Tucker Operating Company Llc
TUCKER OPERATING COMPANY LLC in TUCKER, GA — inspection on November 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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) (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 R1's face sheet showed 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] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated R1 had severe cognitive impairment.Review of R1's Comprehensive Care Plan (CCP) Initiated on 10/1/2025 documented R1 was at risk for wandering looking for his home. R1 was disoriented to place, had impaired safety awareness and wandered aimlessly.
Care plan directed staff to distract 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 R1 was missing.
She told staff to look everywhere inside and outside the building.
The Administrator explained that facility staff were under the impression 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 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 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tucker Operating Company LLC
2165 Idlewood Road Tucker, GA 30084
SUMMARY STATEMENT OF DEFICIENCIES
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 R1 was missing. He stated he drove around the facility and located R1 a quarter of a mile away from the facility at approximately 10:15 pm. He stated 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 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 R1 was a visitor and staff stated R1 was a Resident. CNA QQ further documented she asked R1 if he needed anything and 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 R1. CNA QQ proceeded outside the building and searched the nearby apartments and was unable to locate R1, she returned to the facility after 10:00 pm and was informed 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 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 R1 was located inside the building and explained to her that R1 never left the building. RR stated 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 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 R1 was not harmed.
The Administrator stated she started the inservice at night on 10/1/2025 and placed a wander guard on R1.
She concluded the facility was unaware R1 had exit seeking behaviors and concluded staff did not go through R1s history and physical prior to admission and stated mistakes were made.
Facility ID: