Safety Report: Rosewood At Tybee Island of Journey LLC, the
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
7Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
9Requirements cited on more than one inspection
L
Government finding: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · Tag F925
J
Government finding: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Tag F835
J
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
L
Government finding: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Tag F867
L
Government finding: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Tag F835
L
Government finding: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Tag F725
L
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
Citations by topic
2Abuse, neglect & exploitation
3Infection control
3Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (14) than in the cycle before (12).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 3 | June 7, 2026; July 31, 2025; September 9, 2024 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. (F835) | 2 | June 7, 2026; July 31, 2025 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | June 7, 2026; December 7, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | June 7, 2026; July 31, 2025 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 2 | March 19, 2026; July 31, 2025 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F725) | 2 | March 19, 2026; July 31, 2025 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | July 31, 2025; September 9, 2024 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | September 9, 2024; December 7, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | September 9, 2024; December 7, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| June 7, 2026 | Payment Denial | Payment denial for 26 days, starting June 11, 2026 |
| July 31, 2025 | Fine | $204,299 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 7, 2026 — 12 citations (includes serious)
L
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Immediate jeopardy to resident health or safety · Widespread · Environmental Deficiencies · F925 · complaint · corrected July 7, 2026
J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Immediate jeopardy to resident health or safety · Isolated · Administration Deficiencies · F835 · corrected July 7, 2026
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected July 7, 2026
F
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F814 · corrected July 7, 2026
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected July 7, 2026
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected July 7, 2026
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected July 7, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected July 7, 2026
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected July 7, 2026
D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F627 · corrected July 7, 2026
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected July 7, 2026
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected July 7, 2026
March 19, 2026 — 2 citations (includes serious) · complaint investigation
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 23, 2026
E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F725 · complaint · corrected April 23, 2026
July 31, 2025 — 8 citations (includes serious) · complaint investigation
L
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F867 · complaint · corrected September 2, 2025
L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F835 · complaint · corrected September 2, 2025
L
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Immediate jeopardy to resident health or safety · Widespread · Nursing and Physician Services Deficiencies · F725 · complaint · corrected September 2, 2025
L
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected September 2, 2025
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · complaint · corrected September 2, 2025
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F726 · complaint · corrected September 2, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected September 2, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected September 2, 2025
March 14, 2025 — 4 citations
F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Widespread · Pharmacy Service Deficiencies · F755 · corrected April 28, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected April 28, 2025
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · complaint · corrected April 28, 2025
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · complaint · corrected April 28, 2025
September 9, 2024 — 6 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected October 18, 2024
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · complaint · corrected October 18, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected October 18, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected October 18, 2024
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · complaint · corrected October 18, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected October 18, 2024
December 7, 2023 — 5 citations · complaint investigation
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected January 15, 2024
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected January 15, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 15, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected January 15, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected January 15, 2024
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare