Cycle 1
Health 2024-10-28 · Fire 2024-10-28
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Tybee Island, GA
Tybee Island Care Center LLC
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
26 Van Horne Street, Tybee Island, GA
(912) 786-4511
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peach Health Group
Operator or chain grouping
Approved since
1997-03-01
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
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
0.73
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
1.70
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
1.11
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
1.33
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,496
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.5
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
0.9
Baseline 53.57% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.07 hours · Performance 2.87 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 24 · Denominator 25 |
| Falls with major injury | 4% |
0.77%
3.2 pts worse
|
Numerator 1 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · 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 19 |
| Staff flu vaccination coverage | 7.41% |
42%
34.6 pts worse
|
Numerator 4 · Denominator 54 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.2
0.8 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.7% |
91.2%
9.5 pts worse
|
93.4%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.2% · Q2 93.6% · Q3 89.1% · Q4 78.7% · 4Q avg 81.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.0%
3.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 42.9% |
9.6%
33.3 pts worse
|
11.4%
31.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 25.0% · Q3 68.3% · Q4 72.1% · 4Q avg 42.9% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.9%
0.9 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 2.3% · Q3 0.0% · Q4 2.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
20.7%
3.1 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 23.8% · Q3 23.1% · Q4 20.9% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 62.2% |
21.4%
40.8 pts worse
|
16.7%
45.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 66.7% · 4Q avg 62.2% · 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 | 11.2% |
17.9%
6.7 pts better
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 3.6% · Q3 26.5% · Q4 0.0% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
16.2%
2.6 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 7.3% · Q3 26.3% · Q4 7.1% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.5%
0.2 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 5.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.1% |
16.1%
11 pts better
|
19.8%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 6.0% · Q4 4.2% · 4Q avg 5.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.2%
0.8 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.5% · Q3 4.3% · Q4 3.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 15.1% |
80.4%
65.3 pts worse
|
81.7%
66.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 15.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-08 · Fire 2023-06-08
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-01-21 · Fire 2022-01-21
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-19
E · Potential for more than minimal harm
2023-06-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-06-08
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-06-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-07-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-10-28
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-10-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-06-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-23
F · Potential for more than minimal harm
2023-06-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-06-08
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-06-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-06-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-06-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-06-08
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-07-23
G · Actual harm
2022-01-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-03-09
G · Actual harm
2022-01-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-03-09
G · Actual harm
2022-01-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-09
G · Actual harm
2022-01-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-09
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Oceanside Care Center LLC
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
#2
Fraser Health Center
Hilton Head Island, SC
5-star overall rating with 3-star inspections with 4 recent health deficiencies
#3
Broad Creek Care Center
Hilton Head Island, SC
5-star overall rating with 5-star inspections
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