passing cars. Both CNAs acknowledged they failed to ensure the resident was properly covered, and the DON confirmed this was a dignity issue per facility policy.
A resident with severe cognitive impairment, muscle weakness, and a high fall risk was not provided with fall mats despite a history of falls and repeated attempts to get out of bed or a chair. Staff interviews confirmed that fall mats were not used, and the DON was unaware of their absence, resulting in inadequate supervision and safety measures.
The facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three medication carts. The policy required documentation and verification of controlled substances by licensed nurses at shift changes. However, reviews of narcotic logs revealed that nurses failed to sign the sheets on multiple dates, indicating a lack of verification. Interviews confirmed the expectation for nurses to sign the logs, and the Nursing Home Administrator acknowledged the deficiency.
A facility failed to create a comprehensive baseline care plan for a newly admitted resident with multiple health conditions. The care plan only addressed nutritional status, neglecting critical needs such as oxygen use, codeine allergy, cognitive deficits, diabetes management, DNR status, and eyeglasses. Staff interviews confirmed the oversight, leading to a deficiency in addressing the resident's immediate needs.
The facility failed to date multi-dose diabetes medications on a medication cart, affecting three residents. During an observation, it was found that three vials of insulin were opened and available for use without being dated, contrary to the facility's policy. An LPN confirmed the oversight, and the Nursing Home Administrator acknowledged the failure to ensure acceptable storage times.
The facility did not adhere to its policy of posting daily nurse staffing information at the beginning of each shift. During a survey, staff could not provide the required postings for certain dates, and a RN admitted to being overwhelmed and unable to organize the files. The Administrator acknowledged the inconsistency in posting the staffing data.
A resident with moderate cognitive impairment was repeatedly observed wearing a hospital gown despite preferring his own clothes, which went missing after a hospital stay. Staff were uncertain about the reason for the gown, and the DON did not see it as an issue, while the Administrator acknowledged the resident's preference for personal attire.
The facility failed to ensure call lights were within reach for four residents, placing them at risk of unmet needs. Observations showed call lights on the floor or out of reach, despite residents having no upper extremity impairments and being dependent on staff for ADLs. Staff interviews confirmed the deficiency, with a CNA and the Administrator acknowledging the issue.
A resident with COPD and CHF did not have a comprehensive care plan addressing their significant health needs, such as ADLs, hospice care, and an indwelling urinary catheter. The facility's policy requires a comprehensive care plan within seven days post-MDS assessment, but the plan only included the resident's enjoyment of activities, omitting critical health areas.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Residents with cognitive impairments and physical limitations were observed with long, dirty fingernails, and one resident was left in a soiled state for several hours. Staff interviews revealed a lack of awareness and prioritization of residents' needs, contributing to the deficiencies in care.
A resident with HIV experienced a five-day delay in obtaining a urine specimen for a urinalysis, culture, and sensitivity test, despite a physician's order. The resident suffered severe pain during this period. Staff interviews revealed confusion and lack of responsibility in collecting the specimen, with the DON and physician acknowledging the delay as unacceptable.
Two residents in a facility shared a single water mug, contrary to infection control policies. One resident, with moderate cognitive impairment, reported not being offered his own mug, while the other confirmed sharing since admission. The DON was unaware of this issue until it was highlighted, and the shared mug was found to be filthy, indicating a lapse in infection control measures.
Raccoon Infestation in Resident Areas
Penalty
Summary
The facility failed to maintain a vermin-free environment when an active raccoon infestation was identified in the attic ceilings, walls, main dining room, hallway, and resident rooms. Survey findings documented that raccoons were heard moving in the ceiling, one raccoon fell through a ceiling into a resident room, and another was found in the hallway near the kitchen. Staff also reported seeing raccoons in traps outside the building and near the dumpsters, and the Executive Director acknowledged that multiple raccoons had been captured over time and that the issue had been ongoing. Resident interviews and observations showed that the infestation directly affected resident rooms and living areas. One resident’s room had a hole in the ceiling after a raccoon fell through a previously wet ceiling tile, and the resident stated she feared sleeping because something else might fall through. Another resident reported hearing heavy movement in the ceiling and feared the stained ceiling tiles above her bed might collapse. A photograph provided by a resident showed a raccoon positioned between the wall and nightstand. Staff confirmed that residents remained in the room with the ceiling exposed after the incident. The record review identified residents with conditions including muscle weakness, difficulty walking, cognitive communication deficit, anxiety, depression, insomnia, and adjustment disorder with mixed anxiety and depressed mood. Staff interviews showed that the raccoon incidents caused fear among residents and staff, that the ceiling hole remained exposed for a period of time, and that the facility had not consistently relocated residents or documented frequent checks or social work follow-up. The Director of Nursing stated she was aware of the risk from the open hole and that raccoons were still present in the facility, while the Executive Director confirmed the infestation had been present before his arrival and that raccoons and cats were associated with broken dumpster lids and other exterior conditions.
Failure to Address Known Raccoon Infestation
Penalty
Summary
Administration failed to manage the facility in a manner that protected residents’ health and safety when a known raccoon infestation in the attic ceilings, main dining room, and walls was not effectively identified, remediated, or eliminated. The facility had documented knowledge of wildlife infestation beginning on 5/18/2026, when staff observed a live raccoon in the attic, and the issue was later discussed with staff at a meeting. Despite this knowledge, the report states that the building was not secured and effective eradication measures were not implemented. On 6/5/2026, R24 was observed lying in bed in her room, where the ceiling tile had a hole and pinkish insulation was bulging through it. The resident stated that a raccoon had fallen through the wet ceiling tile on 6/2/2026 and showed a photo on her phone of a raccoon crouching between the wall and nightstand, timestamped 6/2/2026 at 6:15 pm. She expressed concern that the hole had not been fixed and feared something else might fall through the ceiling while she slept. During the same survey, the hallway between the main lobby and main dining area was observed with an opening in the ceiling, exposed insulation, and several soiled or saturated ceiling tiles near the dining area and east wing. The DNS stated she witnessed a raccoon fall near the dining room and that staff relocated residents, but she did not interview other residents and only spoke with one resident outside at the time. The ED stated that one raccoon was captured on 5/19/2026 and another after it fell through the ceiling in the east wing, and that additional traps were added later. The ED also confirmed that holes were repaired on 6/5/2026 or 6/6/2026 and acknowledged the facility had been aware of the raccoon issue. The report states the facility was informed of Immediate Jeopardy on 6/6/2026, and no acceptable removal plan had been received by exit on 6/7/2026.
Food Storage, Ice Machine Sanitation, and Wet Plate Handling Deficiencies
Penalty
Summary
Food safety deficiencies were identified in the kitchen and storage areas when surveyors observed expired, unlabeled, and undated food items being stored with active stock. In the dry storage area, there were expired packages of enriched macaroni lasagna and a box of lasagna with an expiration date of 4/9/2025, along with several open bags of pasta that were not labeled or dated. The Dietary Manager confirmed these observations during the kitchen tour. Additional storage concerns were found in the reach-in freezer, reach-in refrigerator, and walk-in freezer. The freezer contained repackaged bags of chicken, a bag of chicken in a blue bag, and pretzels that were neither labeled nor dated. The refrigerator contained a 4-quart container of boiled eggs that were neither labeled nor dated, and a piece of cake on a paper plate without a label or date. The walk-in freezer contained repackaged pork chops in a clear bag that were unlabeled and undated. The Dietary Manager confirmed these findings. Surveyors also observed sanitation issues with the ice machine and wet nesting of plates. A Department of Public Health inspection noted mold-like buildup on the baffles of the ice machine in the front dining service area, and the Dietary Manager later confirmed brown-like residue on the ice machine when wiping it with a napkin. During lunch tray preparation, plates taken from the plate warming station were found to be excessively wet and were used for meal service. The Registered Dietitian confirmed the wet plates, and staff stated the plate warmer had not been plugged in as intended.
Open Dumpsters and Unsecured Refuse Area
Penalty
Summary
The facility failed to ensure outdoor garbage was secured in safe working conditions and that the refuse area was maintained in a sanitary manner. During observation of the dumpster area with the Dietary Manager, two blue dumpsters were found open: the left dumpster had its left door open, and the right dumpster had a broken lid on the left side with exposed trash. The area around the dumpsters was also observed to have discarded bulk furniture and a black wheelbarrow containing trash. The Dietary Manager confirmed the dumpsters were open and that trash should not have been present on the ground or in the surrounding area. On a later observation, the left dumpster door remained open and the right dumpster still had a damaged lid with trash placed on top of the broken lid. The surrounding area continued to be cluttered with abandoned bulk furniture. The Executive Director confirmed the dumpsters were a contributing factor to raccoons and cats being present and stated the top of the dumpsters was missing or broken. A CMA reported that raccoons were seen going into the open dumpsters regularly, including as recently as 6/2/2026.
Infection Control Deficiencies in Resident Bathroom, Shower Room, and Laundry Area
Penalty
Summary
Infection prevention and control practices were not maintained in the facility’s resident bathroom and shower areas, and resident personal care items were not stored in a sanitary manner. In the bathroom of room [ROOM NUMBER], a brown smeared substance was observed on the floor in front of the toilet during multiple observations. The same bathroom also had two urinals resting inside a bedpan and two additional urinals and one bedpan on a shelf above the toilet, and neither the bedpans nor the urinals were labeled or bagged. The Director of Nursing Services confirmed by observation that the items needed to be bagged and labeled and that the brown smeared substance needed to be removed and cleaned immediately. The [NAME] Wing Shower Room was also observed to be unsanitary. A soiled washcloth covered with dark substances was sitting on a rack, and a dirty razor was on the bathroom floor. During a walk-through tour of the laundry room, the Consulting Housekeeping Staff confirmed the sanitation conditions of the shower room. These observations showed that resident personal care items and shower room surfaces were not maintained in a condition that prevented contamination. The facility laundry room also had multiple infection control concerns affecting resident laundry. The exterior/interior entrance door had large gaps from missing wood on the side frame, top frame, and bottom frame, and staff reported that insects or rodents could enter. Dirty bed coverings were being used to block the door, and the laundry room floor was dirty with wet bed linen coverings and towels used to soak up water leaks. A commercial fan in the laundry area was coated with thick dark gray and black speckled substances and was blowing directly toward the resident clothes area. The wall-mounted washer chemical dispenser pumps were detached, and laundry staff reported using a measuring cup and estimating detergent amounts rather than following manufacturer guidance. The Administrator and a sister-facility administrator both confirmed the ongoing laundry room sanitation and repair concerns.
Unsafe Water Temperatures in Resident Rooms and Shower Area
Penalty
Summary
The facility failed to maintain safe water temperatures in eight resident rooms and one common-use shower room. The facility policy titled Safe Water Temperatures stated that water temperatures in resident care areas were to be maintained at no more than 120 F or the state's allowable maximum, and that maintenance staff were to check water heater controls and hot water circuit temperatures weekly and as needed. During observations, water in multiple resident room sinks and in the shower room was found to be uncomfortably hot to the touch and could not be run over bare skin for more than 10 seconds. During the environmental tour, water temperatures were measured with a digital thermometer in the identified resident rooms and shower room. The recorded temperatures included 122.5 F, 122.3 F, 123.2 F, 122.0 F, 121.2 F, 120.0 F, 121.8 F, and 120.2 F in resident room sinks, and 121.2 F at the shower room sink and 123 F at the shower. The Housekeeper Floor Technician stated the facility no longer had an active Maintenance Worker or Maintenance Department, and that he had been instructed by the ED to check the temperatures even though this was not part of his job duties. Residents identified as potentially at risk included R10, who had dementia, a BIMS score of 10 indicating severe cognitive impairment, and was ambulatory with a walker; R28, who had Alzheimer's disease, a BIMS score of six indicating moderate cognitive impairment, and was ambulatory; R30, who had schizoaffective disorder and bipolar disorder, a BIMS score of six indicating moderate cognitive impairment, and was non-ambulatory but able to self-propel in a wheelchair; and R69, who had cognitive impairment, a BIMS score of six indicating moderate cognitive impairment, and was ambulatory. The ED confirmed awareness of the elevated water temperatures and stated the facility did not have maintenance workers at that time. The ED also reported being unable to access water temperature logs because the electronic maintenance system and the maintenance director's log book were not available.
Unclean Resident Rooms and Unresolved Environmental Hazards
Penalty
Summary
The facility failed to maintain a clean and comfortable homelike environment in two resident rooms. Observations found thick grayish fuzzy debris in PTAC filters in both rooms, and one room also had thick gray debris underneath the PTAC unit with a business card embedded in it. In that same room, a square black item wrapped in a black garbage bag was placed next to the bedroom sink, an unidentified clear bag containing clothing items was on the floor near the bedside, and the bathroom ceiling had a light bulb base hanging by wires. The resident in that room had a BIMS score of 14, indicating little to no cognitive impairment. During interview, the resident stated the black square item belonged to a previous occupant and had been in the room for a while, the unidentified clothing items were not his, and the hanging light bulb had been that way for a while. He also stated he was not satisfied with the condition of his room and said it was not cleaned on a routine basis. The Executive Director later confirmed the dirty PTAC filters, the debris under the PTAC unit, the hanging light bulb base, the unidentified clothing items in an unclear and unlabeled bag, and the unknown bagged item in the room, and stated that daily rounds were expected to identify and address these concerns.
Advance directive and code status documentation not provided or maintained
Penalty
Summary
The facility failed to provide written information to two residents about their right to accept or refuse medical or surgical treatment and to formulate an advance directive, and it failed to ensure that physician orders matched the residents’ documented code status wishes. The facility policy titled Advance Directives stated that, prior to or upon admission, the Social Services Director or designee would provide written information about the resident’s right to make decisions about medical care, including the right to accept or refuse treatment and to formulate advance directives, and that the DNS or designee would notify the attending physician so appropriate orders could be documented in the medical record. For one resident, the admission packet did not contain language about the facility providing written information regarding the right to accept or refuse treatment. The resident was admitted with diagnoses including heart failure, COPD, and acute and chronic respiratory failure, and the quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The record contained an active physician order for full code and a POLST dated later that documented DNR. The care plan also referenced full code interventions. During interview, the resident stated she wanted to be DNR and did not remember receiving or signing anything about advance directives. The admission coordinator confirmed there was no evidence the resident had been provided written information about the right to accept or refuse medical or surgical treatment, and the DNS confirmed the full code order should have been discontinued when the DNR POLST was signed. For the second resident, the EMR contained conflicting code status documentation. The resident was admitted with diagnoses including type 2 diabetes mellitus, acute bronchitis, and dysphagia, and the quarterly MDS showed a BIMS score of 14. The physician orders section had no code status order, while the care plan, EMR banner, admission records, DNR book, and code status list contained inconsistent entries showing both DNR and full code. The POLST showed attempted CPR with the resident’s signature, but staff later identified that the DNR documentation belonged to the resident’s family member at the sister facility. The resident stated he signed himself as full code during admission and said the POLST provided by staff was incorrect. The AD, MDS Coordinator, and DON each confirmed the documentation mix-up and that the resident’s code status was inaccurate throughout the EMR.
Failure to Document and Properly Process Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure that a resident was not inappropriately transferred or discharged against the resident's or representative's wishes and failed to document the transfer/discharge appropriately. R85 was admitted with diagnoses including chronic kidney disease, unspecified dementia without behavioral disturbance, type 2 diabetes mellitus without complications, mood disturbance, and anxiety. The quarterly MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and that R85 required substantial to maximal assistance with toileting, supervision or touching assistance with bathing, and a manual wheelchair for mobility. R85 was discharged from the facility, but the medical record contained no transfer/discharge summary. There was no documentation of the basis for the transfer/discharge, the resident's status at the time of discharge, or that appropriate information was communicated to the receiving health care institution or provider. There was also no documentation that the physician or ombudsman was notified of the transfer/discharge. The DNS stated that R85 was at a sister facility and that staff did not document the transfer because they felt he was going across the street and believed documentation was not needed since it was one building.
Failure to Submit PASARR Level II for Two Residents with Qualifying Diagnoses
Penalty
Summary
The facility failed to ensure that two residents with qualifying mental health diagnoses were submitted for PASARR Level II review after admission. The facility policy required residents with possible mental disorder, intellectual disability, or related conditions to be referred to the state-designated authority for Level II evaluation, and the Social Services Director was responsible for tracking PASARR status and referrals. For one resident, the record showed diagnoses including anxiety disorder, bipolar disorder, schizophrenia, and depression, but the PASARR Level I assessment did not mark schizophrenia, bipolar disorder, or anxiety disorder, and no PASARR Level II submission was found in the clinical record. During interview, the Admission Coordinator initially stated the resident’s diagnosis was major depression and did not qualify, then confirmed schizophrenia was documented at admission and is a qualifying diagnosis. For the second resident, the record showed diagnoses including schizophrenia disorder, bipolar disorder, cognitive communication deficit, and hypertension, with a BIMS score indicating moderate cognitive impairment. The resident’s PASARR Level I was approved, but the facility’s PASARR Level II list did not include the resident and the Social Services Director did not have a Level II on file. Interviews with the Social Services Director and Admission Coordinator confirmed that no PASARR Level II had been submitted, and the Admission Coordinator stated she had never submitted one for the resident despite the documented schizophrenia diagnosis. The resident also expressed feeling isolated and said, "I feel like I am going to go crazy, no one talks to me."
Care plans not revised to match residents' advance directives
Penalty
Summary
The facility failed to revise the comprehensive care plan for two sampled residents related to advance directives and code status. The facility policy stated that comprehensive care plans are to be developed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. For one resident, the quarterly MDS showed a BIMS score of 14, indicating little to no cognitive impairment, but the care plan banner listed DNR while the care plan text documented full code orders and instructions to ensure staff awareness of code status. The MDS Coordinator confirmed the EMR was inaccurate and stated the resident's POLST was full code, while the banner and care plan still showed DNR. For the second resident, the record showed diagnoses including heart failure, COPD, and acute and chronic respiratory failure with hypoxia or hypercapnia, and the quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The medical record contained an active physician order for full code and a POLST for DNR, but the care plan remained focused on full code interventions, including CPR and 911 instructions. The MDS Coordinator confirmed the code status change had not been communicated and the care plan was not revised to reflect the resident's DNR status. The DON also verified the mismatch between the physician order, POLST, and care plan and stated the care plan reflected full code status.
Failure to Follow Pharmacy GDR Recommendation
Penalty
Summary
The facility failed to address a consultant pharmacist’s recommendation for a gradual dose reduction for a resident with diagnoses including major depressive disorder, recurrent anxiety disorder, chronic obstructive pulmonary disease with acute exacerbation, and chronic obstructive pulmonary disease. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, and she was receiving an antianxiety medication, anticoagulant, opioid, and antidepressant during the assessment period. Physician orders from March through June 2026 showed Buspirone HCl 5 mg by mouth twice daily for anxiety. The last attempted GDR was documented on 3/22/2026, when the consultant pharmacist noted that the resident was receiving trazodone 50 mg at bedtime and Buspirone 5 mg twice daily and recommended a GDR to Buspirone 5 mg daily, then discontinuation if appropriate. The physician accepted the recommendation only with a modification to trazodone, ordering trazodone 25 mg at bedtime for two weeks, then stop. The resident’s March, April, May, and June 2026 MARs showed Buspirone 5 mg twice daily was administered each day. During interview, the DNS stated she was not aware of the pharmacy recommendation and said she was responsible for monitoring and following up with GDRs.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
Lack of Licensed Nurse Coverage on One Wing Leading to Missed Medications
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff on the [NAME] Wing during the 3:00 PM to 11:00 PM shift on December 25, 2025, resulting in no licensed nurse coverage after approximately 6:00 PM. The facility’s daily staffing document for that date showed no licensed nurse scheduled for the [NAME] Wing on the 3:00 PM to 11:00 PM shift. The scheduler confirmed that no licensed nurses were assigned for that shift on the [NAME] Wing and that she was unable to fill the assignments despite using agency staff and being aware of multiple call-outs. She stated that the DON was notified and did not come in to work the shift, and the Administrator later reported being unaware that there was no nurse on the wing after 6:00 PM. On December 25, 2025, two nurses (an LPN and an RN) worked the [NAME] Wing day shift and reported that no nurse arrived to relieve them at 3:00 PM. Both nurses stated they notified the scheduler, DON, and Administrator that there was no relief nurse. One nurse reported that the DON told her there was nothing she could do. Both nurses remained on duty until nearly 6:00 PM, then counted the medication cart together, secured the medication keys in the locked medication room or at the nurse’s station, and left the facility, leaving the [NAME] Wing without licensed nurse coverage for the remainder of the evening shift. A regional nurse consultant later confirmed there was no nurse on the [NAME] Wing after 6:00 PM on that date. Multiple residents with little to no cognitive impairment, as evidenced by BIMS scores of 14 and 15 on their quarterly MDS assessments, reported that there was no nurse available on the [NAME] Wing during the evening of December 25, 2025. One resident stated that there was no nurse after 3:00 PM to give medications, and another resident reported that there had been a couple of days, usually around holidays, when no nurse was available. A resident who returned from an outing with family around 7:00 PM stated there was no nurse working on the [NAME] Wing and that, as a diabetic, he did not receive any medicine until the next day. A grievance/complaint report filed by the DON on December 26, 2025, documented that some residents on the [NAME] Wing reported not receiving their 9:00 PM medications on December 25, 2025, and that the Medical Director was notified.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on every shift, as observed and documented by surveyors.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility's management practices did not support optimal resource utilization. Specific actions or inactions leading to this deficiency were not detailed in the report.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
CMAs Administered Medications Without Required Competency and Gave Narcotics
Penalty
Summary
Certified Medication Aides (CMAs) at the facility were permitted to administer medications, including narcotics, without having completed the required skills competency check-offs. Review of facility records showed that six out of seven active CMAs did not have current, signed, and dated annual competency documentation. Additionally, one CMA's skills checklist specifically indicated that she was not certified to administer narcotic medications, yet records showed that she had administered a narcotic medication to a resident. Staff interviews confirmed that CMAs were administering narcotics, and some staff members, including a Registered Nurse, admitted to giving narcotics to CMAs to administer to residents. Multiple facility staff, including the Regional Consultant Nurse, Interim Director of Nursing, Operations Consultant, Medical Director, and Nurse Practitioner, were unaware that CMAs were administering narcotics or controlled substances. The facility's own policy and staff statements indicated that CMAs were not supposed to administer narcotics, yet this practice was occurring. The lack of proper competency verification and unauthorized administration of narcotics by CMAs placed all residents at risk of receiving medication from unqualified personnel.
Failure to Maintain Sanitary Laundry Conditions Resulting in Cross-Contamination Risk
Penalty
Summary
The facility failed to maintain the laundry area in a sanitary manner, resulting in the potential for cross-contamination of residents' clothing and linens. Observations revealed a thick, dark greyish substance coating the ceiling, pipes, and a large industrial fan in the laundry room. Clean clothes, blankets, sheets, and pillowcases were found uncovered and coated with dust and debris. The fan, also covered in dust, was blowing directly onto clean laundry. Additionally, a window in the laundry room was covered with dust and broken glass, further exposing clean laundry to contamination. There was only one apron available as PPE, which was itself coated with dust and debris, and no other PPE was present. No separate designated hazardous container was available; instead, a trash can was being used for biohazardous materials. Interviews with staff revealed a lack of awareness regarding the need to cover clean laundry and the proper use of PPE. The Housekeeping Manager and Laundry Aide both confirmed that cleaning of the ceiling and pipes was not being performed as required, and the Laundry Aide reported never seeing these areas cleaned. The Director of Nursing/Infection Preventionist stated she was unaware of the laundry room's condition. Requested cleaning logs for the laundry room were not provided, indicating a lack of documentation and oversight in maintaining sanitation standards in the laundry area.
Resident Exposed While Outside, Dignity Not Maintained
Penalty
Summary
Certified Nursing Assistants (CNA) II and CNA JJ were observed pushing a resident in a geriatric chair outside of the facility. The resident was wearing a hospital gown that was pulled up above his stomach, with a blanket folded across his chest, leaving his legs and lower torso exposed. This exposure revealed the resident's brief and bandages on his right leg stump. The observation took place in an area visible to construction workers and passing cars on a nearby street. During concurrent interviews at the time of the observation, both CNAs confirmed that they did not ensure the resident's body was properly covered and acknowledged that they should have done so. The Director of Nursing (DON) later confirmed that staff are expected to ensure residents are properly dressed and not exposed, and agreed that this incident constituted a dignity issue. The facility's policy on promoting and maintaining resident dignity requires all staff to provide care in a manner that maintains or enhances each resident's quality of life and respects their rights.
Failure to Provide Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate safety measures for a resident with multiple risk factors for falls, including muscle weakness, epilepsy, unsteadiness on feet, and severe cognitive impairment. The resident was assessed as a high fall risk, with a history of falls documented in progress notes, including incidents where the resident was found on the floor or observed attempting to get out of bed or a chair. Despite these risk factors and repeated fall incidents, observations revealed that no fall mats were placed around the resident's bed or chair during multiple checks, and the bed was only placed in the lowest position. Interviews with staff confirmed that the resident was capable of moving in bed and often attempted to get out of bed or the geriatric chair. Staff reported they were not instructed to use fall mats, and the DON was unaware that fall mats were not in place, despite knowing the resident was a high fall risk. These actions and inactions resulted in the facility failing to ensure adequate supervision and safety measures to prevent accidents for this resident.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs across three medication carts. The facility's policy required that all controlled substances obtained from a non-automated medication cart or cabinet be recorded on a designated usage form, with a daily visual audit conducted by the charge nurse or designee. Additionally, two licensed nurses were expected to account for all controlled substances and access keys at the end of each shift. However, the review of the Change of Shift Narcotic Logs for the West Medication Cart One, [NAME] Medication Cart Two, and East Medication Cart revealed that the on-coming and/or off-going nurses failed to sign the sheets during shift changes on multiple dates, indicating a lack of verification for the completion of the controlled drug count. Interviews with LPNs AA, BB, and CC confirmed the observations and acknowledged that licensed nurses were expected to sign the count verification at the change of shift. The Nursing Home Administrator also confirmed the lack of additional documentation and stated that it was her expectation for nursing staff to sign the Control Substance logs at shift changes to identify any discrepancies. The failure to adhere to these procedures resulted in the facility's inability to properly reconcile controlled drugs, as required by their policy.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia, dysphagia, cognitive communication deficit, essential hypertension, type 2 diabetes mellitus, restless legs syndrome, and insomnia, had a baseline care plan that only addressed nutritional status. Critical care needs such as the use of oxygen, an allergy to codeine, cognitive communication deficits, diabetes management, DNR code status, and the use of eyeglasses were not documented or addressed in the baseline care plan. Interviews with facility staff, including an LPN/MDS Coordinator and the Nursing Home Administrator, confirmed the oversight. The LPN acknowledged the single entry in the care plan and the failure to include essential healthcare information. The Nursing Home Administrator also confirmed that the facility did not adequately address the resident's care and management needs in the baseline care plan, leading to a deficiency in meeting the resident's immediate needs upon admission.
Failure to Date Multi-Dose Diabetes Medications
Penalty
Summary
The facility failed to adhere to acceptable storage requirements and use-by dates for multi-dose diabetes medications on one of the medication carts, specifically West Cart Two. During an observation, it was found that three vials of insulin, belonging to three different residents, were opened and available for use without being dated when initially opened. This is contrary to the facility's policy, which requires multi-dose vials to be re-labeled with a beyond-use date 28 days after being opened, unless otherwise specified by the manufacturer. The policy also mandates that the medication label should include the initials of the nurse who opened the vial, and that staff should visually inspect the vial before each use to check the expiration date and ensure there is no visible contamination. The observation was confirmed by an LPN present at the time, who acknowledged that the medications should have been dated when opened. Additionally, the Nursing Home Administrator confirmed that the facility failed to date multi-dose medications when opened, which is necessary to assure acceptable storage times. This deficiency affected three residents who were using the diabetes medications stored on the cart.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a four-day survey. The facility's policy mandates that the Nurse Staffing Sheet be posted at the beginning of each shift daily. However, upon request, the staff was unable to provide the postings for certain dates. During an interview, a Registered Nurse admitted to being unable to locate the nurse staffing data, citing an overwhelming workload and difficulty in organizing files. The Administrator later acknowledged the inconsistency in posting the Daily Nurse Staffing information.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was treated with dignity, which potentially diminished his quality of life. R2, who has moderate cognitive impairment as indicated by a BIMS score of 10, was observed multiple times wearing a hospital gown despite having brought his own clothes to the facility. R2 expressed a preference for wearing his own clothes and mentioned that his clothing went missing after a hospital stay, although he could not recall if this was reported. Staff interviews revealed uncertainty about why R2 was consistently in a hospital gown, with one CNA stating she would change his clothes and another mentioning that R2 is dressed in sweatpants and a shirt for dialysis. The Director of Nursing stated that residents who do not get out of bed typically wear hospital gowns and did not identify this as an issue for R2. However, the Administrator confirmed that R2 was particular about his appearance and should not be in a hospital gown unless he desired it. This lack of attention to R2's preferences and the failure to address the missing clothing contributed to the deficiency in maintaining the resident's dignity and quality of life.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which placed them at risk of accident, injury, and/or unmet needs due to their inability to call for staff assistance. Observations revealed that the call lights for these residents were either on the floor, coiled around bed rails, or positioned over the headboard, making them inaccessible. Each of these residents was documented as having no impairment of the upper extremities and was dependent on staff for activities of daily living (ADLs). Interviews with staff confirmed the deficiency, with a Certified Nursing Assistant (CNA) acknowledging that the call lights were not within reach and should not be on the floor. The facility's Administrator also stated that call lights should always be within the residents' reach. These observations and interviews highlight a failure in the facility's responsibility to reasonably accommodate the needs and preferences of each resident, as required.
Deficient Care Planning for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as R4, which is a deficiency in their care planning process. The facility's policy on Comprehensive Care Plans requires that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS) assessment. This care plan should consider all Care Assessment Areas triggered by the MDS and describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, the review of R4's care plan, dated August 14, 2023, revealed that it only included a focus area on the resident's enjoyment of activities such as TV, music, and arts and crafts, without addressing critical areas such as activities of daily living (ADLs), chronic obstructive pulmonary disease (COPD), hospice care, or the management of an indwelling urinary catheter. R4 was admitted with diagnoses including chronic obstructive pulmonary edema (COPD) and congestive heart failure (CHF), and the MDS indicated that R4 required assistance with ADLs, had an indwelling urinary catheter, and was receiving hospice services. Despite these significant health needs, the care plan did not include focus areas for these conditions, which are essential for providing appropriate care. An interview with the Director of Nursing (DON) confirmed that baseline care plans are created upon admission, and a comprehensive person-centered care plan should be developed by the 14th day. The DON acknowledged that the care plan is used by nurses to determine the type of care a resident requires, highlighting the importance of having a comprehensive plan in place for R4's care needs.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Resident 18, with cognitive communication deficit and muscle weakness, was observed with long, dirty fingernails and reported that staff rarely offered to trim them. Resident 20, diagnosed with hemiplegia and muscle weakness, also had untrimmed, dirty nails and stated that staff were too busy to assist. Resident 16, with severe cognitive impairment and muscle weakness, had not had his nails trimmed in six months, as confirmed by staff interviews. Certified Nursing Assistant (CNA) HH admitted to not having time to trim residents' nails, and Licensed Practical Nurse (LPN) CC was unaware of the need for nail care. Resident 15, with severe cognitive impairment and incontinence, was found lying in bed with a strong odor of bowel movement, indicating a lack of timely incontinent care. Despite being aware of the situation, CNA FF prioritized passing out meal trays over providing immediate care to Resident 15. The Director of Nursing (DON) and the Administrator acknowledged that staff should have checked on Resident 15 every two hours and provided necessary care promptly. The failure to provide timely ADL care for these residents highlights significant deficiencies in the facility's care practices.
Delayed Urine Specimen Collection for Resident
Penalty
Summary
The facility failed to obtain a critical laboratory test for a resident in a timely manner, specifically a urine specimen, which was delayed for five days after the physician's order. The resident, who has a diagnosis of Human Immunodeficiency Virus (HIV) and a BIMS score indicating little to no cognitive impairment, experienced urinary discomfort and severe pain. Despite the physician's order for a urinalysis, culture, and sensitivity test on 8/8/2024, the specimen was not collected until 8/13/2024. The delay in obtaining the urine sample was noted in the resident's progress notes, and the resident reported relief and decreased pain once the sample was finally collected. Interviews with staff revealed a lack of clarity and responsibility in collecting the urine specimen. An LPN acknowledged the order but did not attempt to collect the sample, passing the information to another nurse whose identity was not recalled. Another LPN confirmed the procedure for collecting a specimen but was unsure why it was delayed. The Director of Nursing verified the order and stated it should have been collected promptly, expressing unawareness of the delay. The physician emphasized that such orders should be executed within 12 to 24 hours, deeming the five-day delay unacceptable.
Failure to Provide Individual Water Mugs for Residents
Penalty
Summary
The facility failed to implement proper infection control precautions by not providing individual water mugs for two residents, R19 and R33, who shared a single water mug in their room. This oversight was identified through observations, resident interviews, and staff interviews. R19, who had moderate cognitive impairment and required minimal assistance with ADLs, reported that staff did not offer him his own water mug, leading to him and R33 sharing the same mug. R33, who had little to no cognitive impairment and also required minimal assistance with ADLs, confirmed that he had been sharing the water mug with R19 since his admission. The facility's policy on infection control, dated 4/1/2024, mandates the establishment and maintenance of an infection prevention and control program to prevent the transmission of communicable diseases. However, the Director of Nursing (DON) was unaware of the shared water mug situation until it was brought to her attention. Upon inspection, the DON found the shared mug to be filthy and acknowledged the infection control concern. The Administrator also confirmed that residents should not share water mugs, indicating a lapse in adherence to the facility's infection control policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tybee Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tybee Island Trails Of Journey Llc | 0.1 mi | ★★★★★ | 13 | 0 |
| Fraser Health Center | 10.3 mi | ★★★★★ | 0 | 0 |
| Broad Creek Care Center | 11.4 mi | ★★★★★ | 1 | 1 |
| Thunderbolt Care Center Llc | 12.3 mi | — | 0 | 0 |
| Riverview Health & Rehab Ctr | 12.9 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.