Rosewood at Tybee Island of Journey LLC, the
7 Rosewood Avenue, Tybee Island, GA 31328 · Chatham County · 85 certified beds · avg 82 residents/day · certified since Feb 7, 2017
Abuse citation flag (CMS)SFF Candidate
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Jun 7, 2026 · F-0925 · triggered by a complaint
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Why it matters: Pests spread germs, contaminate food, and signal broader problems with cleanliness.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
▲ Immediate jeopardy, one-off · Mar 19, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 23, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, facility-wide · Jul 31, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, facility-wide · Jul 31, 2025 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, facility-wide · Jul 31, 2025 · F-0835 · triggered by a complaint
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, facility-wide · Jul 31, 2025 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 7, 2026 | ▲ L · Immediate jeopardy, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jun 7, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 19, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 19, 2026 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jul 31, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 31, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jul 31, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Jul 31, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Jul 31, 2025 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jul 31, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 14, 2025 | F · Potential for harm, facility-wide | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 14, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Sep 9, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 7, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2024 | 6 | 0 | D |
| 2025 | 12 | 4 | L ▲ |
| 2026 | 4 | 2 | L ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $200,733, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2026 | Payment Denial | 1 days from Apr 16, 2026 |
| Jul 31, 2025 | Fine | $200,733 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Georgia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.06 | 3.54 | 3.95 | bottom 1% in Georgia; bottom 1% in the U.S. |
| Registered Nurse hours | 0.09 | 0.50 | 0.69 | bottom 1% in Georgia; bottom 1% in the U.S. |
| Weekend total nurse staffing | 1.80 | 3.09 | 3.50 | bottom 1% in Georgia; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.12 | 0.35 | 0.48 | bottom 5% in Georgia; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 78.4 | 46.0 | 45.8 | bottom 1% in Georgia; bottom 2% in the U.S. |
| RN turnover (%) | 87.5 | 44.5 | 42.9 | bottom 3% in Georgia; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.76, RN 0.11, weekend 2.42. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How is pest control handled here, and when was the last treatment or inspection?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Tybee Island Trails of Journey LLC | 0.1 mi | Tybee Island, GA | ★☆☆☆☆ | 2/5 | |
| Fraser Health Center | 10.3 mi | Hilton Head Island, SC | ★★★★☆ | 3/5 | |
| Broad Creek Care Center | 11.4 mi | Hilton Head Island, SC | ★★★★★ | 4/5 | |
| Riverview Health & Rehab Ctr | 12.9 mi | Savannah, GA | ★☆☆☆☆ | 1/5 | |
| Oaks Health Ctr at the Marshes of Skidaway Island | 13.4 mi | Savannah, GA | ★★★★☆ | 4/5 | |
| Savannah Crossing of Journey LLC | 13.8 mi | Savannah, GA | ★★★☆☆ | 3/5 | |
| Candler Skilled Nursing Unit | 15.1 mi | Savannah, GA | ★★★★★ | 4/5 | |
| Life Care Center of Hilton Head | 16.1 mi | Hilton Head Island, SC | ★☆☆☆☆ | 1/5 | abuse |
| The Preston Health Center | 16.1 mi | Hilton Head Island, SC | ★★★★★ | 5/5 | |
| Savannah Post Acute LLC | 17.0 mi | Savannah, GA | ★☆☆☆☆ | 2/5 | |
| Pruitthealth - Savannah | 17.3 mi | Savannah, GA | ★★☆☆☆ | 2/5 | |
| Abercorn Rehabilitation Center | 18.3 mi | Savannah, GA | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
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Facility data as of CMS processing date 2026-08-01. CCN 115730.