Tybee Island Trails of Journey LLC

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to report injuries of unknown origin to the State Survey Agency (SSA) within the required time frame for one of three sampled residents (R) (R6) reviewed for abuse and neglect. The deficient practice had the potential for future unreported injuries of unknown origin, with the potential to affect residents' quality of life.

Inspectors wroteBased on observation, staff interviews, record review, and a review of facility's policy titled Pain Management and Wound Treatment Management, the facility failed to stop and address a resident pulling back during a dressing change and facial grimacing expressions of pain during wound care for one resident (R) (R33) of two residents observed for wound care. Actual harm occurred on 1/28/2026 when Licensed Practical Nurse (LPN) AA failed to assess and administer pain medication to R33 prior to providing wound care treatment, which resulted in pain during the treatment. Findings Include: [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to label, store, prepare, and discard food under sanitary conditions. In addition, the facility failed to ensure the cleanliness of the kitchen floors and equipment used for residents. The deficient practices had the potential to place the 48 residents receiving nutrition and hydration at risk for foodborne illness.

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility failed to ensure three of 32 sampled residents' (R) (R2, R1, and R45) were treated with dignity. This deficient practice had the potential to place R2, R1, and R45 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident and/or the resident's responsible party when their personal funds were within $200.00 of the Social Security Income (SSI) limit and when accounts exceeded the $200.00 limit for one of 48 resident (R) (R43) accounts reviewed.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure submission to the state-designated authority for a Preadmission Screening and Resident Review (PASRR) Level II for two residents (R) (R1 and R19) reviewed for PASRR from a sample of 32 residents. This deficient practice increased the potential to place R1 and R19 at risk of not receiving services and/or care according to their needs.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that one of two medication rooms was free of expired medication. This deficient practice had the potential to place residents at risk of receiving expired medications.

Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the facility's policy titled Enhanced Barrier Precautions, the facility failed to ensure infection control practices were followed for four of 32 sampled residents (R) (R33, R7, R30, and R40). This deficient practice had the potential to place R33, R7, R30, and R40 at risk of infection due to cross-contamination and exposure.

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date items in the freezer, failed to ensure items in dry food storage were not expired, failed to prevent cross-contamination hazards by storing scoops in the container, failed to wear hairnets, and failed to ensure routine cleaning and sanitation of the kitchen. This deficient practice had the potential to place 49 of 49 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings Include: During the initial kitchen tour on 10/26/2024 at 7:47 am the following items were identified: 1. Dietary Aide AA and Dietary Aide BB were not wearing hairnets upon the surveyor's entry into the kitchen. 2. Items in the white standup freezer were not labeled or dated, including pancakes, cookies, biscuits, sausage, and fish nuggets. 3. In the dry storage pantry there were: a. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. This deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food leading to food borne illness for the 49 residents residing in the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene and Infection Surveillance, the facility failed to maintain an effective infection prevention control program to ensure proper sanitation between resident interactions, failed to ensure beverages were covered before delivering on the hallway, failed to ensure hand sanitation when delivery meal trays, and failed to demonstrate ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. These deficient practices placed all 49 residents residing in the facility at risk of contracting avoidable infections.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a clean, comfortable, and homelike environment for nine of 26 resident rooms (Rooms 15, 10, 11, 18, 20, 7, 16, 17, and 9) and one of two shower rooms (Ladies' Shower Room). These deficient practices had the potential to place the residents residing in and using the rooms at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop or implement comprehensive person-centered care plans for eight of 38 sampled residents (R) (R39, R42, R8, R19, R3, R10, R13, and R22). This failure increased the potential for R39, R42, R8, R19, R3, R10, R13, and R22 to not receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to promote dignity during dining for four of 36 sampled residents (R) (R16, R45, R42, and R250) related to staff referring to residents as feeders and not serving resident meals at the same time for residents who were dining together. These failures had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Residents' Rights and Treatment Regarding Advance Directives, the facility failed to ensure there were no discrepancies related to Advanced Directives for one of 38 sampled residents (R) (R3). The deficient practice had the potential to result in R3's Advance Directives not being followed.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to provide ADL care to three of 38 sampled residents (R) (R3, R10, and R22) related to facial shaving and nail trimming/cleaning. This failure had the potential to cause R3, R10, and R22 to have unmet needs and to feel self-conscious of their appearance.

Inspectors wroteBased on observations, staff interviews, record review, facility document review, and review of the facility policies titled Fall Risk Assessment and Elopements and Wandering Residents, the facility failed to ensure a complete post-fall assessment was performed for one of 13 residents (R) (R23) who sustained a fall. The facility also failed to complete an elopement assessment for one of 38 sampled R (R6). This deficient practice created a potential risk to the safety and well-being of R23 and R6.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Dental Services, the facility failed to provide routine and emergency dental services for three of 38 sampled residents (R) (R3, R13, and R22). This failure placed R3, R13, and R22 at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that the Nursing Call System was functioning and operational for four of 26 resident rooms/bathrooms (Rooms 16, 17, 18, and 7). This failure placed the residents residing in the rooms at risk of accident, injury, or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on observation, staff interviews, and review of the facility policy titled, Food Receiving and Storage, the facility failed to ensure that items were labeled/dated and used before the expiration date in the main kitchen. The facility also, failed to ensure that items in the dry storage area in the main kitchen were dated when received and were labeled and dated with a use by date. The deficient practice had the potential to affect 40 of 40 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Homelike Enviornment, the facility failed to ensure a personalized and homelike setting was provided for the residents that resided in the facility. Specifically, the facility failed ensure that the residents name and room number was posted outside of the residents door.

Inspectors wroteBased on record review, family interview, staff interviews, and review of the facility policy titled, Accounting and Records of Resident Funds, the facility failed to provide a quarterly financial statement of a resident trust fund account for one of 40 residents (R) (#3). The deficient practice had the potential to affect the 40 residents with trust fund accounts managed by the facility.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Change in a Resident's Condition or Status, the facility failed to notify the physician of a change in residents' behavioral status for 0ne of one residents (R#243). Specifically, the facility failed to inform the physician of the noted behavioral changes of R#243 which resulted in an resident -to resident altercation.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, the facility failed to report abuse timely related to an employee-to-resident incident involving Resident (R) #292, for one of nine (9) facility reported incidents reviewed. Findings Include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating (Revised September 2022), revealed: Policy Interpretation and Implementation- Reporting Allegations to the Administrator and Authorities 1. If resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Investigating Allegations: the facility failed to ensure that abuse allegations, including staff to resident altercations were thoroughly investigated for one resident (R#292).

Inspectors wroteBased on record review, staff interview, and review of the facility's policy titled, Transfer Agreement the facility failed to comply with the requirements for an involuntary discharge for one of three residents (R) (#142). Specifically, the facility failed to ensure that R#142 was provided with proper notification of discharge from the facility. Additionally, the facility also failed to comply with the requirements for an involuntary discharge in accordance with their policy.