Rosewood at Tybee Island of Journey LLC, the
7 Rosewood Avenue · Tybee Island, GA · 31328 · 9127864511
85 certified beds For profit - Limited Liability company Chain: Peach Health Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (5 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
5 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
RN staffing in the bottom 10% nationally
0.23 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
1.94 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
75% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 1.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.23 | 0.55–0.75 |
| Weekend hours / resident-day | 1.72 | ≈ weekday level |
| Nursing turnover / year | 75% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (25 in the current record)
-
Immediate jeopardy · J March 19, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 23, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E March 19, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected April 23, 2026 · Nursing and Physician Services
-
Immediate jeopardy · L July 31, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · L July 31, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 2, 2025 · Nursing and Physician Services
-
Immediate jeopardy · L July 31, 2025 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected September 2, 2025 · Administration
-
Immediate jeopardy · L July 31, 2025 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected September 2, 2025 · Administration
-
Potential for harm · D July 31, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 2, 2025 · Resident Rights
-
Potential for harm · D July 31, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 2, 2025 · Quality of Life and Care
-
Potential for harm · F July 31, 2025 · found via complaint
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.
Corrected September 2, 2025 · Nursing and Physician Services
-
Potential for harm · F July 31, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 2, 2025 · Infection Control
-
Potential for harm · F March 14, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 28, 2025 · Pharmacy Service
-
Potential for harm · D March 14, 2025
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.
Corrected April 28, 2025 · Pharmacy Service
-
Potential for harm · D March 14, 2025 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected April 28, 2025 · Resident Assessment and Care Planning
-
No harm found · C March 14, 2025 · found via complaint
Post nurse staffing information every day.
Corrected April 28, 2025 · Nursing and Physician Services
-
Potential for harm · D September 9, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected October 18, 2024 · Resident Rights
-
Potential for harm · D September 9, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected October 18, 2024 · Resident Rights
-
Potential for harm · D September 9, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 18, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D September 9, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 18, 2024 · Quality of Life and Care
-
Potential for harm · D September 9, 2024 · found via complaint
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected October 18, 2024 · Administration
-
Potential for harm · D September 9, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected October 18, 2024 · Infection Control
-
Potential for harm · D December 7, 2023 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 15, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D December 7, 2023 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 15, 2024 · Quality of Life and Care
-
Potential for harm · D December 7, 2023 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 15, 2024 · Quality of Life and Care
-
Potential for harm · D December 7, 2023 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected January 15, 2024 · Quality of Life and Care
-
Potential for harm · F December 7, 2023 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 15, 2024 · Nutrition and Dietary
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 19, 2026 | Payment Denial | 1 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 115730 · certified since February 7, 2017. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.