Inspection Reports for
Tucker Nursing & Rehab Center

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.

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.

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.

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.

Complaint Intake Numbers GA00243895, GA00244095, GA00246234, GA00244818, GA00243591, and GA00246194 were investigated and found unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.