Inspection Reports for Tucker Nursing & Rehab Center
2165 Idlewood Rd, Tucker, GA 30084, GA, 30084
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found substantiated complaints but no deficiencies were cited. Earlier inspections identified deficiencies related to medication storage, assistance with activities of daily living, hazardous chemical storage, nurse staffing data reporting, environmental cleanliness, and fire safety issues. Notably, a prior inspection in November 2023 found Immediate Jeopardy due to failures in enforcing a no-smoking policy and maintaining emergency tracheostomy supplies, but corrective actions were implemented and validated. Complaint investigations were mostly unsubstantiated, with substantiated complaints not resulting in cited deficiencies in recent surveys. The facility has shown improvement since the Immediate Jeopardy findings, with recent inspections indicating correction of prior deficiencies and no new citations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
124 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an elopement incident involving a resident (R1) and to prevent elopement and ensure adequate supervision.
Complaint Details
The complaint involved the facility's failure to report an elopement incident within two hours to law enforcement and the State Agency. The investigation found that staff did not follow facility protocols for supervision, alarm response, and reporting. The resident was found unharmed after being missing for several hours. The complaint was substantiated with findings of deficient practices.
Findings
The facility failed to report the elopement of resident R1 within two hours to law enforcement and the State Agency, and did not follow proper supervision and alarm response protocols. Staff were unaware of R1's exit-seeking behaviors, did not conduct thorough searches or elopement drills, and failed to notify authorities as required. R1 was found outside the facility after several hours without harm.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to elopement.
Failed to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically failing to prevent the elopement of resident R1.
Report Facts
Residents sampled: 4
BIMS score: 3
Time resident missing: 2
Alarm hold time: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Turned off alarm without investigating cause and did not report elopement as required |
| LPN CC | Licensed Practical Nurse | Observed resident R1 and documented progress notes related to elopement incident |
| Administrator | Responsible for notifying police and State Agency; attempted to call law enforcement but did not complete report | |
| Director of Nursing BB | Director of Nursing | Reported staff did not follow facility policy and procedure regarding elopement |
| Maintenance Director EE | Maintenance Director | Reported alarm was turned off and staff did not follow protocol |
| Social Services Director II | Social Services Director | Reported elopement assessments were due at admission and visited resident after incident |
| Corporate Owner FF | Corporate Owner | Located resident R1 outside the facility after elopement |
| CNA QQ | Certified Nurse Assistant | Observed resident R1 outside and participated in search |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including restraint use, baseline care planning, comprehensive care planning, environmental safety, and sanitation in the nursing home.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints (Geri chair without medical order), failure to develop baseline care plans within 48 hours of admission, incomplete comprehensive care plans for several residents, failure to maintain clean and safe garbage disposal areas, and inadequate maintenance and repair of resident rooms and equipment.
Deficiencies (6)
Failure to ensure residents are free from physical restraints unless medically necessary, specifically use of a Geri chair without physician order for Resident 47.
Failure to develop and implement a baseline care plan within 48 hours of admission for Resident 178.
Failure to update/revise comprehensive care plans for Residents 47, 113, and 4, resulting in incomplete documentation of care needs.
Failure to ensure garbage dumpsters were kept covered and surrounding areas free of debris, leading to pest attraction.
Failure to maintain a safe, clean, and homelike environment including unresolved mold, water damage, damaged walls, stained ceilings, and disrepair of resident room furnishings for multiple residents.
Failure to maintain overbed tables in safe condition, with exposed particle board posing risk of injury to Resident 132.
Report Facts
Residents sampled: 64
Residents reviewed for restraint use: 26
Residents affected by restraint deficiency: 1
Residents affected by baseline care plan deficiency: 1
Residents affected by comprehensive care plan deficiency: 3
Garbage dumpsters inspected: 2
Residents affected by environmental deficiencies: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant HH | CNA | Interviewed regarding Resident 47's use of Geri chair |
| Licensed Practical Nurse II | LPN | Interviewed regarding absence of physician order for Geri chair for Resident 47 |
| Director of Rehabilitation | Interviewed about Resident 47's chair use and therapy discharge | |
| Director of Nurses | DON | Interviewed about care plans and restraint policies |
| Registered Nurse Minimum Data Set Coordinator | RN MDS Coordinator | Interviewed about MDS coding and care plan deficiencies |
| Dietary Manager | Interviewed about garbage dumpster lids and cleanliness | |
| Registered Nurse CC | RN | Interviewed about Resident 84's room condition |
| Administrator AA | Administrator | Interviewed about renovation delays |
| Corporate Officer FF | Corporate Officer | Interviewed about renovation progress |
| Maintenance Coordinator DD | Maintenance Coordinator | Interviewed about renovation status and mold |
| Certified Nursing Assistant EE | CNA | Interviewed about overbed table disrepair for Resident 132 |
| South Registered Nurse Unit Manager | RN Unit Manager | Interviewed about overbed table safety concerns |
| Maintenance Director | Maintenance Director | Interviewed about maintenance processes and overbed table inspections |
Inspection Report
Abbreviated Survey
Census: 124
Deficiencies: 0
Date: May 28, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00255151 and GA00255279 at Tucker Wellness and Rehabilitation Center.
Complaint Details
Complaints GA00255151 and GA00255279 were substantiated with no deficiencies cited.
Findings
The complaints were substantiated but no deficiencies were cited during the survey.
Report Facts
Census: 124
Inspection Report
Abbreviated Survey
Census: 131
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their codes from 11/12/2024 through 12/3/2024.
Complaint Details
Complaints GA00252583, GA00252568, GA00252008, GA00251984, GA00251425, GA00250731, GA00248890, GA00248355, and GA00247669 were investigated and found to be unsubstantiated.
Findings
All complaints investigated during the survey were unsubstantiated, and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Tucker Wellness and Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific details on deficiencies or findings.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected at the time of the revisit.
Inspection Report
Follow-Up
Census: 103
Deficiencies: 0
Date: Jun 23, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the June 6, 2024 Recertification Survey conducted in conjunction with a Complaint survey.
Findings
All deficiencies cited as a result of the June 6, 2024 Recertification Survey and Complaint survey were found to be corrected.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was a State Licensure survey conducted from June 2, 2024 through June 6, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for deficiencies including failure to properly store over-the-counter medication securely for one resident, and failure to provide adequate assistance with activities of daily living related to facial hair removal for another resident.
Deficiencies (2)
Failure to store one bottle of over the counter liquid indigestion medication in a locked medication storage area for one of 45 sampled residents.
Failure to ensure ADL care was provided related to the removal of facial hair for one of five residents sampled.
Report Facts
Sample size: 45
Residents with ADL deficiency: 1
Residents with medication storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed and verified resident had facial hair and discussed facial hair removal procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration policies and facial hair removal expectations |
Inspection Report
Routine
Census: 113
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
A standard survey was conducted from June 2, 2024 through June 6, 2024, including investigation of multiple complaint intake numbers which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00243895, GA00244095, GA00246234, GA00244818, GA00243591, and GA00246194 were investigated and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to ADL care, hazardous chemical storage, medication storage, and inaccurate nurse staffing data reporting.
Deficiencies (4)
Failure to ensure ADL care was provided for one resident related to removal of facial hair.
Failure to ensure hazardous chemicals were safely secured for two residents, placing them at risk for chemical incidents.
Failure to store one bottle of over the counter liquid indigestion medication in a locked medication storage area for one resident.
Failure to report accurate nurse staffing data to CMS, resulting in a One-Star Staffing rating.
Report Facts
Facility census: 113
Sample size for residents reviewed: 45
BIMS score: 13
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Confirmed facial hair on resident R50 and described ADL care expectations. | |
| Director of Nursing (DON) | Confirmed facial hair on resident R50, expectations for staff to remove facial hair, and described medication storage and self-administration policies. | |
| Administrator | Confirmed observations of unsecured chemicals and medications, and discussed staffing and PBJ rating. |
Inspection Report
Routine
Census: 113
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication storage, and staffing based on observations, interviews, and record reviews.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living (specifically facial hair removal), securing hazardous chemicals in resident rooms, proper medication storage, and accurate nurse staffing data reporting to CMS.
Deficiencies (4)
Failed to ensure ADL care was provided for one resident related to removal of facial hair.
Failed to ensure hazardous chemicals were safely secured for two residents, placing them at risk for chemical incidents.
Failed to store one bottle of over the counter liquid indigestion medication in a locked medication storage area.
Failed to electronically submit complete and accurate direct care staffing information to CMS.
Report Facts
Sample size: 45
Facility census: 113
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed and verified resident had facial hair and discussed facial hair removal procedures. |
| Director of Nursing | Director of Nursing (DON) | Confirmed facial hair issue, expectations for staff, and medication storage policies. |
| Administrator | Administrator | Interviewed regarding staffing data and hazardous chemical storage. |
Inspection Report
Routine
Census: 113
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, medication storage, and staffing.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living (specifically facial hair removal), securing hazardous chemicals in resident rooms, proper medication storage, and accurate nurse staffing data reporting to CMS.
Deficiencies (4)
Failed to ensure ADL care was provided for one resident related to removal of facial hair.
Failed to ensure hazardous chemicals were safely secured for two residents, placing them at risk for chemical incidents.
Failed to store one bottle of over the counter liquid indigestion medication in a locked medication storage area for one resident.
Failed to electronically submit complete and accurate direct care staffing information to CMS, resulting in a One-Star Staffing rating.
Report Facts
Sample size: 45
Facility census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed resident had facial hair and described facial hair removal procedures |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations for facial hair removal and medication storage policies |
| Administrator | Administrator | Interviewed regarding staffing and chemical safety policies |
Inspection Report
Life Safety
Census: 110
Capacity: 136
Deficiencies: 3
Date: Jun 3, 2024
Visit Reason
The visit was a Life Safety Code survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper sealing of penetrations above the North Hall smoke compartment with foam instead of proper U.L. caulk, a deteriorated door latch at the South shower room, and an unsafe extension cord running through the ceiling in the laundry room behind the boilers.
Deficiencies (3)
Improper foam used to seal penetrations above ceiling at the North Hall smoke compartment instead of proper U.L. caulk, risking smoke migration.
Failed to maintain the door at South shower room; latch area deteriorated and door needs replacement, risking smoke infiltration.
Extension cord running through ceiling in laundry room behind boilers, risking electrical shock and smoke generation.
Report Facts
Residents at risk in North Hall smoke compartment: 30
Residents at risk due to South shower room door: 4
Staff members at risk: 2
Census: 110
Total licensed capacity: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Tucker Wellness and Rehabilitation Center following a survey completed on 12/28/2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2023-11-03.
Complaint Details
This survey was a follow-up to a complaint survey conducted on 11/3/2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 11/3/2023 complaint survey were found to be corrected.
Report Facts
Census: 116
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 5
Date: Nov 3, 2023
Visit Reason
The inspection was a Licensure Survey conducted from October 10, 2022 through November 3, 2023, to assess compliance with facility regulations including enforcement of the no smoking policy and emergency care preparedness for residents with tracheostomies.
Findings
The facility failed to enforce its no smoking policy, allowing staff and a resident to smoke near an active propane tank, and failed to maintain emergency tracheostomy supplies at the bedside of a resident with a tracheostomy. These failures created Immediate Jeopardy risks to resident safety. The facility submitted a credible allegation of compliance and removal plan, which was validated as of October 20, 2023, but the facility remains out of compliance while continuing to implement a Plan of Correction.
Deficiencies (5)
Facility administration failed to enforce the 'No Smoking Facility/Property' policy, allowing staff and a resident to smoke near an active propane tank.
Facility administration failed to maintain emergency tracheostomy supplies at the bedside for a resident with a tracheostomy.
Facility administration failed to ensure nursing staff were trained and competent to provide emergency care for tracheostomy tube dislodgement.
Facility administration failed to develop and implement a care plan for smoking for a resident and failed to implement care plan interventions for emergency care and supplies at bedside for a resident with a tracheostomy.
Facility failed to ensure the environment was free from accident hazards by not enforcing no smoking near an active propane tank.
Report Facts
Census: 118
Sample size: 33
Distance: 65
Distance: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Observed smoking on facility property in violation of no smoking policy |
| EE | Housekeeper | Observed smoking on facility property in violation of no smoking policy; signed Tobacco-Free Workplace Policy Acknowledgement |
| EEE | Licensed Practical Nurse | Unable to locate emergency tracheostomy supplies at resident bedside |
| Administrator | Informed of Immediate Jeopardy situations and interviewed regarding no smoking policy and facility property boundaries | |
| Director of Nursing | Informed of Immediate Jeopardy situations and responsible for nursing staff competency and tracheostomy care | |
| RR | MDS Licensed Practical Nurse | Interviewed regarding care plan development and smoking policy |
| Social Service Director II | Interviewed regarding smoking policy and resident/family education | |
| Maintenance Director | Measured distances related to propane tank and smoking areas; confirmed propane tank status |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint numbers initiated on 10/10/2023 and concluded on 11/3/2023, focusing on allegations including lack of emergency tracheostomy supplies, smoking violations, and medication issues.
Complaint Details
The investigation was initiated due to multiple complaints including GA00239990 and GA00233483. Immediate Jeopardy was identified related to lack of emergency trach supplies and smoking violations. A credible allegation of compliance was received on 10/25/2023 with corrective actions implemented by 10/20/2023.
Findings
The facility was found to be in Immediate Jeopardy due to failure to have emergency tracheostomy supplies at the bedside for resident R2, failure to enforce a no-smoking policy resulting in staff and a resident smoking near an active propane tank, and failure to ensure licensed nursing staff were trained and competent in emergency tracheostomy care. Additionally, non-pharmacist labeled medications were provided at discharge for resident R9. A credible allegation of compliance was received on 10/25/2023 with corrective actions implemented by 10/20/2023, but the facility remains out of compliance while continuing oversight and plan of correction.
Deficiencies (8)
Failed to implement the comprehensive care plan for resident R2 by not having emergency tracheostomy supplies at the bedside.
Failed to develop a comprehensive care plan for smoking for resident R1.
Allowed smoking on facility property near an active propane tank by staff and resident, violating the no-smoking policy.
Provided two non-pharmacist labeled prescription medications at discharge for resident R9.
Failed to meet professional standards by not having emergency tracheostomy supplies at bedside and lack of staff training for emergency trach care for resident R2.
Facility administration failed to provide oversight and enforcement of no-smoking policy and failed to ensure nursing staff competency in emergency tracheostomy care.
Failed to ensure clinical staff were trained and competent to provide emergency care for accidental tracheostomy tube dislodgement for resident R2.
Failed to ensure a policy outlining procedures and consequences for smoking on facility property, resulting in staff and resident smoking near an active propane tank.
Report Facts
Complaint numbers investigated: 23
Census: 118
Distance from propane tank to smoking area: 65
Date of inspection completion: Nov 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Observed smoking on facility property near propane tank; involved in Immediate Jeopardy findings |
| EE | Housekeeper | Observed smoking on facility property near propane tank; signed tobacco-free workplace policy; involved in Immediate Jeopardy findings |
| EEE | Licensed Practical Nurse | Unable to locate emergency trach supplies at bedside for resident R2 |
| MM | Registered Nurse | Dispensed unlabeled medications to resident R9; unaware of illegality |
| DDD | Nurse Pharmacy Consultant | Acknowledged illegality of nurse dispensing unlabeled medications |
| RR | MDS Licensed Practical Nurse | Stated no smoking care plan developed because facility is smoke-free |
| II | Social Service Director | Confirmed facility is smoke-free and residents/families are informed |
| BBB | Medical Director | Stated standard of practice to have extra trach tubes at bedside |
Inspection Report
Routine
Census: 118
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, and facility operations, including tracheostomy care, medication administration, smoking policy enforcement, and staff training.
Findings
The facility failed to implement comprehensive care plans for residents with special needs, maintain emergency tracheostomy supplies at the bedside, enforce the no smoking policy on facility property, ensure proper medication labeling at discharge, and provide adequate staff training on emergency tracheostomy care. These failures posed potential risks to resident safety and well-being.
Deficiencies (8)
Failed to implement a comprehensive person-centered care plan for a resident with a tracheostomy by not having emergency trach supplies at the bedside.
Failed to develop a comprehensive person-centered care plan for smoking for one resident.
Provided two non-pharmacist labeled prescription medications at time of discharge for one resident.
Failed to ensure the environment was free from accident hazards by not enforcing the no smoking policy near an active propane tank.
Failed to provide respiratory/tracheostomy care by trained and competent nursing staff, failed to develop a policy for accidental dislodgement of trach tubes, and failed to have emergency tracheostomy supplies at the bedside.
Facility administration failed to provide oversight and monitoring related to enforcement of the no smoking policy and failed to ensure licensed nursing staff were knowledgeable and competent to act in emergency situations for trach dislodgement.
Failed to have a policy outlining procedures of a non-smoking facility and smoke free property including potential outcomes when individuals smoke on facility property.
Failed to ensure clinical staff were trained and competent to provide emergency care for accidental trach dislodgement.
Report Facts
Census: 118
Sample size: 33
Medication orders: 2
Distance: 65
Distance: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EEE | Licensed Practical Nurse (LPN) | Unable to locate emergency trach supplies at bedside; involved in trach care |
| XX | Licensed Practical Nurse (LPN) | Received trach supplies bag from LPN EEE to take to Director of Nursing |
| DON | Director of Nursing | Expected trach supplies to be at bedside; assured supplies were placed at bedside |
| EE | Housekeeping Staff | Observed smoking with resident near propane tank |
| RR | MDS Licensed Practical Nurse (LPN) | Described baseline care plan process and smoking care plan policy |
| MM | Registered Nurse (RN) | Dispensed unlabeled medications to resident's responsible party |
| CCC | Pharmacist | Acknowledged illegal nurse dispensing unlabeled medications |
| DDD | Nurse Pharmacy Consultant | Confirmed illegality of nurse dispensing unlabeled medications |
| DD | Certified Nursing Assistant (CNA) | Observed smoking on facility property near propane tank |
| SSD II | Social Service Director | Confirmed smoke free policy and resident/family education |
| SDC | Staff Development Coordinator | Provided education on tracheostomy care but not on emergency trach tube replacement |
| BBB | Medical Director | Stated standard of practice for trach emergency supplies at bedside |
| Administrator | Facility Administrator | Responsible for facility operations and enforcement of policies |
Inspection Report
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
A revisit was conducted at Tucker Wellness and Rehabilitation Center to verify correction of deficiencies cited during the standard recertification survey and complaint investigations.
Findings
All deficiencies cited as a result of the standard recertification survey and complaints investigated were found to be corrected as of 2023-01-25.
Inspection Report
Renewal
Census: 87
Deficiencies: 2
Date: Dec 27, 2022
Visit Reason
The inspection was a Licensure Survey conducted from December 22, 2022 through December 27, 2022 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to maintain a clean and comfortable home-like environment, evidenced by dirty wheelchairs for four residents and six resident rooms with dirty floors, windowsills, damaged walls and doors, dirty equipment, and an improperly functioning air mattress. Environmental concerns were verified by the Administrator and Director of Nursing.
Deficiencies (2)
Failure to maintain clean wheelchairs for residents R#37, R#31, R#51, and R#62, with wheelchairs observed dirty and never cleaned.
Resident rooms (217, 219, 220, 222, 224, 227) had dirty floors, dirty windowsills with dead bugs, damaged walls and doors, dirty equipment, and an improperly functioning air mattress causing discomfort.
Report Facts
Facility census: 87
BIMS scores: 13
BIMS scores: 15
BIMS scores: 11
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding wheelchair cleaning responsibilities and maintenance system | |
| Environmental Services Director | Interviewed regarding responsibility for washing wheelchairs and maintenance tasks | |
| Administrator | Verified environmental concerns during the survey | |
| Director of Nursing | Verified environmental concerns during the survey |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Dec 27, 2022
Visit Reason
A standard survey was conducted from December 20, 2022 through December 27, 2022, investigating multiple complaint intake numbers in conjunction with the standard survey to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Multiple complaint intake numbers (GA00219341, GA00220202, GA00221218, GA00222995, GA00224925, GA00226440, GA00226866, GA00219892, GA00221202, GA221847, GA00223746, GA00226148, GA00228037, GA00220096) were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including unclean wheelchairs for four residents, dirty and damaged resident rooms, failure to develop a baseline care plan for a newly admitted resident with complex needs, and incomplete discharge summary documentation for one resident.
Deficiencies (3)
Failure to maintain clean wheelchairs for four residents and dirty, damaged resident rooms including floors, windowsills, walls, doors, and equipment.
Failure to develop a baseline care plan for one newly admitted resident that included goals and interventions related to oxygen use, tracheostomy care, and gastrostomy tube feeding.
Failure to ensure the Discharge Summary was completed in its entirety for one resident, with multiple sections incomplete and not signed or dated by the physician.
Report Facts
Resident census: 87
Sample size: 43
Oxygen flow rate: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed no baseline care plan was in place for resident R#382 and was unaware of omissions; also commented on discharge summary policy. |
| Maintenance Director | Maintenance Director | Interviewed regarding wheelchair cleaning responsibilities and documentation. |
| Environmental Services Director | Environmental Services Director | Interviewed regarding responsibility for washing wheelchairs and uncertainty about last cleaning. |
| Social Services Director | Social Services Director | Interviewed regarding discharge summary and employment status during resident discharge. |
Inspection Report
Life Safety
Census: 87
Capacity: 136
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations, including review of the Emergency Preparedness Program.
Findings
The facility was found in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. The North Hallway was not surveyed due to 16 COVID patients being assessed in their rooms.
Report Facts
COVID patients: 16
Inspection Report
Routine
Census: 87
Deficiencies: 3
Date: Dec 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to maintaining a safe, clean, and comfortable environment for residents, including treatment and supports for daily living.
Findings
The facility failed to maintain a clean and comfortable home-like environment for several residents, with issues including dirty wheelchairs, dirty floors, damaged walls and doors, dirty equipment, and an improperly functioning air mattress. Additionally, the facility failed to develop a baseline care plan for a newly admitted resident addressing oxygen use, tracheostomy care, and gastrostomy tube feeding, and failed to complete a discharge summary for one resident.
Deficiencies (3)
Failure to maintain clean wheelchairs and resident rooms, including dirty floors, windowsills, damaged walls and doors, dirty equipment, and improper functioning air mattress.
Failure to develop a baseline care plan for a newly admitted resident that included goals and interventions related to oxygen use, tracheostomy care, and gastrostomy tube feeding.
Failure to ensure the Discharge Summary was completed in its entirety for one resident, with incomplete sections and missing physician signature.
Report Facts
Facility census: 87
Sample size: 43
Oxygen flow rate: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed no baseline care plan for resident R#382 and unawareness of omissions |
| Social Services Director | Social Services Director | Interviewed regarding discharge concerns for resident R#232 |
| Maintenance Director | Maintenance Director | Interviewed about wheelchair cleaning responsibilities and maintenance system |
| Environmental Services Director | Environmental Services Director | Interviewed about responsibility for washing wheelchairs and cleaning tasks |
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a COVID-19 Focused Infection Control survey to investigate multiple complaints and infection control compliance at Tucker Wellness and Rehabilitation Center.
Complaint Details
Complaints #GA00213332, #GA00214278, #GA00217100, and #GA00218932 were unsubstantiated. Complaints #GA00211238, #GA00214317, #GA00214957, #GA00216742, #GA00216784, #GA00217463, and #GA00217654 were substantiated with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations. Several complaints were investigated, with some substantiated but no deficiencies identified. The facility implemented CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Resident Census: 92
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