Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.