Tucker Operating Company Llc

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) (Resident R1). Findings include:Review of the undated facility policy titled Elopements and Wandering Residents documented under Policy: This facility ensures that Residents who exhibit and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with the Resident Centered Care Plan addressing the unique factors contributing to wandering or elopement risk. Under Policy Explanation and Compliance Guidelines: 2.

Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in

a timely manner.4. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.d. Adequate supervision will be provided to help prevent accidents or elopements. 5. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between facility and the police department. g. Appropriate reporting requirements to the State Survey agency should be conducted.Review of Resident R1's face sheet showed Resident R1 was admitted with diagnoses of but not limited to cerebral infarction, end stage renal disease, cognitive communication deficit, unspecified dementia, and psychotic mood disturbance.Review of R1s admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident R1 had severe cognitive impairment.Review of Resident R1's Comprehensive Care Plan (CCP) Initiated on 10/1/2025 documented Resident R1 was at risk for wandering looking for his home. Resident R1 was disoriented to place, had impaired safety awareness and wandered aimlessly. Care plan directed staff to distract Resident R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books.During an

interview on 10/8/2025 at 11:59 am with the Administrator revealed on 10/1/2025 at approximately 8:20 pm, staff reported Resident R1 was missing. She told staff to look everywhere inside and outside the building. The Administrator explained that facility staff were under the impression Resident R1 was unable to walk and concentrated on searching the inside of the facility. The Administrator explained at approximately 10:15 pm that the facility owner located Resident R1. The Administrator stated she attempted to call law enforcement and was

on hold for 40 minutes and eventually hung up without making a police report.During an interview on 10/9/2025 at 12:29 pm, the Administrator revealed she did not notify the State Agency since Resident R1 was not harmed.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tucker Operating Company LLC

2165 Idlewood Road Tucker, GA 30084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to look everywhere inside and outside the building. The Administrator explained that facility staff were under

the impression Resident R1 was unable to walk and concentrated on searching the inside of the facility. The Administrator explained at approximately 10:15 pm that the facility owner located Resident R1. The Administrator stated she attempted to call law enforcement and was on hold for 40 minutes and eventually hung up without making a police report.During an interview on 10/8/2025 at 12:45 pm, the Social Services Director (SSD) II revealed elopement assessments were due at admission. She stated she visited Resident R1 the night after

the incident occurred. She stated Resident R1 could not recall he had exited the facility and was not aware of the date and time. She stated R1s family requested Resident R1 to be transferred. During an interview on 10/8/2025 at 3:37 pm, the Cooperate Owner (CO) FF revealed he was in the area when the Administrator reported Resident R1 was missing. He stated he drove around the facility and located Resident R1 a quarter of a mile away from the facility at approximately 10:15 pm. He stated Resident R1 was seated on the curbside of a road. Corporate Owner FF was unaware if local law enforcement were notified. Review of a written statement signed and dated 10/9/2025, CNA QQ documented she recalled she observed Resident R1 on 10/1/2025 at approximately 7:00 pm, when the morning shift was leaving for the day. CNA QQ documented she asked if Resident R1 was a visitor and staff stated Resident R1 was a Resident. CNA QQ further documented she asked Resident R1 if he needed anything and Resident R1 stated he was okay. At approximately 8:40 pm, CNA QQ checked R1s room and was unable to locate him. CNA QQ informed the nurse and another CNA, and they started looking for Resident R1. CNA QQ proceeded outside the building and searched the nearby apartments and was unable to locate Resident R1, she returned to the facility after 10:00 pm and was informed Resident R1 had been located. During an interview on 10/9/2025 at 9:12 am, CNA JJ revealed she worked on the Rehabilitation Unit. She stated she had not done training regarding elopement drills and explained the facility talked about elopement training on 10/2/2025. She explained prior to that the facility had not done any elopement drills or training.During an interview on 10/9/2025 at 9:55 am, RN OO explained that the facility had not done elopement drills and stated RN DD did not investigate the cause of

the alarm as required and stated that a head count should have been completed and staff should have completed rounds and made sure all residents were accounted for.During an interview on 10/9/2025 at 10:55 am, the Administrator revealed she was the only one with access regarding video camera reviews.

She said she did not review the video camera because she was too busy.During an interview on 10/9/2025 at 11:55 am, R1s Resident Representative (RR) revealed a facility nurse called her on 10/1/2025 between 7:00 pm - 8:00 pm and stated Resident R1, her father, was missing. RR stated that staff told her the police had been notified. She stated facility staff later called her and informed her that Resident R1 was located inside the building and explained to her that Resident R1 never left the building. RR stated Resident R1 had attempted to leave the hospital without medical advice and explained he had wandering tendencies. She stated facility staff did not ask the family if Resident R1 had elopement tendencies prior to his admission.During an interview on 10/9/2025 at 12:29 pm,

the Administrator revealed she did not notify the State since Resident R1 was not harmed. The Administrator stated

she started the inservice at night on 10/1/2025 and placed a wander guard on Resident R1. She concluded the facility was unaware Resident R1 had exit seeking behaviors and concluded staff did not go through R1s history and physical prior to admission and stated mistakes were made.

Event ID:

Facility ID:

If continuation sheet