Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tybee Island Trails Of Journey Llc during CMS and state inspections, most recent first.
Failure to address pain during wound care: A resident with severe cognitive impairment, dementia, and schizophrenia was dependent on staff and unable to communicate pain. During a dressing change, the resident pulled back and showed facial grimacing, but an LPN did not assess pain or give PRN analgesic before starting the procedure and continued the wound care despite the resident’s nonverbal signs of pain. The resident had an order for PRN Mapap, and facility leadership stated pain should be assessed before wound care.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors found multiple unlabeled or expired food items, spoiled produce, and food stored on the floor or on a cart with trash and discarded items. The can opener, prep area, floors, vents, hand sanitizer dispenser, and ice machine were also observed with heavy soil, residue, and black specks; the CDM and Maintenance Director confirmed the unsanitary conditions and that staff were responsible for cleaning and discarding items.
A facility failed to ensure dignity during resident care when a CNA fed one resident while standing over her, an LPN provided catheter care to another resident without pulling the privacy curtain while the roommate was present, and an RN Unit Manager fed a third resident while standing. The residents had significant cognitive and medical conditions, including dementia, Down syndrome, dysphagia, and other complex diagnoses, and staff confirmed the care was not done appropriately.
Failure to Notify Resident of Excess Trust Fund Balance: A resident with schizophrenia and moderate cognitive impairment had a trust fund balance above the SSI limit, but there was no documented evidence that the resident or RP was notified when the account exceeded the $2,000 limit or when it was within $200 of that limit. The BOM/Financial Coordinator confirmed the balance and acknowledged the facility had not provided the required notification.
The facility failed to submit PASRR Level II reviews for two residents with qualifying diagnoses. One resident had bipolar disorder, Down syndrome, and severe cognitive impairment, while the other had schizophrenia, bipolar disorder, moderate cognitive impairment, and was receiving antipsychotic and antidepressant medications. Staff confirmed neither resident had a PASRR Level II, and one staff member stated the review was not submitted because there had not been an increase in behaviors.
Expired medications were found in the supply room and over-the-counter medication room on Hall One, including calcium with vitamin D, aspirin, and milk of magnesia. The Unit Manager confirmed the medications were expired, and the Central Supply Clerk stated she stocked the room and checked for expired medication every other day. The DON stated that medication storage was completed by nurses and central supply staff, and that Central Supply stocked, rotated supplies, and removed expired medications.
Infection control practices were not followed for residents receiving wound care, PICC line care, and influenza-related room placement. An LPN performing wound care did not sanitize hands between glove changes or wear a gown, and an RN changing a PICC dressing did not wear a gown or perform hand hygiene between glove changes. In addition, a resident with influenza was placed in a room with another resident who had no flu symptoms, and the room lacked droplet precaution signage even though a vacant room was available.
The facility failed to maintain food safety and sanitation standards, with staff not wearing hairnets, unlabeled and undated freezer items, expired pantry items, and improper scoop storage. Additional issues included a staff member licking a gloved finger without proper hygiene, a dirty kitchen floor, and a rusted refrigerator. The Dietary Manager and Administrator acknowledged these deficiencies.
The facility failed to maintain the outdoor garbage and refuse area in a sanitary manner, risking pest attraction and microorganism transfer to food. Observations revealed open dumpster doors and trash on the ground. The Dietary Manager and Administrator acknowledged the issue, noting that dumpsters should be closed and separate dumpsters were designated for nursing and dietary trash.
The facility failed to maintain an effective infection prevention and control program. A nurse did not change gloves between residents, and a CNA delivered meal trays without hand hygiene. Beverages were uncovered during delivery. The facility also lacked infection control surveillance data for most of 2024, with the Interim DON unable to locate the necessary documentation.
The facility failed to ensure a clean and homelike environment in several resident rooms and a shower room, with issues such as unlabeled personal care products, unclean and broken fixtures, stained linens, and a strong urine smell. A housekeeper acknowledged the odor as normal, and the Administrator confirmed the concerns during a tour.
The facility failed to develop comprehensive care plans for eight residents, missing critical areas such as dementia, communication, and dental care. Observations revealed unmet personal hygiene and dental needs, while interviews confirmed the care plans were not comprehensive.
The facility failed to promote resident dignity during mealtimes, as staff referred to dependent residents as 'feeders' and did not serve meals simultaneously to residents dining together. One resident was left without a meal while others at the same table were served, due to oversight and lack of preparation for a new resident. The staff's actions were inconsistent with the facility's policy on maintaining resident dignity.
A discrepancy was found in a resident's Advance Directives at a facility, where the EMR indicated a Full Code status, but the physical medical record showed a DNR order. Staff interviews confirmed the inconsistency, with the RN, MDS Coordinator, DON, and Administrator acknowledging the need for the EMR to be updated to reflect the resident's current DNR status.
The facility failed to provide necessary ADL care, including facial shaving and nail trimming, for three residents with cognitive impairments. Observations revealed unshaven faces and untrimmed nails, with staff admitting to not offering or documenting these services. Residents expressed unmet needs, and staff confirmed the lack of documentation for ADL care offered or refused.
The facility failed to complete a post-fall assessment for a resident who sustained a fall and a fractured wrist, as well as an elopement assessment for another resident who left the facility without supervision. The Interim DON and staff were unsure about the completion of necessary assessments, leading to potential safety risks for both residents.
The facility failed to provide routine and emergency dental services for three residents, resulting in unmet needs and diminished quality of life. One resident, who was edentulous, had no dental assessment documented. Another resident, with moderate cognitive impairment and frequent pain, required full mouth extractions but received no dental care since February. A third resident had documented cavities or broken teeth but lacked a dental assessment. The facility had not provided dental services since changing providers in July.
The facility failed to maintain a functional Nursing Call System in four resident rooms and a shared bathroom, affecting multiple residents. Observations revealed unplugged cords, non-functional panels, and insufficient accommodations for call lights, confirmed by staff including a CNA, RN, and the Interim DON. The Administrator and RDES were not informed of these issues.
Failure to Address Pain During Wound Care
Penalty
Summary
Provide safe, appropriate pain management for a resident who required wound care services was not done for one resident with severely impaired cognition related to dementia and schizophrenia, who was dependent on staff for all care and unable to effectively communicate pain. The resident’s care plan directed staff to monitor for non-verbal signs of pain, including facial grimacing, and to administer pain medication per physician orders. The resident had an order for Mapap 2 tablets every 6 hours as needed for pain, and the medication was administered only once during the month reviewed. During wound care observation, the resident was seen pulling back and showing facial grimacing during the dressing change. The LPN confirmed the resident displayed non-verbal signs of pain, had not been medicated before the procedure, and had not been assessed for pain prior to the dressing change. The LPN also stated she continued the dressing change despite the resident’s grimacing and pulling back. The Unit Manager and DON stated wound care staff should assess pain before wound care and address pain prior to the dressing change.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to label, store, prepare, and discard food under sanitary conditions, and failed to keep kitchen floors and equipment clean. During a kitchen tour with the Certified Dietary Manager, surveyors found multiple food items without proper labels or dates, including red sauce labeled 12/31/2025, partially covered butter without a label or date, barbecue sauce without an expiration date, a partially covered pie without an open or expiration date, five unidentified bags of meat, and three jars of applesauce without an expiration date. Surveyors also observed wilted lettuce, cabbage with yellow leaves and black spots, and bananas stored on the floor next to a container of sanitizing wash and walk solution. A rolling serving cart held boxes, empty cans, lettuce with brown leaves, and empty thickener containers that were to be discarded, and the Certified Dietary Manager confirmed these items should have been thrown away. Additional observations showed unsanitary conditions in the kitchen and dining area. The can opener had a greasy, black substance, the prep table had paper, dishcloth, and cup lids on it, and the floor under the can opener had a sticky red substance. The vents and light fixtures over the stove and the hand sanitizer dispenser next to the hand-washing sink were covered with thick, grey particles. The ice machine in the dining hall had dried white and rust-colored residue on the front, inner lip of the bin opening, and inside the lid, with black specks around the dispenser and the ice scoop left uncovered in the ice bin. The Maintenance Director confirmed the ice machine and dining area vents were dirty and stated he was unsure when they had last been cleaned.
Residents Not Treated with Dignity During Care
Penalty
Summary
The facility failed to ensure that three sampled residents were treated with dignity during care. R2 had a BIMS score of 14, diagnoses including encephalopathy, dysphagia, gastrostomy, end-stage renal disease, hypothyroidism, type 2 diabetes mellitus, and acute respiratory failure with hypoxia, and required assistance with ADLs. During observation, a CNA was feeding R2 while standing over her, and the CNA confirmed she should not stand to feed residents. R2 also had an order for a pureed texture, nectar consistency pleasure tray. R1 had a BIMS score of 0 and diagnoses including Down syndrome, bipolar disorder, cognitive communication deficit, obstructive and reflux uropathy, and muscle weakness. R1 had a urinary catheter, and during catheter care an LPN knocked, introduced herself, and explained the procedure, but did not pull the privacy curtain while the resident’s roommate was present in the room. The LPN confirmed the curtain was not pulled and stated she should have. R45 had a BIMS score of 2, diagnoses including dementia with behavioral disturbance and dysphagia, and required supervision and touching assistance with eating. During a meal observation, an RN Unit Manager II was standing while feeding R45 and confirmed she should not stand to feed residents.
Failure to Notify Resident of Excess Trust Fund Balance
Penalty
Summary
The facility failed to notify the resident and/or the resident's responsible party when the resident's personal funds were within $200.00 of the SSI limit and when the account balance exceeded the $200.00 limit. Review of the electronic health record for the resident showed diagnoses including paranoid schizophrenia, schizophrenia, and brief psychotic disorder. The quarterly MDS dated 12/9/2025 showed a BIMS score of 11, indicating moderate cognitive impairment. Review of the Trial Balance report dated 01/30/2066 showed the resident's trust fund account exceeded the SSI limit of $2,000.00. The Resident Statement Landscape showed the resident was awarded $13,115.98 in March 2025 and had a remaining balance of $4,856.73. There was no documented evidence that the resident or responsible party was notified of the amounts exceeding the SSI limit. During interview, the resident stated she was unaware of the exact amount in her account and reported being told on 01/30/2026 that she had $6,000.00 in her account. The BOM/Financial Coordinator confirmed the SSI limit was $2,000.00, confirmed the account balance, and confirmed the facility had not notified the resident and/or responsible party of the excess balance.
Failure to Submit PASRR Level II for Two Residents
Penalty
Summary
The facility failed to ensure submission to the state-designated authority for PASRR Level II for two residents, R1 and R19, who were reviewed for PASRR. R1 was admitted with diagnoses including bipolar disorder and Down syndrome. The EHR, MDS, hospital record, and PASRR Level I assessment showed diagnoses and history consistent with serious mental illness and intellectual/developmental disability, yet there were no PASRR Level II submissions after admission and R1 was not listed on the facility’s Level II PASRR list. In interview, the Business Development Specialist confirmed R1 did not have a PASRR Level II and stated it should have been initiated on admission; the Interim Administrator stated PASRR Level II should be initiated on admission or at the onset of admission if not done initially. R19 was admitted with diagnoses including other schizophrenia and bipolar disorder, unspecified. The MDS documented a BIMS score of 11, active diagnoses of schizophrenia and bipolar disorder, and use of antipsychotic and antidepressant medications during the look-back period. Physician orders included olanzapine and Depakote related to schizophrenia and bipolar disorder, but the PASRR Level I assessment did not indicate schizophrenia or bipolar disorder, and there were no PASRR Level II submissions after admission. R19 was also not listed on the facility’s Level II PASRR list. In interview, the Business Development Specialist confirmed R19 did not have a PASRR Level II and stated she had not submitted one because the resident had not had an increase in behaviors, despite acknowledging the resident had qualifying diagnoses.
Expired Medications Found in Medication Storage
Penalty
Summary
The facility failed to ensure that one of two medication rooms was free of expired medication. During observation of the supply room and over-the-counter medication room on Hall One with the Unit Manager, surveyors found two bottles of calcium 600 mg plus vitamin D3 400 units expired in 12/2025, three bottles of aspirin 325 mg expired in 10/2025, one bottle of aspirin 325 mg expired in 12/2025, two bottles of calcium 600 plus D3 expired in 11/2025, and one bottle of milk of magnesia expired in 10/2025. The Unit Manager confirmed the medications were expired and stated the nurse was responsible for confirming medications were not expired before removing them from the storage closet. The Central Supply Clerk confirmed the medications had expired and stated she stocked the medication and supply room, placed medications on the shelves according to the medication, and checked for expired medication every other day to remove them from the shelves. The DON stated that medication storage was completed by nurses and central supply staff, and that Central Supply stocked, rotated supplies, and removed expired medications.
Infection Control and Isolation Practices Not Followed
Penalty
Summary
The facility failed to follow infection control practices for four sampled residents during wound care, PICC line care, and room placement. The facility policy on Enhanced Barrier Precautions stated that residents with wounds or indwelling medical devices, including PICC lines, should have an order for enhanced barrier precautions. Review of the records for one resident showed dependence for all care, bowel and bladder incontinence, impaired cognition, and a right foot abrasion with an order for daily wound treatment. During wound care, an LPN wore gloves and a mask and changed gloves during the procedure, but did not sanitize hands between glove changes and did not wear a gown. The LPN confirmed this during interview. A second resident had diagnoses including pressure ulcers and was on enhanced barrier precautions for pressure ulcers on the right and left ischium. During a PICC line dressing change, an RN did not wear a gown and did not perform hand hygiene between glove changes. The RN confirmed she did not wear a gown and stated she did not need one for the PICC line change. The Unit Manager stated that a gown, gloves, and a mask should be worn for PICC line dressing changes, and the DON stated wound care should be provided with enhanced barrier precautions, including a gown, gloves, goggles, and a mask. Two other residents were involved in room-placement concerns related to influenza. One resident had a hospital record showing influenza positive and returned to the facility while another resident without influenza symptoms was already in the room. The room door did not have droplet precaution signage. The Medical Director confirmed the resident was on transmission-based precautions because of flu and stated the resident should have been placed in a different room. The RN Supervisor, admission Manager, Administrator, and DON all acknowledged that a vacant room was available and that the resident with influenza should have been placed there rather than in a room with a resident who had no influenza diagnosis or symptoms.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, as observed during a survey. Dietary staff were not wearing hairnets, which is a basic requirement to prevent contamination. Items in the freezer, such as pancakes, cookies, biscuits, sausage, and fish nuggets, were not labeled or dated, posing a risk of using expired or spoiled food. In the dry storage pantry, expired thickened water was found, and scoops were improperly stored in containers with sugar, rice, and flour, increasing the risk of cross-contamination. The Dietary Manager confirmed these issues and acknowledged the lack of proper labeling and storage practices. Further observations revealed additional sanitation concerns, such as a staff member licking her gloved finger after sampling food without washing hands or changing gloves, and a build-up of dirt on the kitchen floor due to immovable equipment. The refrigerator was rusted, reportedly due to inappropriate cleaning products, and the cleaning schedule was disrupted during the Dietary Manager's absence. An email from the Licensed Dietitian highlighted similar concerns about labeling and dating, and the Administrator acknowledged the deficiencies, including the lack of a clear cleaning schedule and the requirement for staff to wear hairnets.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the outdoor garbage and refuse area in a sanitary manner, which had the potential to attract pests and rodents and transfer harmful microorganisms to food, potentially leading to foodborne illness for the 49 residents residing in the facility. During an initial observation of the dumpster area, two blue dumpsters were found with one door fully open and the other partially open, with trash hanging out. A second tour revealed trash on the ground next to one dumpster and an open door on the other. The Dietary Manager acknowledged the trash and the need for the dumpsters to be closed. The Administrator confirmed that dumpsters should be kept closed on both the top and sides and mentioned that separate dumpsters were designated for nursing and dietary trash.
Infection Control Deficiencies in Hand Hygiene and Surveillance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. A Registered Nurse was observed cleaning multiple residents' hands with wipes without changing gloves between residents, which is against the facility's hand hygiene policy. Additionally, during meal delivery, beverages were not covered, and a Certified Nursing Aide was seen delivering meal trays without using hand sanitizer or washing hands between deliveries, citing eczema as a reason for not using hand sanitizer. The Administrator and Interim Director of Nursing acknowledged these practices were not in line with the facility's expectations and policies. Furthermore, the facility lacked documented evidence of infection control surveillance data for nine out of ten months in 2024. The Interim Director of Nursing, who took on the role of Infection Control Preventionist in August 2024, was unable to locate any documentation for the monthly infection control tracking system for that year. The Administrator also could not find the updated book with the 2024 monthly infection control surveillance data, indicating a significant lapse in the facility's infection surveillance system.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in nine resident rooms and one shower room, as observed during a survey. Specific deficiencies included unlabeled and unbagged personal care products, unclean and broken fixtures, stained linens, and writing on walls. Additionally, there were issues with missing paint, rust, dirt, and broken window blinds. The air unit in one room was not sealed properly, allowing outside light to be visible. Shared bathrooms were found with empty soap dispensers, peeling floor vinyl, and dirty sinks. A strong urine smell was noted in one room, and the Ladies' Shower Room contained a rusty chair and a black substance on a mesh shower chair. During interviews, a housekeeper acknowledged the strong urine smell in one room, describing it as a normal nursing home scent, and was unable to specify the frequency of deep cleaning. The facility's Administrator and Regional Director of Environmental Services confirmed the areas of concern during a comprehensive tour. These observations and interviews indicate a failure to provide a sanitary and safe living environment, potentially affecting the residents' quality of life.
Inadequate Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive person-centered care plans for eight residents, which increased the potential for these residents to not receive treatment and/or care according to their needs. The facility's policy on Comprehensive Care Plans required that care plans be developed within seven days after the completion of the Minimum Data Set (MDS) assessment, considering all Care Assessment Areas (CAAs) triggered by the MDS. However, the care plans for residents R39, R42, R8, and R19 did not include plans for various medical conditions and needs identified in their assessments and medical records. Resident R39's care plan lacked plans for dementia, communication, ADL functional/rehabilitation potential, urinary incontinence, psychosocial well-being, behavioral symptoms, risk for pressure ulcer, and hypertension, despite these areas being triggered in the MDS assessment. Similarly, R42's care plan did not address cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, pressure ulcer risk, psychotropic drug use, hypertension, anxiety, antipsychotic drug use, insomnia, GERD, hyperlipidemia, and manic disorder. R8's care plan was missing plans for dementia, communication, dental care, antipsychotic drug use, pain, narcotic use, COPD, hyperlipidemia, seizures, hypertension, GERD, atrial fibrillation, cerebral infarction, mental disorder, and insomnia. R19's care plan did not include plans for hyperlipidemia and GERD. Additionally, residents R3, R10, R13, and R22 had care plans that were not reflective of their current needs. R3 and R10's care plans did not adequately address their personal hygiene needs, as observed by their unshaven faces and long nails. R13 and R22 had dental issues that were not properly addressed in their care plans, with R13 experiencing pain from broken teeth and R22 having decayed teeth. Interviews with the MDS Coordinator, Interim Director of Nursing, and Administrator confirmed that the care plans were not comprehensive and did not include all necessary areas identified during assessments.
Failure to Promote Resident Dignity During Mealtimes
Penalty
Summary
The facility failed to promote dignity during dining for four residents, as observed during a breakfast dining session. Staff members referred to dependent residents as 'feeders,' which was noted multiple times by a CNA in the presence of the residents. This terminology was used despite the facility's policy on maintaining resident dignity during mealtimes. Additionally, the facility did not serve meals simultaneously to residents dining together, leading to one resident, R250, not receiving a meal tray while others at the same table were served and finished their meals. During the observation, it was noted that R250 was left without a meal while his tablemates were served and completed their meals. The delay in serving R250 was attributed to him being new to the facility, and his meal tray was not prepared in advance. The CNA and LPN involved acknowledged the oversight, with the CNA explaining that the delay was due to R250's recent arrival over the weekend. The LPN was unaware of the issue until informed by the DON, who then ensured R250 received his meal. The staff's actions and language during mealtimes were inconsistent with the facility's policy on promoting resident dignity.
Discrepancy in Advance Directives for a Resident
Penalty
Summary
The facility failed to ensure there were no discrepancies related to Advance Directives for one resident, which could result in the resident's Advance Directives not being followed. The facility's policy supports a resident's right to request, refuse, and/or discontinue treatment and to formulate an advance directive, with decisions periodically reviewed and documented. However, a review of the Electronic Medical Record (EMR) for the resident revealed a discrepancy between the EMR and the physical medical record regarding the resident's code status. The EMR indicated the resident was a Full Code, while the physical medical chart contained a Physician Orders for Life-Sustaining Treatment (POLST) form indicating a Do Not Resuscitate (DNR) order. Interviews with facility staff, including a Registered Nurse (RN), the Minimum Data Set (MDS) Coordinator, the Director of Nursing (DON), and the Administrator, confirmed the discrepancy. The RN stated she would use the EMR to determine the code status and acknowledged the discrepancy. The MDS Coordinator noted that the outdated POLST form indicating Full Code should have been removed, and the new DNR order should have been updated in the EMR. The DON and Administrator both confirmed the discrepancy and acknowledged the need for the EMR to be updated to reflect the resident's current DNR status.
Failure to Provide ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, specifically in the areas of facial shaving and nail trimming/cleaning. Resident 3, who has severe cognitive impairment and requires partial/moderate assistance with personal hygiene, was observed multiple times with an unshaven face. A CNA admitted to not asking the resident if he wanted to be shaved, citing that men usually refused, and confirmed that there was no documentation of whether shaving was offered or refused. Resident 10, with moderate cognitive impairment and requiring partial/moderate assistance, was observed with a full beard and long, sharp nails. The resident stated that no one had asked him if he wanted his nails cut. Although his face was eventually shaved, his nails remained untrimmed. Resident 22, also with moderate cognitive impairment and requiring supervision with personal hygiene, was observed with an unshaven face and long, dirty nails. The resident expressed a desire for a shave, and a Wound Care Nurse confirmed that there was no documentation of ADL care being offered or refused. A CNA admitted to not completing the tasks of shaving or nail care for this resident without providing a reason.
Incomplete Assessments for Fall and Elopement Risks
Penalty
Summary
The facility failed to perform a complete post-fall assessment for a resident who sustained a fall. The resident, identified as R23, had diagnoses including generalized muscle weakness, difficulty walking, insomnia, and unspecified dementia. After a fall on 10/11/2024, R23 was transferred to the hospital and returned with a fractured wrist. The Interim Director of Nursing confirmed that the post-fall assessment was triggered but not fully completed, specifically noting that the User Defined Assessment (UDA) section was not completed. Interviews with staff, including an LPN and the Administrator, revealed uncertainty about the completion of the UDA after fall events. Additionally, the facility did not complete an elopement assessment for another resident, R6, who had diagnoses such as dementia with behaviors, paranoia with schizophrenia, and cognitive communication deficit. R6's clinical record showed no elopement assessment was completed before the resident eloped from the facility on 9/11/2024. The Administrator recalled receiving a call about R6 being found outside the facility and directed staff to escort the resident back. The lack of an elopement assessment created a potential risk to R6's safety and well-being.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services for three residents, leading to unmet needs and diminished quality of life. Resident 3, who was edentulous, had no dental assessment documented in their electronic medical record (EMR) since admission. Observations confirmed the absence of teeth or dentures. Resident 13, with moderate cognitive impairment and frequent moderate pain, had a documented need for full mouth extractions due to pain and infection. Despite a referral to an oral surgeon, no dental care was provided since February 2024, and the resident continued to experience pain. Resident 22, with documented cavities or broken teeth, also lacked a dental assessment in their EMR, and observations confirmed decayed and broken teeth. Interviews with facility staff revealed that the last dental services were provided in July 2024, and the facility had changed dental providers at that time. The Interim Director of Nursing acknowledged the lack of documentation regarding the location of Resident 13's pain, and the Administrator confirmed that Residents 3 and 22 had not received any dental assessments since admission. The Administrator also confirmed that Resident 13 had not received dental care since February 2024, despite the referral for oral surgery. These deficiencies highlight the facility's failure to adhere to its policy of assisting residents in obtaining necessary dental care.
Nursing Call System Malfunction in Multiple Rooms
Penalty
Summary
The facility failed to ensure that the Nursing Call System was functioning and operational in four of 26 resident rooms and bathrooms, specifically in Rooms 16, 17, 18, and 7. During observations, it was noted that the call light cord in one room was on the floor and unplugged, with only one hole available in the Nursing Call Light Panel to accommodate one cord, despite two residents being assigned to the room. Additionally, the shared bathroom for two rooms lacked an accessible Nursing Call Light Panel, and in another room, the call light cord was not functioning for a resident in Bed B. These deficiencies were confirmed by a CNA and the Interim DON, who acknowledged the issues with the call light system. Further observations revealed that the call light system was not functioning in another room, as the call light did not activate when pressed by a resident. An RN confirmed the malfunction and suggested that a new call light cord might be needed. A subsequent observation indicated that the Nursing Call System had not been repaired and remained non-functional for both residents in the room. The Administrator and RDES were unaware of the non-functional call lights, as staff had not informed them of the issues in the specified rooms and shared bathroom.
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What surveyors actually found near you
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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.
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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) |
|---|---|---|---|---|
| Rosewood At Tybee Island Of Journey Llc, The | 0.1 mi | ★★★★★ | 2 | 1 |
| Fraser Health Center | 10.3 mi | ★★★★★ | 0 | 0 |
| Broad Creek Care Center | 11.4 mi | ★★★★★ | 1 | 1 |
| Thunderbolt Care Center Llc | 12.1 mi | — | 0 | 0 |
| Riverview Health & Rehab Ctr | 12.8 mi | ★★★★★ | 11 | 0 |
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