12 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Tybee Island, GA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
7 Rosewood Avenue, Tybee Island, GA
(912) 786-4511
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
85
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peach Health Group
Operator or chain grouping
Approved since
2017-02-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.27
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.20
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.19
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.05
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
1.69
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 73.53% · Performance 73.97% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 2.7 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 0% · Lower 95% interval 5.81% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 1.96% |
95.27%
93.3 pts worse
|
Numerator 1 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 10 · Denominator 28 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 12 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 49 |
| Staff flu vaccination coverage | 3.85% |
42%
38.1 pts worse
|
Numerator 4 · Denominator 104 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.13% |
25.2%
9.1 pts worse
|
Numerator 5 · Denominator 31 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 10.5% |
91.2%
80.7 pts worse
|
93.4%
82.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 11.0% · Q3 6.9% · Q4 5.5% · 4Q avg 10.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.3% |
95.0%
26.7 pts worse
|
95.5%
27.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.2%
2.5 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.4% |
9.6%
39.8 pts worse
|
11.4%
38 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 42.6% · Q3 63.1% · Q4 90.3% · 4Q avg 49.4% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.9%
5.2 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
20.7%
8.9 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 11.1% · Q3 10.0% · Q4 19.7% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
21.4%
3.3 pts better
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 16.2% · Q3 23.3% · Q4 18.6% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.1% |
17.9%
6.2 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 31.5% · Q3 23.4% · Q4 26.6% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
16.2%
5.5 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 22.2% · Q3 18.8% · Q4 31.7% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.3% |
16.1%
10.8 pts better
|
19.8%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.6% · Q3 4.0% · Q4 4.3% · 4Q avg 5.3% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.2%
1.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.8% · Q3 6.7% · Q4 1.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 0.0% |
80.4%
80.4 pts worse
|
81.7%
81.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
12.2%
5.5 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 19.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 2.0% |
78.2%
76.2 pts worse
|
79.7%
77.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 2.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
24.2%
4.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 26.2% · Expected 21.9% · Used in QM five-star |
Survey summary
Top issue: Nursing and Physician Services (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-28
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-28
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-15
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-02
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-02
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-02
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-09-02
Health
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 2025-09-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-28
Health
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 2025-04-28
Health
Post nurse staffing information every day.
Corrected 2025-04-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-18
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-10-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-15
Penalties and ownership
Nearby options
Tybee Island, GA
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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5-star overall rating with 3-star inspections with 4 recent health deficiencies
Hilton Head Island, SC
5-star overall rating with 5-star inspections
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