Rosewood at Tybee Island of Journey LLC, The

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Met the expected recovery: 21.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 85 beds and averages 82.0 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.76 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.42 hrs/resident/day on weekends vs 2.91 on weekdays — 17% thinner on weekends. RN hours go from 0.11 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 78% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 16 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · L2026-06-07 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review, the facility failed to ensure a vermin-free environment related to an active raccoon infestation within the facility's attic ceilings, main dining room, and walls. This failure placed 82 of 82 residents at substantial and immediate risk for physical injury (scratches/bites) and exposure to infectious vectors and diseases, including rabies.On 6/6/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Executive Director (ED) and Director of Nursing Services (DNS) were informed of the Immediate Jeopardy (IJ) on 6/6/2026 at 6:17 pm. The noncompliance related to the IJ was identified as having existed on 5/18/2026.An Acceptable Removal Plan was not received at the time of exit on 6/7/2026. Therefore, the IJ status was ongoing.Findings included:1. A review of the electronic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has plan of correction
• Immediate jeopardy · Jcited before2026-03-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility's policies titled Abuse Neglect and Exploitation and Proper Use of Bed Rails, the facility failed to protect one Resident (R) (R3) from neglect by not providing adequate supervision and oversight to ensure the resident was free from the risk of entrapment related to the use of side rails. Specifically, the assigned Certified Nursing Assistant (CNA) FF failed to provide required monitoring and assistance with Activities of Daily Living (ADL) care for R3 on [DATE] between 12:46 am to 4:30 am. As a result, R3 was found unresponsive with agonal breathing and entrapped in the siderails for an unknown amount of time. R3 required emergency resuscitation by Emergency Medical Services (EMS) enroute to the hospital and had to be intubated (a procedure to insert a tube into the airway to maintain breathing). R3 later expired at the hospital on [DATE]. The facility's failure to protect the resident from neglect caused or was likely to cause serious injury,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-07-31 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On July 15, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on July 15, 2025, at 3:48 pm. The noncompliance related to the IJ was identified to have existed on June 13, 2025.An acceptable Immediate Jeopardy Plan of Removal was provided on July 18, 2025, and included interviews and skin assessments, education on abuse policy, threatening or violent behavior in the workplace, policy review, no weapons signage, night receptionist and weekend managers' new addition. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on July 24, 2025. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-07-31 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents. Specifically, the facility did not have a licensed nurse (Registered Nurse RN or Licensed Practical Nurse LPN) on duty for at least 30 minutes on [DATE] between 7:00 pm through 7:30 pm. The census was 83 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included additional staffing agency support, daily staffing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2025-07-31 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight related to workplace violence, failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents, and failed to protect residents from alleged emotional and potential physical abuse during an active shooter incident. The census was 83.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Nurse Consultant, and Operations Consultant were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] and included…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2025-07-31 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included review of policies and procedures for emergency staffing, review of job descriptions, education on additional staffing agency support, daily staffing schedules, shift rounding, emergency staffing plan, education on how to respond to active shooter events and emergency preparedness, and an ad hoc QAPI meeting. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident staff interviews, and record review, the facility failed to maintain a clean and comfortable homelike environment for two of 27 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) related to dirty Packaged Terminal Air Conditioner (PTAC) filters, debris build-up on the floor, unidentified clothing items on the floor, a unknown bagged item stored in the residents room, and a light bulb base hanging from the ceiling bathroom. Findings included: During an observation on 6/5/2026 at 8:42 am, the PTAC Unit in room [ROOM NUMBER] revealed that the PTAC Unit filter contained thick, grayish-colored fuzzy debris. During an observation on 6/5/2026 at 9:17 am and 6/6/2026 at 7:46 am in room [ROOM NUMBER] revealed the PTAC filter obtained a gray thick fuzzy debris, a thick gray substance underneath the PTAC unit with a business card embedded in the debris, a square black item wrapped in a black garbage bag placed next to the bedroom sink, unidentified clear bag containing clothing items, and the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-03-19 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interviews, record review, and review of facility documents, the facility failed to provide sufficient licensed nursing staff to meet the needs of residents (R) residing on one of two wings, the [NAME] Wing. Specifically, the facility did not have licensed nurse coverage for the [NAME] Wing after 6:00 PM during the 3:00 PM to 11:00 PM shift on December 25, 2025. This deficient practice had the potential to place residents residing on the [NAME] Wing at increased risk of unmet care needs.Findings include:Review of the facility provided document titled [facility name] Daily Staffing, dated December 25, 2025, revealed that the schedule documented no licensed nursing staff listed for the [NAME] Wing for the 3:00 PM to 11:00 PM shift.A review of the facility-provided Grievance/Complaint Report dated 12/26/2026 revealed that DON CCC filed a report stating some residents, who resided on the [NAME] Wing, reported not receiving medication doses at 9:00 PM on 12/25/2025. The report also listed that the Medical Director was notified, and no further orders or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-31 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interviews, record review, and review of facility documents, the facility failed to ensure that Certified Medication Aides (CMAs) completed a skills competency check-off before being allowed to administer medications. In addition, the facility failed to ensure CMAs did not administer narcotic medications to one of 18 sampled residents (R) (R12). This deficient practice had the potential to place the 83 residents residing in the facility at risk of receiving medication from incompetent staff. Findings include: Review of the facility-provided undated document titled Medication Technician/Aide revealed the Position Purpose section stated, Assists licensed nursing staff by administering daily medications as ordered by the physician in accordance with established nursing standards, facility policies, and procedures and state requirements.1. The facility was unable to provide current annual competencies that were signed and dated for six of the seven Certified Medication Aides (CMAs) (CMA JJ, CMA GGG, CMA KKK, CMA RRR, CMA UUU, CMA YY) actively working at the facility. 2.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-07-31 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, record reviews, and review of the facility policy titled Laundry, the facility failed to maintain the laundry area in a sanitary manner to ensure residents' clothes were free from contamination. This deficient practice had the potential to place all residents residing in the facility at increased risk for infection related to cross-contamination. Findings include:Review of the facility policy titled Laundry, revised 6/11/2025, revealed the Policy section stated, The facility launders linens and clothing in accordance with current CDC [Center for Disease Control and Prevention] guidelines to prevent transmission of pathogens. The Policy Explanation and Compliance Guidelines section included, .2. The facility's laundry area will provide hand washing facilities and products as well as PPE [personal protective equipment]. 4. Soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. a. Linens shall be bagged separately from resident's clothing at the point of use. b. Sorting…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-31 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, and review of the facility policy titled Promoting/ Maintaining Resident Dignity, the facility failed to promote dignity for one of 18 residents (R) (R1) in an environment that promotes the maintenance or enhancement of each resident's quality of life. This failure had the potential to diminish R1's quality of life.Findings include:Review of the facility policy titled Promoting/Maintaining Resident Dignity, revised 10/21/2024, revealed the Policy section stated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintain or enhances resident's quality of life by recognizing each resident's individuality. The Compliance Guidelines section included, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.Observation on 7/14/2025 at 9:55 am revealed Certified Nursing Assistant (CNA) II and CNA JJ pushing R1 in a geriatric…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure safety measures were initiated for one of 18 sampled residents (R) (R1). This deficient practice had the potential to place R1 at risk of avoidable injuries. Findings include: Review of the admission Record for R1 revealed diagnoses including, but not limited to, muscle weakness, epilepsy, and unsteadiness on feet.Review of the Quarterly Minimum Data Set (MDS), dated [DATE], for R1 revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section J (Health Conditions) documented falls since admission. Review of the Fall Risk Assessment for R1, dated 6/9/2025, revealed a score of 15 (indicating high risk for falls). Review of the Progress Notes for R1 revealed an entry dated 3/4/2025 of the nurse found the resident on the floor in his room. Further review revealed an entry dated 4/2/2025 of the nurse observed R1 trying to get out of bed,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-14 · tag F0755 — failed to provide safe pharmacy services — widespread
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interviews, review of controlled drug count records, and facility policy review, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three out of three medication carts (West Medication Cart One, [NAME] Medication Cart Two, and East Medication Cart). Findings include: Review of a facility's policy titled, Controlled Substance Administration and Accountability, undated, revealed all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. A review of a document titled Change of Shift Narcotic Log identified by Licensed Practical Nurse (LPN) AA as the change of shift…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-14 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one out of 21 sampled residents, Resident (R) #79. Findings include: Review of R#79's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include acute respiratory failure with hypoxia, dysphagia - oropharyngeal phase, cognitive communication deficit, essential hypertension, type 2 diabetes mellitus, restless legs syndrome, and insomnia. A review of a Nurses Note dated 2/18/25, at 5:09 a.m., revealed R#79 was on oxygen via nasal cannula at two (2) liters (L) resident stated allergic to codeine, V/S (vital signs) wnl (within normal limits), blood glucose level 127. A review of a Social Services Note dated 2/18/25, at 2:34 p.m., revealed R #79's code status as DNR (do not resuscitate), was on 2 L of oxygen, and utilized eyeglasses as an aid due to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-14 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility policy, it was determined that the facility failed to adhere to acceptable storage requirements and use by dates for multi-dose diabetes medication on one of three medication carts observed, (West Cart Two. This affected Resident (R) #10, R#48, and R#70. Findings include: A review of facility policy titled Multi-Dose Vials, undated, revealed multi-dose vials would be re-labeled with a beyond use date, 28 days after the vial is opened or punctured (unless otherwise specified by the manufacturer). The beyond-use date rule would begin on the first (1st) day the multi-use vial was opened or punctured. The medication label would also include the initials of the nurse who opened the vial. The policy indicated that staff should visually inspect the vial before each use to double check the expiration date, beyond use date if previously opened, and ensure there was no visible contamination. The Unit Manager would perform random checks of opened multi-dose vials for appropriate dating. Observation of the [NAME] Medication Cart Two, on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-09-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to ensure that one of 33 sampled residents (R) (R2) was treated with dignity. This failure had the potential to diminish R2's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings included: A review of R2's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment). During an observation on 8/29/2024 at 11:11 am, R2 was observed in his room and wearing a hospital gown. During an observation and interview on 9/3/2024 at 11:28 am, R2 was observed in his room and wearing a hospital gown. R2 stated that he had brought clothes to the facility, and when he returned from a hospital stay, his clothing was missing. He could not recall the date of the hospital stay or if missing clothing had been reported to anyone. During an observation and interview on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$200,733 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $200,733 — penalty dated 2025-07-31
• Medicare payment denial — starting 2026-04-16 for 1 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $319K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA