Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tucker Operating Company Llc during CMS and state inspections, most recent first.
Failure to report a resident elopement to law enforcement and the State Agency. A resident with severe cognitive impairment, dementia, and wandering risk was reported missing, later found by the facility owner, but the Administrator did not complete the required police report after being on hold and did not notify the State Agency because the resident was not harmed.
Failure to Prevent Resident Elopement: A resident with severe cognitive impairment, dementia, and documented wandering risk exited the facility after staff observed him asking to leave and later heard an alarm but silenced it without investigating. Staff searched the building after he was reported missing, but he was found outside on a sidewalk. Interviews showed staff did not follow elopement procedures, elopement drills had not been done, and the resident’s exit-seeking history was not reviewed before admission.
Open Dumpsters and Debris Around Garbage Area: Surveyors observed two garbage dumpsters with lids left open and trash, food particles, milk cartons, and plastic cups scattered around the area with flies present. The Dietary Manager stated staff should have closed the lids after each use and that housekeeping was responsible for keeping the surrounding area clean.
Delayed room repairs and poor environmental maintenance: Multiple resident rooms had visible damage, stains, mold, cracked or missing fixtures, and unfinished repairs, including a resident room with scraped walls, ceiling damage, and a concealed wall patch. Staff and leadership acknowledged the conditions and stated renovations had been ongoing for months, while an overbed table was found with exposed particle board and no routine inspection process was in place.
Improper Use of Geri Chair as a Physical Restraint: A resident with severe cognitive impairment, prior CVA-related deficits, and a history of falls was observed seated in a Geri chair at the nurses’ station without a physician order or care plan inclusion for the chair. The chair was positioned against a wall with the footrest extended, preventing the resident from rising independently while the resident attempted to get out by pulling on the arm rests.
A resident admitted with multiple diagnoses, including dementia with agitation and a history of suicidal behaviors, had an admission order for Quetiapine 25 mg at bedtime for behaviors. The baseline care plan was not completed within 48 hours and did not include the psychotropic medication, which the DON confirmed should have been included.
The facility failed to keep care plans current for three residents. One resident’s plan did not reflect the use of a Geri chair or related transfer/fall needs, another resident’s plan did not document PT/OT services, and a third resident’s plan did not include wound care treatments. The MDS Coordinator and DON confirmed these items were not captured on the care plans.
The facility failed to report accurate nurse staffing data to CMS for Q1 2024, resulting in a One-Star Staffing rating. Despite efforts by new ownership to increase RN, CNA, and CMA numbers, inaccuracies in the PBJ Staffing Data Report persisted. The Administrator was unaware of the rating.
A resident with cognitive and physical impairments was not assisted with facial hair removal, despite facility policies requiring such care. The resident expressed a desire for assistance, but staff failed to document or perform the necessary grooming. Interviews with staff confirmed the oversight, revealing a lapse in adherence to grooming protocols.
The facility failed to secure hazardous chemicals, with ant and roach killer spray found in one resident's room and disinfectant spray in another's. Both residents had intact cognition and required wheelchairs. The facility's policy mandates staff to identify and report hazards, but these chemicals were not removed or reported as expected.
A facility failed to store an OTC liquid indigestion medication in a locked area for a resident with multiple diagnoses, including cerebral infarction and hemiplegia. The medication was found unsecured on the resident's nightstand, with no physician's order or authorization for self-administration. The facility's policy requires all medications to be stored securely, and staff are expected to report and remove unsecured medications, which was not done in this case.
Failure to Report Resident Elopement to Law Enforcement and State Agency
Penalty
Summary
The facility failed to report an elopement within two hours to law enforcement and the State Agency for one resident who was missing from the building. The facility policy titled, Elopements and Wandering Residents, stated that if the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department and appropriate reporting requirements to the State Survey agency should be conducted. The resident had diagnoses including cerebral infarction, end stage renal disease, cognitive communication deficit, unspecified dementia, and psychotic mood disturbance, and the admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan identified him as at risk for wandering in search of his home; he was disoriented to place, had impaired safety awareness, and wandered aimlessly. On 10/1/2025 at about 8:20 PM, staff reported the resident missing and were instructed to search inside and outside the building. The Administrator stated staff believed the resident was unable to walk and focused on searching inside the facility. The resident was later found by the facility owner at about 10:15 PM, but the Administrator stated she attempted to call law enforcement, was on hold for 40 minutes, and hung up without making a police report. She also stated she did not notify the State Agency because the resident was not harmed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident with severe cognitive impairment and documented wandering risk. The resident had diagnoses including cerebral infarction, end stage renal disease, cognitive communication deficit, unspecified dementia, and psychotic mood disturbance. His admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. His care plan identified him as at risk for wandering while looking for his home, noted that he was disoriented to place and had impaired safety awareness, and directed staff to distract him with diversions, structured activities, food, conversation, television, and books. Before the incident, the resident had already demonstrated exit-seeking behavior. The hospital history and physical documented altered mental status and that he had required a sitter when he attempted to leave the hospital without medical advice and proper discharge. On the evening of the incident, staff observed him standing near the nurses’ station asking to leave and telling staff he was ready to go. Later that evening, a CNA reported the resident missing after being unable to locate him in his room. Staff searched the unit and other areas, announced a missing resident code, and notified administration. The resident was eventually found seated outside the facility on a sidewalk and was brought back inside in a wheelchair. The investigation showed that staff did not respond appropriately when the alarm sounded and did not follow the facility’s elopement procedures. An LPN and an RN both stated they silenced the alarm without determining whether a resident had exited, and both said they did not realize a resident may have triggered it. Staff interviews also showed that elopement drills and training had not been done before the incident. The Administrator stated staff believed the resident could not walk and focused their search inside the building, and she also stated she attempted to call law enforcement but ended the call without making a police report. The resident’s representative stated the family had not been asked about elopement tendencies before admission, and the Administrator later stated the facility was unaware of the resident’s exit-seeking behavior and had not reviewed his history and physical before admission.
Open Dumpsters and Debris Around Garbage Area
Penalty
Summary
The facility failed to keep the areas around the garbage dumpsters free from debris and failed to keep the lids of two of two garbage dumpsters closed when not in use. During an initial tour of the kitchen with the Dietary Manager, surveyors observed two dumpsters outside the facility with the lids left open. Surveyors also observed food particles, trash, and debris on the ground around the dumpsters, including milk cartons, food particles, and plastic cups, with flies present in the area. The Dietary Manager stated the trash on the ground was likely due to the dumpster being picked up, but closer inspection showed the dumpsters had not been picked up and were approximately two-thirds full. The Dietary Manager stated staff should have closed the lids after every use and that housekeeping was responsible for keeping the surrounding area clean.
Delayed room repairs and poor environmental maintenance
Penalty
Summary
The facility failed to make necessary repairs in a timely manner to maintain a safe, clean, comfortable, and homelike environment for multiple residents. The cited concerns involved nine of 64 sampled residents, including rooms with visible wall damage, stained or damaged ceiling tiles, mold, rusted and soiled bathroom tile, cracked or missing electrical receptacle covers, and an overbed table with exposed particle board. The facility policies reviewed stated that the environment should be safe, clean, comfortable, homelike, and maintained in a sanitary manner, with environmental concerns reported to the Administrator and corrected immediately. Resident 84, who had a BIMS score of 14/15, was observed in a room with scraped walls, visible dents, uneven drywall patches behind the headboard, large brown spots on the ceiling, and a concealed board behind the headboard that staff had placed to cover a hole in the wall. The resident stated the room had been that way when she first occupied it and that she was not sure how much longer it would take the facility to fix and repair the wall. Staff interviews confirmed the room had appeared unfinished for over a month, and facility leadership stated renovations had been ongoing for months to over a year. Additional observations showed Room N-132 with rusted and soiled bathroom tile, a stained ceiling tile, and walls with missing paint and holes; Room S-206 with a soiled alcohol swab on the floor, spilled brown liquid, and walls discolored black with missing paint and chunks of wall; and Room S-209 with a black substance and cracks on the wall, a cracked and partially missing electrical receptacle cover, a stained ceiling tile, and a stained toilet seat. In another observation, Resident 132's overbed table was missing trim on all four sides with exposed particle board, and staff and management verified the condition and stated there was no process for checking overbed tables. A grievance also documented that Resident 189 reported her room smelled like mold, and the Maintenance Director verified mold was present in the room.
Improper Use of Geri Chair as a Physical Restraint
Penalty
Summary
The facility failed to provide freedom from physical restraints for one resident who was observed using a Geri chair without a physician order and without the chair being included in the care plan. The facility policy titled, Restraint Free Environment, stated that physical restraints are prohibited for discipline or convenience and may only be used when a resident has medical symptoms that warrant restraint use; it also stated that falls do not constitute a medical symptom that warrants a physical restraint. Review of the resident’s record showed diagnoses including aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, history of falling, traumatic cerebral edema without loss of consciousness, focal traumatic brain injury without loss of consciousness, encephalopathy, and cerebrovascular disease. The annual MDS showed severe cognitive impairment with a BIMS score of 00, no behaviors, no falls since admission or reentry, and coding that restraints were not used. The resident’s care plan identified fall risk related to mobility and cognitive impairments and noted behaviors such as non-compliance with the call light, utilizing a wheelchair, sitting and crawling on the floor in the room, and being not easily redirected at times. The record also showed no order for a Geri chair and no care plan inclusion for its use, although the care plan did include a wheelchair. During observation, the resident was seated at the nurses’ station in a Geri chair with the feet elevated and the left side of the chair pushed against the wall. On another observation, the resident was reclined in the Geri chair with the left side against the wall and was trying to get out of the chair by pulling up on the arm rests, while the footrest was extended and prevented the resident from getting out of the chair.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to fully develop and implement a baseline care plan within 48 hours of admission for one resident, R178. Review of the facility policy titled Baseline Care Plan showed the baseline care plan was to be developed within 48 hours of admission and include minimum healthcare information necessary to properly care for a resident, including physician orders. R178 was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, anemia, dementia with unspecified severity with agitation, adjustment disorder with mixed anxiety and depressed mood, and personal history of suicidal behaviors. Admission physician orders included Quetiapine Fumarate 25 mg at bedtime for behaviors, but the baseline care plan was not completed until 9/9/2025 and did not include the use of psychotropic medications. The DON confirmed on 9/16/2025 that the baseline care plan was not completed within 48 hours of admission and verified that R178 was taking psychotropic medication at the time of admission and should have been included in the baseline care plan.
Care Plans Not Updated for Current Resident Needs
Penalty
Summary
The facility failed to update and revise comprehensive care plans for three sampled residents, despite the requirement that care plans be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals. Review of the facility policy titled Comprehensive Care Plans showed that each resident should have a comprehensive person-centered care plan with measurable objectives and timeframes based on the resident’s comprehensive assessment. Based on observations, staff interviews, and record review, the care plans for R47, R113, and R4 did not reflect current care needs documented elsewhere in the record. For R47, the annual MDS dated 7/3/2025 coded no restraints or alarms and indicated the resident did not use a wheelchair, yet the care plan did not include the use of a Geri chair and instead included a wheelchair. The MDS Coordinator stated R47 was usually in a high back wheelchair, that if a Geri chair was used it should be on the care plan, and that transfer abilities and fall risks were not on the care plan; she also stated the resident was sitting in a Geri chair instead and that the care plan should be updated as things change. For R113, the revised care plan dated 9/9/2025 did not document rehabilitation services, and the MDS Coordinator confirmed there was nothing in the care plan for PT/OT. For R4, the revised care plan dated 9/10/2025 did not document wound treatments, and both the MDS Coordinator and DON confirmed wound care management should have been captured on the care plan.
Inaccurate Nurse Staffing Data Reporting
Penalty
Summary
The facility failed to report accurate nurse staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of fiscal year 2024, resulting in a One-Star Staffing rating. The review of the Payroll Based Journal (PBJ) Staffing Data Report for this period revealed inaccuracies in the reported nursing staff coverage. During an interview, the Administrator was unaware of the One-Star rating and mentioned that since the new ownership took over last summer, efforts have been made to increase the number of registered nurses (RNs), certified nursing assistants (CNAs), and certified medication aides (CMAs). Despite these efforts and other investments in the facility, the deficiency in accurate staffing data reporting persisted.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, specifically in the removal of facial hair. The resident, identified as R50, was admitted with conditions including cerebral infarction, hemiplegia, and lack of coordination, requiring substantial assistance with personal hygiene. Despite the facility's policy to maintain residents' grooming and hygiene, R50 was observed with long facial hair on her chin, which had not been addressed by the staff. The resident expressed a desire for the facial hair to be removed, indicating that staff had not offered assistance in this regard. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed the oversight. The LPN acknowledged that facial hair should be removed during morning care and that it was customary to shave residents on Sundays. However, there was no documentation on R50's ADL task sheet regarding facial hair removal, and the staff did not follow through with the expected grooming care. The DON confirmed the expectation that staff should remove facial hair during ADL care, highlighting a lapse in the facility's adherence to its own policies and procedures.
Failure to Secure Hazardous Chemicals in Resident Rooms
Penalty
Summary
The facility failed to ensure hazardous chemicals were safely secured, placing residents at risk for avoidable chemical incidents. Observations revealed that a can of ant and roach killer spray was found in a box in front of the PTAC unit in the room of a resident with intact cognition and physical limitations, including the use of a wheelchair. Similarly, a can of disinfectant spray was observed on the dresser of another resident, who also had intact cognition and required a wheelchair. Both residents were part of a sample of 45 residents reviewed for accidents. Interviews with the Administrator and the DON confirmed the presence of these hazardous chemicals in the residents' rooms. The facility's policy on accidents and supervision requires all staff to observe and identify potential hazards, considering each resident's unique characteristics and abilities. Despite this policy, the chemicals were not removed, and the staff did not report these findings as expected. The DON stated that CNAs should report any chemicals found in resident rooms to a nurse, who should then remove the chemicals and notify the resident's representative.
Failure to Secure Medication in Resident's Room
Penalty
Summary
The facility failed to store a bottle of over-the-counter (OTC) liquid indigestion medication in a locked medication storage area for one of the residents, identified as R50. This deficiency was observed during a survey where the medication was found on R50's nightstand on multiple occasions. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, and there was no physician's order for the OTC medication nor any authorization for R50 to self-administer medications. R50 was admitted to the facility with several diagnoses, including cerebral infarction, hemiplegia, hemiparesis, ataxia, contracture of the left hand, and lack of coordination. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, but required substantial assistance for activities of daily living. Despite this, there was no care plan focus area related to self-administration of medications, and no nursing assessment had been completed to authorize self-administration. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the facility does not encourage self-administration of medications without proper assessment and physician approval. They acknowledged that R50 was not allowed to self-administer medications and that the care plan did not reflect any assessment for self-administration. The DON stated that staff are expected to observe and report any unsecured medications found in resident rooms, and that unsecured medications should be removed and the physician notified. However, this protocol was not followed in R50's case, leading to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tucker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tucker Park Crossing Of Journey Llc | 1.2 mi | ★★★★★ | 10 | 0 |
| Briarwood Health Center By Harborview | 2.6 mi | ★★★★★ | 1 | 0 |
| Stone Mountain Run Of Journey Llc | 2.9 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Lilburn | 5 mi | ★★★★★ | 0 | 0 |
| Harborview Decatur | 5.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.