Tybee Island Trails of Journey LLC

In the surveyor’s words

From the most serious findings on record at Tybee Island Trails of Journey LLC, in the surveyor’s own words.

• Actual harm, isolatedF697Jan 30, 2026

  Based on observation, staff interviews, record review, and a review of facility's policy titled Pain Management and Wound Treatment Management, the facility failed to stop and address a resident pulling back during a dressing change and facial grimacing expressions of pain during wound care for one resident (R) (R33) of two residents observed for wound care. Actual harm occurred on 1/28/2026 when Licensed Practical Nurse (LPN) AA failed to assess and administer pain medication to R33 prior to providing wound care treatment, which resulted in pain during the treatment.Findings Include: Review of the facility policy titled Pain Management, date reviewed/revised 04/1/2025, revealed the Policy section included, The facility must ensure that pain management is provided to residents who require… […]

• Actual harm, isolatedF580Jan 21, 2022

  Based on observation, record review, review of facility policy titled Change in a Resident's Condition or Status, and staff interviews, the facility failed to notify the physician of pain and worsening contracture to the left hand for one resident (R) (#12) of two residents with contractures. Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. Findings include: Review of facility's policy titled Change in a Resident's Condition or Status revised February 2021 revealed: 1. The Nurse will notify the resident's attending physician or on-call physician when there has been: d. […]

• Actual harm, isolatedF600Jan 21, 2022

  Based on observations, record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program the facility failed to protect two of four residents (R#140 and R#14) from physical abuse. Actual Harm occurred on 12/14/2021, when R#6 physically abused R#140 causing bruising to R#140's jaw and two lacerations to the residents ear. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 revealed Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• Actual harm, isolatedF656Jan 21, 2022

  Based on record review, review of the facility policy titled Comprehensive Person-Centered Care Plans, and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan that included interventions to address hand contractures for one resident (R) (#12) of two residents with contractures. Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. […]

• Actual harm, isolatedF688Jan 21, 2022

  Based on observation, record review, review of the facility policy titled Restorative Nursing Services, and staff interviews, the facility failed to provide restorative nursing services for one of two residents with contractures (R) (#12). Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. Findings include: Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]