Tucker Operating Company LLC

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Elopements and Wandering Residents, the facility failed to report elopement within two hours to law enforcement and the State Agency for one of four sampled residents (R) (R1).

Inspectors wroteBased on observations, resident representative and staff interviews, record review, and review of the facility policies titled, Incident and Accidents and Elopements and Wandering Residents, the facility failed to prevent the elopement of one of four sampled residents (R) (R1). The deficient practice had the potential to place R1 and other cognitively impaired residents at risk of compromised health and safety.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from debris and failed to ensure the lids of two of two garbage disposals were kept close when not in use to prevent pest and rodents.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy's titled, Safe and Comfortable Environment and Environmental Services Inspection, the facility failed to make necessary repairs as needed to maintain a homelike environment in rooms for nine of 64 sampled residents (R) (R39, R178, R47, R5, R65, R84, R93, R115 and R185) in a timely manner.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Restraint Free Environment, the facility failed to provide freedom from restraints for one of five residents reviewed who used a Geri chair (a large, padded chair that is designed to help residents with limited mobility) out of 26 residents in the sample (Resident (R) 47).

Inspectors wroteBased on record review, staff interview, and a review of the facility policy titled, Baseline Care Plan, the facility failed to fully develop and implement a baseline care plan within 48 hours of admission for one of 64 sampled residents (R) (R 178).

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to update/revise the care plan for three of 64 sampled residents (R) (R47, R113, and R4). This failure had the potential to result in nursing personnel providing inaccurate or inappropriate care for R47, R113, and R4.

Inspectors wroteBased on staff interview and review of the PBJ (Payroll Based Journal) Staffing Data Report, [NAME] Report 1705D for the First Quarter (Q1) of fiscal year 2024 (October 1-December 31), the facility failed to report accurate nurse staffing data to the Centers for Medicare and Medicaid (CMS) related to nursing staff coverage. The facility census was 113 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for one of five residents (R) R50 related to the removal of facial hair. The sample size was 45 residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Accidents and Supervision, the facility failed to ensure hazardous chemicals were safely secured for two of three residents (R) (R6 and R21) reviewed for accidents. This deficient practice placed residents at risk for avoidable chemical incidents, injuries, and a diminished quality of life. The sample size was 45 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Accident and Supervision, Medication Storage, and Resident Self-Administration of Medication, the facility failed to store one bottle of over the counter (OTC) liquid indigestion medication in a locked medication storage area for one of 45 sampled residents (R) (R50). The deficient practice had the potential to place the resident at risk for medical complications, unauthorized persons access to medications, and a diminished quality of life.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the policy titled Comprehensive Care Plan, the facility failed to implement the Comprehensive person-centered care plan for one resident (R) R2 with a tracheostomy (trach) by not having emergency trach supplies at the bedside in the event of decannulation. In addition, the facility failed to develop a Comprehensive person-centered care plan for smoking for one resident, R1. The facility's failures created potential risks for the safety and well-being of the residents. The sample size was 33 residents.

Inspectors wroteBased on observations, record review, resident and staff interview, review of the facility's admission Agreement and Employee Handbook and review of the policy titled Smoking Policy, the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff, by failing to enforce the facility's No Smoking Property guidelines in an area that has an active propane tank. The facility's failures created potential risks for the safety and well-being of the residents. The census was 118 residents.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Tracheostomy Care, the facility failed to provide respiratory/tracheostomy care by trained and competent nursing staff according to professional standards, failed to develop a policy/procedure for accidental dislodgement of trach tubes, and failed to have emergency tracheostomy supplies at the bedside for one resident (R2) of three residents receiving tracheostomy care. The facility's failures created potential risks for the safety and well-being of the residents.

Inspectors wroteBased on observations, record review, interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Smoling Policy, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its No Smoking Policy and failed to ensure that licensed nursing staff were knowledgeable and competent to act in emergency situations for decannulation of tracheostomy tubes. The facility's failures created potential risks for the safety and well-being of the residents. The census was 118 residents. Specifically 1. Facility Administrator and Director of Nursing failed to perform duties of their job descriptions that facilitated medical care to the residents of the facility. 2. [...]

Inspectors wroteBased on observations, record review, interviews, review of facility's Employee Handbook, admission Packet, and policy titled Smoking Policy, the facility failed to ensure that there was a policy developed outlining the procedures of a non-smoking facility and smoke free property, including the potential outcomes when individuals smoke on the facility property. Specifically, two facility staff and one resident (R) R1 were allowed to smoke on the facility property near an active propane tank. The facility's failures created potential risks for the safety and well-being of the residents. The census is 118 residents.

Inspectors wroteBased on record review, staff interviews, and review of the job description for the Director of Nursing, the facility failed to ensure clinical staff were trained and competent to provide emergency care for accidental trach dislodgement for one of three residents (R) R2 reviewed for tracheotomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance resulted in R2 trach becoming dislodged, and R2 required surgical intervention to reinsert tracheostomy tube. The facility's failures created potential risks for the safety and well-being of the residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, and the Georgia Comprehensive Rules and Regulations, r. 410-10-.03, the facility failed to meet professional standards of quality by providing two non-pharmacist labeled prescription medications at time of discharge for one resident (R) R9 of three sampled residents.

Inspectors wroteBased on observations, facility documentation, resident and staff interviews, the facility failed to ensure that it maintained a clean and comfortable home-like environment for four residents (R), (R#37, R#31, R#51, R#62) related to dirty wheelchairs; and six resident rooms (217, 219, 220, 222, 224, 227) with dirty floors, dirty windowsills, damaged walls and doors, dirty equipment, and improper functioning air mattress. The facility census was 87 residents.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Comprehensive Care Plans, the facility failed to develop a baseline care plan for one newly admitted resident (R) (R#382) that included goals and interventions related to oxygen use, tracheostomy care, and gastrostomy tube feeding. The sample size was 43 residents.

Inspectors wroteBased on record review, staff interviews, and review of policy titled Transfer, Discharge, Return to Facility, the facility failed to ensure the Discharge Summary was completed in its entirety, for one resident (R) (R#232). The sample size was 43 residents.