Rosewood at Tybee Island of Journey LLC, the

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the Administrator and Director of Nursing Job Description, the facility administrations failed to manage the facility in a manner that protects residents' health and safety by failing to identify, remediate, and eliminate a known active raccoon infestation within the facility's attic ceilings, main dining room, and walls. Specifically, administration had documented knowledge of wildlife infestation since 5/19/2026, when staff observed a live raccoon in the ceiling, but failed to implement effective eradication measures or secure the building. This administrative failure placed 82 residents at substantial and immediate risk for physical injury (scratches/bites) and exposure to infectious vectors and diseases, including rabies, resulting in a determination of an ongoing immediate jeopardy. [...]

Inspectors wroteBased on observations, staff interviews, review of the facility documents, and review of the facility's policies titled Food Safety Requirements and Ice Machines and Portable Ice Carts, the facility failed to properly discard expired food items and properly store, label, and date them. Additionally, the facility failed to prevent wet nesting and maintain the ice machine in a sanitary condition. These deficiencies posed a potential risk to 79 out of 82 residents who received an oral diet from the kitchen, increasing their vulnerability to foodborne illnesses.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Soiled Linen and Trash Containers, the facility failed to ensure outdoor garbage was secured in safe working conditions and that the refuse area was maintained in a sanitary manner, creating the potential for harboring pests, insects, and rodents. Census 82.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Laundry, the facility failed to maintain infection control practices realted to: (1) resident personal care items not stored properly to prevent cross-contamination; (2) maintaining one of two shower rooms (West Hall) in a sanitary condition; and (3) ensuring that the resident laundry was free of exposure of environment hazardous material and contamination. The deficient practice had the potential to expose residents to infections due to cross-contamination.

Inspectors wroteBased on observations, staff interview, record view, and a review of the facility policy titled Safe Water Temperature, the facility failed to maintain safe water temperatures in eight of 43 Residents' Rooms (RM) (RM 204, RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]) and one of two common-use shower rooms.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Advance Directives, the facility failed to provide two of three residents (R) (R49 and R58) written information with options regarding their right to accept or refuse medical or surgical treatment and failed to ensure a physician's order matching the resident's documented wishes was established and maintained in the medical record. This failure denied the residents the opportunity to have choices and preferences with their health care decisions and to formulate an Advance Directive, and placed the residents at risk for receiving or not receiving unwanted cardiopulmonary resuscitation in a medical emergency.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review, and a review of facility policy titled Discharge Planning Process, the facility failed to ensure residents were not inappropriately transferred or discharged against the resident's/residents' representative's wishes for one resident of 82 sampled residents (R)(R85).

Inspectors wroteBased on staff interviews, record reviews, and the facility policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure submission to the state-designated authority for a Preadmission Screening and Resident Review (PASARR) Level II for two of two residents (R) (R4 and R29) reviewed for PASARR. This deficient practice increased the potential to place R4 and R29 at risk of not receiving services and/or care according to their needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for two of 32 sampled residents (R58 and R49) related to the residents' advance directive. This failure placed residents at risk of not having their end-of-life wishes honored.

Inspectors wroteBased on record review and interviews, the facility failed to address pharmacy recommendations for a gradual dose reduction (GDR) for one of five residents (R) (81).

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteOn 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. [...]

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteOn [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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and record review, the facility failed to post the required nursing staffing data on a daily basis. This was observed for four (4) of four (4) days of survey.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the call light was within reach for four of 33 sampled residents (R) (R28, R29, R15, and R16). This failure placed the residents at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop a person-centered comprehensive care plan for one of 33 sampled residents (R) (R4). The deficient practice had the potential to affect the care and services provided to R4.

Inspectors wroteBased on observations, resident interviews, staff interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide ADL care for four of 33 sampled residents (R) (R18, R20, R16, and R15). This failure placed R18, R20, R16, and R15 at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on resident interviews, staff interviews, and record reviews, the facility failed to obtain a critical laboratory test for one of 33 sampled residents (R) (R6) in a timely manner. Specifically, the facility failed to obtain a urine specimen for five days after the physician's order. The deficient practice had the potential to place R6 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, resident interviews, staff interviews, record review, and review of the facility policy titled Infection Control, the facility failed to ensure staff implemented infection control precautions to provide individual water mugs for two of 33 sampled residents (R) (R19 and R33) who shared a single water mug for an undetermined period in their room. This failure created the potential of exposing R19 and R33 to infections due to cross-contamination.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Food Storage and Family Members, the facility failed to discard expired food items and failed to label, and date opened food items in two of two resident pantry refrigerator/freezers. This deficient practice had the potential to affect all residents that received food items from two of two resident pantries. The census was 68 residents.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled Comprehensive Person-Centered Care Plan, the facility failed to follow a care plan for one resident (R) R62. This failure increased the potential for R62 to not receive treatment and/or care according to their needs and placed R62 at risk for harm or adverse consequences. The sample size was 23 residents.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for one dependent resident (R) (R30), related to shaving facial hair. This failure had the potential to negatively impact R30's quality of life. The sample was 23 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled Skin Tears - Abrasions and Minor Breaks, Care of and Prevention of Pressure Injuries, the facility failed to provide treatment and care in accordance with professional standards for one of 23 residents (R) (R62) sampled for skin assessments. Specifically, the facility failed to assess and monitor an open skin area secondary to a previous intravenous site and failed to follow the facility's processes related to weekly skin assessments. This deficient practice had the potential to cause R62 to develop a complicated skin infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to evaluate the effectiveness of prescribed pain medications for one resident (R) (R30) during wound care. This failure had the potential to place R30 at risk for unmet needs. The sample size was 23 residents.