Below average — CMS composite of the measures below.
The next survey window likely opens 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 Park Crossing Of Journey Llc during CMS and state inspections, most recent first.
Surveyors found that the facility lacked a Legionella water management program, with leadership and maintenance staff unaware of any such program despite a prior isolated Legionella test. A nurse administering medication via a G-tube to a resident on Enhanced Barrier Precautions wore gloves but not a gown, contrary to facility policy, and reported not knowing a gown was required. An LPN performing wound care for a resident with a Stage IV sacral pressure ulcer and multiple comorbidities failed to disinfect the treatment cart, bedside table, or bed surface before placing clean supplies, used the same gloves to cleanse the wound and handle clean dressings, and only washed a reusable wound cleanser bottle with soap and water. Additionally, a resident’s oxygen concentrator was repeatedly observed with a filter covered in thick gray debris, while staff interviews showed confusion about who was responsible for cleaning oxygen equipment and how often tubing and filters should be maintained.
The facility failed to maintain clean PTAC filters in multiple resident rooms across all sampled halls. Surveyors observed that PTAC units in several rooms had two filters each that were covered with a grey, fuzzy substance thick enough to make the filters opaque, and re-observations on a later day showed the buildup remained. A walk-through with the Maintenance Director confirmed that PTAC units on all halls required cleaning, indicating that the issue was building-wide and affected the environment for residents, staff, and visitors.
A resident with dementia and moderate cognitive impairment, who required supervision for eating and mobility, was asked by an LPN to leave the dining room and return to her room after she had finished her meal so that other residents who had not yet eaten could do so without it appearing they had not been fed. When the resident returned to the dining room a short time later, the LPN again redirected her out, citing that others were still eating. Facility policies stated that residents have the right to exercise their rights without interference and to have unrestricted access to common areas unless there is a safety risk, and leadership later acknowledged that asking the resident to leave a preferred common area was a dignity and rights issue.
Surveyors found that the facility failed to control environmental hazards and prevent elopement. A cognitively intact resident with a seizure disorder and multiple cardiac and psychotropic meds kept and self-administered unsecured OTC cold and flu medication in his room without a physician order. Two other residents, one severely cognitively impaired with vascular dementia and visual loss and another with hemiplegia and contractures, had unsecured shaving razors accessible on top of bedside furniture, contrary to the DON’s expectation that razors be stored in enclosed bags out of reach. In addition, a resident with dementia, depression, and documented wandering and exit-seeking behaviors, care planned as at moderate to high elopement risk and ordered to have a wanderguard on a secure unit, was able to leave the building during a power disruption related to sprinkler system work; staff later observed her crossing multiple lanes of traffic after an exit door had been found open.
Surveyors identified multiple medication administration errors and policy noncompliance, including an LPN giving a multivitamin without minerals instead of an ordered vitamin-mineral tablet, failure to apply a prescribed Lidoderm patch when it was unavailable and inaccurate MAR documentation indicating it was given, administration of Metoprolol despite the resident’s SBP being below the ordered hold parameter, and an RN administering long-acting insulin outside the ordered morning time without priming the insulin pen or holding it in place after injection. Staff interviews revealed lack of adherence to MAR verification requirements and unfamiliarity with proper insulin pen technique.
Surveyors found that medications were not properly stored or managed, including expired floor-stock Dextrose injections discovered in a medication room and multiple insulin pens on a medication cart that were either expired, missing required open/expiration dates, or labeled with an incorrect 7-day expiration instead of the manufacturer-recommended 28 days. An RN acknowledged unawareness of expired Dextrose stored in a box under the counter, and an LPN confirmed that multiple nurses use the carts and that the insulin pens had not been labeled according to expectations. The DON reported that nurses are required to verify the MAR before administration, unit managers must routinely check carts and medication rooms, and all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, noting that expired medications may be harmful and have unknown side effects.
A resident with schizophrenia, bipolar disorder, and moderate cognitive impairment did not receive a PASARR II assessment or referral despite having diagnoses that qualified for review. The EMR contained a PASARR I, but no PASARR II or application for one. During observation, the resident was sitting on the bed in street clothes, listening to music, and her thoughts were very disorganized and at times delusional. Staff interviews showed the Social Services Director did not complete a PASARR II application unless the PASARR I triggered it, the DON deferred the process to admissions, and the Administrator said he knew nothing about the PASARR process.
A resident with dementia, anxiety, depression, and wandering behaviors did not have a timely comprehensive care plan for elopement risk. The record showed exit-seeking, difficulty with redirection, and later documentation of moderate to high elopement risk, packing belongings to go home, and staying near exit doors. Staff interviews indicated the elopement-related care plan and wanderguard intervention were developed after the resident eloped, and the DON was unsure why the care plan had been revised earlier to include a wanderguard.
A resident with CHF, kidney disease, diabetes, and other diagnoses had repeated loose and diarrheal stools documented by CNAs on day and night shifts, but the change in condition was not consistently reported to the provider. Interviews showed some staff were unaware of the diarrhea, while others acknowledged seeing it or hearing about it, and no labs were drawn after the resident's symptoms began. The deficiency involved failure to assess and report the resident's ongoing diarrhea and related condition changes, and the resident was later hospitalized.
A resident with moderate cognitive impairment and their POA were not invited to participate in care plan meetings, nor provided with copies or summaries of the care plan, despite facility policy requiring their involvement. The POA made multiple unreturned requests to participate, and staff interviews confirmed that only the resident was routinely invited unless family involvement was specifically requested.
A resident with moderate cognitive impairment and multiple diagnoses was transferred to the hospital after vomiting coffee ground-like emesis. Although staff attempted to contact the POA/family, no follow-up was made when there was no answer, resulting in the POA being unaware of the hospital transfer and ongoing hospitalization.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A facility failed to maintain a resident's privacy by displaying a sign above their bed that disclosed personal information, indicating the resident was visually impaired. The resident, who had little cognitive impairment, was unaware of the sign. Staff interviews revealed a lack of awareness and adherence to privacy protocols, with a CNA relying on nurses for care instructions and an LPN stating she would have removed the sign if noticed. The Administrator was unaware of the sign and did not expect private information to be posted.
A facility failed to follow its bed-hold policy for a resident transferred to the hospital. Despite the policy requiring information to be provided during transfers, the resident did not receive the necessary paperwork on multiple occasions. Interviews revealed that staff were unaware of the proper procedures, and the RN responsible for the transfer had not been trained on the bed-hold process. The resident, with multiple health conditions, was transferred due to edema, but the facility's process breakdown led to the oversight.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. One resident lacked a care plan for opioid management despite having multiple pain medication orders. Another resident, dependent on dialysis, did not have a care plan for her treatment. A third resident's care plan did not address his refusal to wear a splint, despite severe cognitive impairment. Staff interviews revealed a lack of coordination and oversight in updating care plans.
A resident with leg fractures was not administered medications according to physician's orders. The resident, aware of her pain levels, often requested specific pain medications, leading to frequent administration of hydrocodone-acetaminophen for pain levels outside the prescribed range. Interviews with staff confirmed that the MAR did not align with physician orders, indicating a failure in medication administration practices.
A resident with hemiplegia was not provided with a required right-hand grip splint for up to 4.5 hours as per their care plan. Observations showed the splint was not worn, and staff interviews revealed lapses in documentation and application. The facility's processes failed to ensure compliance with care plans and documentation requirements.
A resident with chronic respiratory conditions was not administered oxygen as ordered, with observations showing higher flow rates than prescribed. Interviews confirmed the discrepancy, highlighting a failure in following physician orders for oxygen administration.
The facility was found to have a staffing deficiency, with a one-star staffing rating and low weekend staffing for Q1 FY 2024. The DON revealed that the facility was operating with 60-70 percent of the required nursing staff and was extremely understaffed during this period. The Administrator was aware and discussed the issues during QAPI meetings.
The facility failed to provide a safe, clean, and comfortable homelike environment for 27 rooms on five halls, with issues such as dirty bathroom ceiling vent grills, oversized bathroom doors, damaged and missing drawer handles, dirty PTAC units, damaged wall handrails, brown ceiling tiles, and damaged walls. The Maintenance Director confirmed the unacceptable conditions and the absence of a specific Maintenance policy.
The facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. Two residents received crushed medications without physician orders, contrary to facility policy and best practices. Interviews confirmed the lack of necessary orders and highlighted the need for proper evaluation and adherence to medication administration guidelines.
The facility failed to follow standard infection control practices during catheter care for a resident with an indwelling catheter and a stage 4 pressure wound, and during meal tray distribution. CNAs did not perform hand hygiene between glove changes and between distributing meal trays, respectively.
The facility failed to conduct a Level II PASARR for a resident admitted with schizoaffective disorder. The Social Service Director confirmed that the diagnosis was not selected on the application, and the PASARR Level II evaluation was not completed, despite the facility's policy requiring it.
The facility failed to implement the care plan for a resident with multiple sclerosis, depression, and insomnia, who was at risk for falls. Despite the resident's repeated requests for side rails and the care plan's documented need for assist bars, the necessary evaluation and installation were not completed, leading to unmet needs.
The facility failed to provide adequate ADL care for three residents, specifically in nail care and scheduled showers. Two residents with severe cognitive impairment were found with extremely long fingernails, and another resident did not receive her scheduled bed baths for two weeks. The Director of Nursing confirmed these oversights.
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident with a contracture of her right hand. Despite the resident's medical history and care plan indicating the need for restorative therapy, staff interviews and observations revealed that the resident was not receiving the necessary care, and no splint or brace was in use.
The facility failed to provide adequate fall prevention interventions for a resident with multiple sclerosis and a history of falls, despite repeated requests for side rails. Additionally, an unsecured oxygen cylinder was found in another resident's room, violating safety protocols.
A resident with multiple diagnoses, including end stage renal disease and aphasia, did not have their G-tube placement properly checked before feeding. The RN failed to check the residual volume as required by the care plan and facility protocol, which was confirmed by the DON.
A resident with chronic obstructive pulmonary disease and acute respiratory failure was observed receiving oxygen without a physician order. The DON acknowledged the oversight, noting that the resident had been using oxygen since re-admission, but the order was not reactivated as required.
The facility failed to ensure full visual privacy for residents in three shared bedrooms due to missing or damaged privacy curtains. Observations revealed gaps and missing curtains, and staff interviews confirmed the lack of a maintenance work order system and the need for immediate repairs.
Infection Control Failures in Water Management, EBP, Wound Care, and Respiratory Equipment
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including the absence of a Legionella water management program. Review of the Infection Prevention and Control Program policy revealed no language addressing Legionella testing or prevention. When surveyors requested the water management program, the Maintenance Director produced an empty clipboard and stated he had never heard of a water management program. The DON and the Administrator both reported they were unaware that there was no water infection prevention program in place, although the Administrator produced a single Legionella test report from the prior year. Surveyors also identified failures to follow Enhanced Barrier Precautions (EBP) and aseptic wound care technique. A nurse administering alprazolam via a G-tube to a resident on EBP wore gloves but did not don a gown for this high-contact care involving an indwelling medical device, despite facility policy requiring gown and gloves for such activities. The nurse later acknowledged she should have worn a gown and stated she was not aware that PPE, including a gown, was required when administering medications via the G-tube, even though EBP signage was posted on the resident’s door. In a separate observation, the LPN responsible for wound, skin, and ostomy care performed dressing care for a resident with a Stage IV sacral pressure wound without disinfecting the treatment cart, bedside table, or bed surface before placing clean supplies. The LPN used the same pair of gloves to cleanse the wound and then handle clean supplies and apply CollaSorb powder and calcium alginate dressing, and washed a reusable wound cleanser bottle with soap and water while gloved before returning it to the cart. The resident with the Stage IV sacral wound had significant comorbidities, including type 1 diabetes mellitus with neuropathy and circulatory complications, chronic kidney disease stage 3A, cerebrovascular disease, and polyneuropathy. The care plan for this resident included goals and interventions focused on wound healing, infection prevention, and monitoring for signs of infection, with physician orders specifying cleansing with wound cleanser or normal saline, application of collagen and calcium alginate, skin prep to the periwound, and dressing changes three times weekly and as needed. During interview, the LPN reported no observed breaches in infection control, believed her actions were appropriate, and stated that hand hygiene was only required twice during the procedure, and that washing the wound cleanser bottle with soap and water was sufficient, which contrasted with the DON’s stated expectations for disinfecting equipment and performing hand hygiene. Additional observations showed an oxygen concentrator in use by another resident with a filter covered in fuzzy, thick, dry gray particles on multiple days, while staff interviews revealed uncertainty among CNAs, nurses, the unit manager, and the DON about who was responsible for cleaning oxygen machine filters, how often tubing was changed, and how often filters should be cleaned, despite the DON stating that the RT was supposed to follow up on all residents on oxygen.
Failure to Maintain Clean PTAC Filters Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not cleaning the Packaged Terminal Air Conditioner (PTAC) filters in multiple resident rooms across all sampled halls. On 01/27/2026, surveyors observed that PTAC units in rooms D16, D12, D15, E52, and E41 had two filters each, and the filters were covered with a grey, fuzzy substance approximately 1/8 inch thick in some cases, making the filters opaque. A re-observation of room D15 later that afternoon showed the filters still had the same grey, fuzzy buildup. On 01/28/2026, follow-up observations revealed that the PTAC filters in rooms D16, D12, D15, and E41 continued to have the grey, fuzzy substance that rendered the filters opaque. During a walk-through with the Maintenance Director on the same day, it was identified that all PTAC units in the building, including those on B, C, E, A, and D halls, required cleaning. This deficient practice was cited as a failure to provide a safe, easy-to-use, clean, and comfortable environment for residents, staff, and the public, with the report stating that it had the potential to cause respiratory irritation and exacerbation of conditions in residents with chronic obstructive pulmonary disease and other related lung diseases.
Resident Rights and Dignity Not Honored in Dining Room Access
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices and have unrestricted access to common areas, as outlined in its own Resident Rights policies. The facility’s policies, revised in November 2025, state that residents have the right to be treated with respect and dignity, to exercise their rights without interference, and to have unrestricted access to common areas open to the public unless there is a safety risk. The resident involved, identified as R38, had diagnoses including unspecified dementia with moderate cognitive impairment (BIMS score of 8), anxiety, and repeated falls, and required supervision/touching assistance for eating and mobility. Her care plan identified a behavior problem related to going in and out of other residents’ rooms and removing items, with interventions focused on providing appropriate activities, anticipating needs, and monitoring behaviors and potential causes. On the observed date and time, during lunch in the E Hall dining room, an LPN entered the dining room and announced that residents who had already eaten should go to their rooms so that residents who had not yet eaten could do so and it would not appear that those without trays had not been fed. The LPN specifically told R38, who had already eaten, to leave the dining room so that other residents who had not been fed could eat, and R38 wheeled herself out of the dining room. When R38 returned a few minutes later, the LPN again redirected her out of the dining room, stating that the other residents had not yet finished eating. In an interview, the LPN acknowledged asking residents to leave so it did not look like a dignity issue to families and stated she did not feel it infringed on R38’s rights because the resident “didn’t know” due to dementia and memory issues. The DON later stated it was not acceptable to ask residents to leave a preferred space if that was where they wanted to be and that it was a dignity issue and a rights issue for the resident to be asked to go to her room.
Unsecured OTC Medications, Razors, and Failed Elopement Prevention
Penalty
Summary
The deficiency involves the facility’s failure to keep resident rooms free of accessible accident hazards, specifically unsecured over-the-counter (OTC) medications and shaving razors, and failure to adequately secure and monitor exit doors to prevent an elopement. Facility policy F 689 Accidents requires the environment to be as free from accident hazards as possible and calls for ongoing identification of safety risks, QAA/Safety Committee evaluation of hazards, and implementation and monitoring of interventions. The facility’s wandering/unsafe resident policy requires assessment of at-risk individuals, care plan identification of elopement risk, and inclusion of safety interventions. Despite these policies, surveyors observed multiple instances where hazardous items were accessible in resident rooms and where an at-risk resident was able to leave the building unsupervised. One cognitively intact resident with a seizure disorder, schizophrenia, depression, hypertension, and multiple prescribed medications, including anticoagulant and antiepileptic drugs, was found with two bottles of brand-name cold and flu OTC medication on a shelf at the foot of the bed. One bottle was nearly empty and the other half full, indicating prior use. The medications were unsecured and accessible. The resident reported he had purchased the cough medication himself because he felt the amount provided by the facility was not enough and that he took more of the medication because it worked for his cough. A nursing progress note documented that the resident had the cold medication in his room without a physician’s order and had been taking it at his discretion. The DON later stated that OTC medications should not be accessible to residents, except for an inhaler after assessment, due to concerns that residents, wandering residents, or visiting children might take them or that residents might not know how much to take. Two other residents were found with unsecured shaving razors accessible in their rooms. One resident with severe cognitive impairment, vascular dementia, visual loss in both eyes, difficulty walking, muscle weakness, and dependence on staff for wheelchair mobility had several shaving razors in a clear plastic bag on top of the bedside nightstand. The resident stated the razors belonged to him and that he used them, which is why they were present in the room. Another cognitively intact resident with hemiplegia/hemiparesis, contractures, difficulty walking, and need for assistance with personal care had a shaving razor in a cup on top of a dresser adjacent to the bed. This resident reported shaving independently and also shaving his head. The Unit Manager RN confirmed the presence of razors in both rooms and acknowledged they were a safety concern. The DON stated that residents are assessed on admission for ability to use razors and may keep them only if they are in an enclosed bag, out of reach, inside the nightstand, and care planned for their use, conditions that were not met in these observations. The facility also failed to prevent an elopement for a resident with dementia, depression, restless legs syndrome, and recent wandering and exit-seeking behaviors. A behavioral health evaluation documented wandering behaviors and difficulty redirecting the resident, and a care plan conference noted that the resident had been having exit-seeking behaviors requiring frequent redirection. The resident’s care plan identified a behavior problem related to walking the halls with belongings and refusing to return them to her room, and a subsequent care plan problem documented that she was at moderate to high risk for elopement, currently wandered, packed belongings to go home, and stayed near exit doors. Interventions included lodging on a secure unit and use of a wanderguard on the right wrist, with orders to check placement each shift and document its location. Despite being on a locked unit with exits that were supposed to be locked, staff interviews revealed that during an electrical outage associated with sprinkler system servicing, the resident was able to leave the building. An LPN reported that the resident went out the front exit during the outage. A CNA described walking by an exit door, feeling a breeze, and noticing the door was open. He checked a gate outside that door but could not open it and suspected the resident had used an alternate door near the activities area with a ramp. He then went to notify the RN and ran to the street, where he saw the resident crossing five lanes of traffic and continuing to walk several houses down from a visible house near the facility. The CNA stayed with the resident until assistance arrived. He stated that the resident exit sought daily, constantly went to the doors shaking them, and always had her bags packed and at the door. The DON and Administrator confirmed that sprinkler system testing had affected the power and that doors had been open while staff were conducting fire watch, during which time the resident was able to elope.
Medication Administration Errors and Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication administration in accordance with physician orders and facility policy, resulting in a 16% medication error rate during the survey’s 25 observed opportunities. One resident had an order for a Multiple Vitamins-Minerals tablet once daily for supplementation, but the LPN administered a One-Daily Multivitamin without minerals, which did not match the ordered medication. Facility policies required verification of the right medication, dose, time, and route against the MAR and checking labels multiple times, but these steps were not followed in this instance. Another resident had an order for a Lidoderm (Lidocaine) 5% patch to be applied to the lower back every 12 hours and removed per schedule, but the nurse did not administer the patch because it was not available on the cart, in the medication room, or in the automated medication system. The physician was not notified of the missed dose, and the MAR reflected that the patch had been administered on multiple occasions despite the lack of available patches. The unit manager was initially unaware of the unavailability, and the resident later reported not receiving the patch the previous day or on the day of interview, instead requesting Tylenol for pain. A third resident had an order for Metoprolol Tartrate 25 mg by mouth once daily for HTN, with instructions to hold the dose if HR was 50 or lower or if SBP was below 120. At the time of administration, the resident’s BP was 109/54 mmHg and HR was 56, yet the LPN administered the medication outside the ordered BP parameter, stating she only considered the HR and not the BP. A fourth resident had an order for Insulin Glargine (Lantus) 26 units subcutaneously every morning and at bedtime for diabetes, but the RN administered the morning dose at 1:11 PM instead of in the morning, did not prime the insulin pen, and did not hold the pen in place after injection as required by manufacturer guidance and facility expectations. The RN reported being unfamiliar with the procedures for priming and holding the insulin pen and had not received training on the facility’s insulin pen administration policy.
Expired and Improperly Labeled Medications and Insulin Pens
Penalty
Summary
Surveyors identified a failure to properly store and manage medications, including expired and undated drugs, in a medication room and on a medication cart. Review of the facility’s policy "Storage of Medications F761" stated that discontinued, outdated, or deteriorated drugs or biologicals must not be used and must be returned to the pharmacy or destroyed. During an observation of the A/B/E-Hall medication room on the second floor with a unit manager RN, five floor-stock 50% Dextrose injection 25 g/50 mL units were found in a box under the counter with an expiration date of 07/2025. The RN confirmed the medications were expired and stated she was not aware they were in that box. During a separate observation of the B-Hall medication cart with an LPN, surveyors found multiple issues with insulin pens. One insulin Aspart pen had an open date of 1/1/2026 and an expiration date of 1/31/2026, indicating it had been in use for more than 28 days and was expired as of 1/28/2026. One Lantus Solostar insulin pen was open and in current use with no documented open date or expiration date. One insulin Lispro (Humalog) KwikPen was labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration instead of the manufacturer-recommended 28 days after opening. The LPN confirmed the labeling issues, stated that multiple nurses use the carts and that she did not open or label those pens, and acknowledged that insulin removed from refrigeration should be dated and assigned a 28-day expiration. The DON later stated that nurses are required to verify the MAR three times before administration, unit managers are responsible for weekly cart checks and daily medication room checks, and that all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, and that use of expired medications may be harmful with unknown potential side effects.
Failure to Complete PASARR II Evaluation
Penalty
Summary
The facility failed to assess and refer a resident whose diagnoses qualified for PASARR II evaluation. R68 was admitted with diagnoses including schizophrenia, bipolar disorder, hypertension, hypothyroidism, and muscle weakness. The resident’s quarterly MDS dated 12/24/2025 showed a BIMS score of 11, indicating moderate cognitive impairment, and functional status findings showed the resident needed setup or cleanup assistance for meals and oral hygiene and supervision with toileting hygiene, dressing, bathing, and footwear. The care plan addressed altered nutritional/hydration status related to schizophrenia and confusion, and psychotropic medication management related to schizophrenia, including Risperdal IM 25 mg PRN for behaviors. Review of the EMR showed a PASARR I from a residential nursing facility, but there was no PASARR II or application for a PASARR II. During observation, R68 was sitting on the bed in street clothes, listening to music, and her thoughts were described as very disorganized and in some cases delusional. The Social Services Director stated that if the PASARR I did not trigger a PASARR II, she did not complete an application for one, and said R68 had dementia, though she could not find dementia as a primary diagnosis in the EMR. The DON stated she knew nothing about the PASARR process and left it to the admissions team, while the Admissions Coordinator said they tried to get the hospital to complete a PASARR I on all admissions but sometimes residents came from home or there was not enough time. The Administrator stated he knew nothing about the PASARR process at the facility.
Failure to Develop Timely Wandering and Elopement Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan regarding wandering and elopement risk for one resident who had been assessed for wandering upon admission. Review of the resident’s EMR showed diagnoses including unspecified dementia, restless legs syndrome, depression, and anxiety. The record also showed a care plan conference documenting that the resident had been having exit-seeking behaviors and that staff had been redirecting her frequently, along with a behavioral health evaluation noting wandering behaviors and that the resident had been difficult to redirect. The resident’s care plan dated 12/4/2025 addressed a behavior problem related to walking the halls with her belongings and refusing to take them to her room, with goals and interventions focused on behavior management. A later care plan dated 12/30/2025 identified the resident as at moderate to high risk for elopement and as currently wandering, packing belongings to go home, and staying near exit doors, with interventions including a secure unit and a wanderguard. Physician orders also dated 12/30/2025 directed placement of a wanderguard on the resident’s right wrist and checking its placement each shift. During interviews, the MDS Assistant and DON stated the elopement care plan and wanderguard intervention were developed after the resident eloped, and the DON stated she was unsure why the care plan had been revised earlier to include a wanderguard.
Failure to Report Resident's Diarrhea and Change in Condition
Penalty
Summary
The facility failed to assess and report changes in condition to the provider for one resident, identified in the report as R138, and the deficient practice led to the resident being hospitalized. The facility policy titled, Change in a Resident's Condition or Status, required the Nurse Supervisor/Charge Nurse to notify the attending physician or on-call physician, and the resident's representative, when there was a significant change in physical, mental, or psychosocial status, including deterioration in health or clinical complications. R138 was admitted with multiple diagnoses including systolic CHF, kidney failure stage III, type 2 diabetes, syncope and collapse, morbid obesity, venous insufficiency, thyrotoxicosis, and myocardial infarction. The admission MDS showed a BIMS score of 14, indicating cognitive intactness. The care plan included monitoring for CHF symptoms and documenting/reporting signs such as edema, shortness of breath, weakness, weight gain, crackles, wheezes, orthopnea, tachycardia, lethargy, and disorientation. Physician orders also included monitoring and documenting bowel movements every shift. Record review showed CNA documentation of large, medium, loose, and diarrhea incontinent stools on both day and night shifts beginning on November 15, 2025 and continuing until the resident left the facility. Interviews showed the Infection Preventionist was not aware of the diarrhea, one CNA recalled multiple episodes of diarrhea and said she would have reported it, and the Unit Manager acknowledged awareness of a few loose stools and stated that if the resident had diarrhea the nurse would have contacted the NP and drawn labs, but no such labs were drawn after 11/11/2025 and no one-time Imodium order was present. The DON stated that diarrhea or refusing medications should have been reported to the physician on call, and the Medical Director stated he expected nursing staff to keep him informed of changes in condition. A family member also reported that facility staff, including the Social Service Director and an RN, were aware of the diarrhea.
Failure to Involve Resident and POA in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and the resident's Power of Attorney (POA) were invited to participate in the development and implementation of the resident's person-centered care plan. Review of facility policies indicated that both the resident and their representative should be provided with a summary of the baseline care plan within 48 hours and be involved in the comprehensive care planning process. However, documentation in the electronic medical record did not show that the resident or POA were invited to or attended care plan meetings, nor was there evidence that they received copies of the care plan or signed acknowledgments. Interviews revealed that the POA had expressed concerns about the resident's care and had made multiple attempts to contact the facility to participate in care planning, but these calls were not returned. The Clinical Reimbursement Coordinator stated that only the resident was invited to care plan meetings unless the resident specifically requested family involvement, despite the resident having moderate cognitive impairment as indicated by a BIMS score of 11. The administrator later confirmed that both the resident and their representative should have been invited, but this was not done in this case.
Failure to Notify POA/Family of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) or family of a change in condition for one resident. The resident, who had diagnoses including asthma and end-stage renal disease and was assessed as having moderate cognitive impairment, experienced an episode of vomiting coffee ground-like emesis. The in-house nurse practitioner was notified and recommended hospital transfer, after which Emergency Medical Services (EMS) transported the resident to the hospital. Although an attempt was made to contact the family, there was no answer, and no follow-up call was documented or made by subsequent shifts. The POA later reported being unaware of the resident's hospital transfer and continued hospitalization.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Privacy Breach Due to Improper Display of Resident Information
Penalty
Summary
The facility failed to maintain the privacy of a resident by displaying a sign on the bedroom wall that disclosed protected personal information. The sign, which stated 'visually impaired,' was observed above the bed of a resident who had highly impaired vision but little to no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 15. The resident was unaware of the sign's presence when asked about it. Interviews with staff revealed a lack of awareness and adherence to privacy protocols. A Certified Nursing Assistant (CNA) mentioned that nurses typically informed them of residents' diagnoses and care instructions, and that they could access the resident's Plan of Care (POC) on the computer if needed. A Licensed Practical Nurse (LPN) stated that she had received training on dignity and privacy and would have removed the sign if she had seen it, explaining the reason to the resident if they were alert. The facility's Administrator was unaware of the sign and stated that it was not their expectation for private information to be posted on residents' walls.
Failure to Follow Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to ensure a bed-hold policy was followed for a resident who was transferred to the hospital. The facility's policy, revised in May 2023, requires that information about the bed-hold policy be provided upon admission and during transfers for non-emergency hospitalizations or therapeutic leave. However, during an emergency transfer on 10/27/2024, the resident did not receive the necessary bed-hold paperwork. Interviews revealed that the Licensed Practical Nurse (LPN) and the Business Office Manager (BOM) were not aware of the proper procedures, and the Registered Nurse (RN) responsible for the transfer was not trained on the bed-hold process. The resident involved had multiple diagnoses, including chronic kidney disease, heart failure, and diabetes, and was transferred to the hospital due to edema. Despite having a cognitive status indicating little to no impairment, the resident did not receive the bed-hold paperwork during transfers on three separate occasions. The BOM confirmed that the bed-hold policy was not issued due to a break in the facility's process, and the Director of Nursing (DON) acknowledged the responsibility of the nursing staff to communicate necessary information to the BOM. The RN involved admitted to not knowing about the bed-hold requirement and had not received training on the procedure.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. For one resident, identified as R23, the facility did not create a care plan specific to the management of opioid medications despite the resident having multiple physician orders for pain management, including tramadol, hydrocodone-acetaminophen, and a fentanyl patch. Interviews with staff revealed that care plans were supposed to be updated quarterly and involve the interdisciplinary team, but there was a lack of coordination and communication, resulting in the omission of a critical aspect of the resident's care plan. Another resident, R64, who was dependent on renal dialysis, did not have a care plan addressing her dialysis treatment. Despite having a port in her chest and attending dialysis sessions three times a week, this essential aspect of her care was overlooked. Interviews with the MDS coordinators and the Director of Nursing confirmed that the responsibility for updating care plans was shared among the MDS team and nursing staff, but an oversight led to the absence of a dialysis care plan for this resident. The third deficiency involved resident R19, who had severe cognitive impairment and required restorative care, including the use of a splint. The care plan did not address the resident's refusal to wear the splint, which was documented in the occupational therapy discharge summary. Staff interviews indicated that the MDS team and nursing staff were responsible for updating care plans, but there was a failure to document and address the resident's refusal, leading to an incomplete care plan for this resident.
Failure to Administer Medications According to Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident with a history of leg fractures. The resident, who has little to no cognitive impairment, was prescribed tramadol for severe pain, hydrocodone-acetaminophen for moderate pain, and a fentanyl patch. However, the Medication Administration Record (MAR) showed that hydrocodone-acetaminophen was frequently administered for pain levels that were higher than the prescribed range for this medication, indicating a deviation from the physician's orders. Interviews with the resident and staff revealed that the resident often requested specific pain medications based on her self-reported pain levels, which were not always aligned with the prescribed pain scale. The Licensed Practical Nurse (LPN) acknowledged that the resident was aware of her pain levels and medication preferences, and the Director of Nursing (DON) confirmed that staff should follow physician orders and contact the physician for any necessary adjustments. Despite this, the MAR did not align with the physician's orders, indicating a failure in medication administration practices.
Failure to Provide Required Splint for Resident
Penalty
Summary
The facility failed to provide a right-hand grip splint for a resident, identified as R19, for up to 4.5 hours as required. R19 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. The resident's care plan included wearing a grip splint on the right hand to maintain function, as recommended by occupational therapy. However, observations revealed that R19 was not wearing the splint during multiple checks, and it was found in the resident's drawer instead. Interviews with staff indicated a lack of documentation and follow-through on the resident's care plan. The MDS coordinators acknowledged that the order for the splint might have been overlooked, leading to a lapse in documentation and application. The LPN and CNA involved confirmed that the splint was not consistently applied, and there was no documentation to support its use in the current year. The facility's policy required that splints be applied and documented, but this was not adhered to in R19's case. The Director of Nursing expressed expectations that the restorative team and nursing staff should ensure residents receive care as ordered, including the application of splints. However, the lack of communication and coordination between therapy, nursing, and restorative teams resulted in the resident not receiving the necessary rehabilitative care. This deficiency highlights a failure in the facility's processes to ensure compliance with care plans and documentation requirements.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident, identified as R9, who was reviewed for respiratory care. R9's medical records indicated diagnoses including chronic systolic congestive heart failure, pleural effusion, chronic obstructive pulmonary disease, and acute and chronic respiratory failure. The resident's physician orders dated October 1, 2024, specified oxygen administration at 2 liters per minute (LPM) via nasal cannula. However, observations on October 27 and 28, 2024, revealed that the oxygen flow rate was set at 3 LPM and 3.5 LPM, respectively, which was not in accordance with the physician's orders. Interviews conducted with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the discrepancy in oxygen administration. The LPN acknowledged that the oxygen was set at 3.5 LPM, contrary to the prescribed 2 LPM. The DON expressed that staff are expected to follow physician orders and noted that setting oxygen at a higher level could have adverse effects depending on the resident's medical condition. This failure to adhere to the prescribed oxygen administration protocol constitutes a deficiency in the facility's respiratory care practices.
Staffing Deficiency and Low Weekend Staffing
Penalty
Summary
The facility was found to have a deficiency in staffing levels, as evidenced by a one-star staffing rating and low weekend staffing for the first quarter of Fiscal Year 2024. The facility census was 115 residents. The Director of Nursing (DON) revealed that during the period from October 1, 2023, to December 31, 2023, the facility was not utilizing agency staff, had only one unit manager, and was operating with 60-70 percent of the required nursing staff. This resulted in the facility being extremely understaffed during this period. The Administrator was aware of the staffing issues and discussed them during Quality Assurance and Performance Improvement (QAPI) meetings.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for 27 rooms on five halls. Observations revealed multiple deficiencies including dirty bathroom ceiling vent grills, oversized bathroom doors that could not be closed, damaged and missing drawer handles and doors on bedside nightstands and clothing chests, dirty and damaged PTAC units, damaged wall handrails, brown ceiling tiles, damaged bathtubs, and damaged, unpainted walls. Specific rooms such as D-5, D-7, D-8, C-22, B-24, B-30, A-19, A-20, E-51, E-52, E-50, E-45, D-1, and several others were noted to have these issues during initial and follow-up observations by surveyors on different dates. In Room B-24, paint was missing around the toilet paper holder, and in Room B-30, there were three holes in the sheetrock behind the bed. Room A-19 had unlabeled and unbagged bath basins and a urinal, spider webs with leaves on the window, dark scuff marks on the wall, a baseboard coming off the wall, and a dirty personal refrigerator. Similar issues were found in Rooms A-20, E-51, E-52, E-50, E-45, D-1, and other rooms, including missing paint, holes in walls, dirty and unlabeled basins, and spider webs with leaves on windows. The Maintenance Director confirmed the unacceptable conditions and stated that he managed and tracked all facility maintenance work orders through the TELS computer system. However, he was not aware of any specific Maintenance policy in place. The Administrator confirmed the absence of an Environmental Maintenance policy. An LPN revealed that maintenance work orders were reported through a computer maintenance system, which was considered more manageable than the previous system of writing work orders in a service requests binder at the nursing stations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 6.9%. Specifically, the facility did not obtain physician orders to crush medications prior to administration for two residents. For Resident 37, who had severe cognitive impairment and multiple diagnoses including acute kidney failure and dysphagia, nine medications were crushed and administered without a physician's order. Similarly, for Resident 90, who had moderate cognitive impairment and multiple diagnoses including type 2 diabetes mellitus and Alzheimer's disease, six medications were crushed and administered without a physician's order. During interviews, it was confirmed by an LPN and the Director of Nursing (DON) that there were no orders to crush the medications for these residents. The DON also confirmed that residents must be evaluated by speech therapy if they have difficulty swallowing medications and that certain medications, such as enteric-coated medications and methadone, should not be crushed without a physician's order. The facility's policy on administering medications requires that medications be administered in accordance with physician orders, including any required time frames.
Infection Control Deficiencies in Catheter Care and Meal Tray Distribution
Penalty
Summary
The facility failed to follow standard infection control practices during catheter care for one resident and during meal tray distribution. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing catheter care to a resident with an indwelling catheter and a stage 4 pressure wound. The CNA acknowledged the lapse in hand hygiene during an interview. Additionally, another CNA was observed distributing meal trays to residents without sanitizing hands between each tray. This CNA was unaware that hand hygiene was required between each resident tray served. The resident involved in the catheter care deficiency had a medical history that included type 2 diabetes, transient cerebral ischemic attack, vascular dementia, and hemiplegia affecting the left nondominant side. The resident's care plan indicated the presence of an indwelling catheter related to a stage 4 pressure wound on the sacrum. The Director of Nursing confirmed that hand hygiene should be conducted before resident contact, when transitioning from clean to unclean tasks, and before and after applying gloves.
Failure to Conduct Level II PASARR for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure a Level II PASARR was conducted for a resident (R40) who was admitted with a diagnosis of schizoaffective disorder. The facility's policy requires that the recommendations of the PASARR Level II and the PASARR evaluation report be incorporated into the resident's assessment, care planning, and transition of care. However, a review of R40's Annual Minimum Data Set (MDS) revealed that the PASARR Level II evaluation was not completed, and the diagnosis of schizoaffective disorder was not selected on the application. The Social Service Director (SSD) confirmed that the Level I PASARR was to be completed by the hospital prior to admission and that Level I and Level II PASARRs for all residents are completed on admission. Despite this, the SSD admitted that she had not personally completed a PASARR for R40 and that the business office manager was responsible for the referral and documentation in the electronic medical record. During an interview, the SSD stated that if residents had documented mental health issues, she would inform the MDS nurse to include the diagnosis. However, in this case, the diagnosis of schizoaffective disorder and depression was not selected on the application, leading to the failure to conduct a Level II PASARR for R40. This oversight indicates a lapse in the facility's adherence to its own PASARR policy and the federal and state regulations mandating the incorporation of PASARR recommendations into resident assessments and care planning.
Failure to Implement Care Plan for Resident at Risk for Falls
Penalty
Summary
The facility failed to implement the care plan for a resident diagnosed with multiple sclerosis, depression, and insomnia, who was at risk for falls and had gait/balance problems. The care plan included an intervention for the resident to be evaluated for assist bars to aid in positioning in bed. However, despite the resident's repeated requests for side rails to prevent falls and discussions with the Social Worker and nurses, the side rails had not been installed. The Quarterly Minimum Data Set (MDS) indicated the resident had moderate cognitive impairment with a BIMS score of 12. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the care plan documented the need for assist bars and that the rehabilitation staff must evaluate the resident and obtain consent before installation. The MDS Coordinator and DON also verified that the clinical team and unit nurses are responsible for updating and following the care plans. Despite these protocols, the necessary evaluation and installation of assist bars for the resident had not been completed, leading to a failure in meeting the resident's needs as outlined in the care plan.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care for three residents, specifically in the areas of nail care and scheduled showers. Resident R23, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed with extremely long fingernails. Despite having a care plan that includes regular nail care and assistance with ADLs, R23 reported that no one had offered to cut or trim his fingernails. Similarly, Resident R87, who also has severe cognitive impairment and requires assistance with personal hygiene, was found with extremely long fingernails. The care plan for R87 includes regular nail care on bath days, but this was not carried out as required. The Director of Nursing confirmed that fingernail care should be part of ADL care and acknowledged the oversight for both residents. Resident R70, who has little cognitive impairment but requires substantial assistance with personal hygiene, did not receive her scheduled bed baths. Her care plan specifies that she should receive bed baths three times a week, but records show she only received a few bed baths in April and none in the first week of May. R70 reported that it had been two weeks since her last bath and that staff informed her she would not receive one until the following Monday, without providing a reason. This failure to adhere to the care plan was also confirmed by the Director of Nursing.
Failure to Provide Restorative Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident (R22) receiving restorative care. The resident, who has a medical history including dementia, altered mental status, adult failure to thrive, and adjustment disorder with depressed mood, was observed to have a contracture of her right hand. Despite this, no splint or brace was noted during the observation, and the resident was not listed for restorative care. Interviews with staff, including a Restorative CNA, LPNs, and a Certified Occupational Therapy Aide, revealed that the resident had not been on the therapy caseload since 2022 and was not receiving the necessary restorative therapy services to address her condition. The facility's policies on range of motion exercises and restorative services indicate that residents with limited range of motion should receive appropriate treatment to prevent further decline. However, the staff interviews and observations showed a lack of adherence to these policies. The Restorative CNA confirmed that the resident was not on the list for restorative care, and the LPNs were unaware of any ongoing therapy for the resident. The Certified Occupational Therapy Aide also confirmed that the resident had not been on the therapy caseload since 2022, highlighting a significant gap in the resident's care plan and the facility's failure to provide necessary restorative services.
Failure to Prevent Falls and Secure Oxygen Cylinder
Penalty
Summary
The facility failed to provide interventions to prevent falls for a resident with multiple sclerosis, depression, and insomnia, who had a history of falls. Despite the resident's repeated requests for side rails and multiple documented falls, the facility did not evaluate or provide side rails. Staff interviews revealed that the resident's safety awareness was poor, and various fall prevention measures were discussed but not fully implemented, such as the absence of fall mats and assist bars. The resident continued to experience falls while reaching for items, indicating inadequate fall prevention interventions by the facility. Additionally, the facility failed to ensure an oxygen cylinder was stored and secured for a resident receiving oxygen therapy. An unsecured oxygen cylinder was observed on the floor of the resident's room, which was confirmed by the Director of Nurses. The facility's policy required portable oxygen cylinders to be strapped to the stand, but this was not followed, posing a safety hazard. The resident had diagnoses including vascular dementia and generalized anxiety disorder, and the unsecured oxygen cylinder was a direct violation of the facility's safety protocols.
Failure to Properly Check G-Tube Placement
Penalty
Summary
The facility failed to properly check for Gastric tube (G-tube) placement for a resident receiving nutrition through a G-tube. The resident, who was admitted with diagnoses including end stage renal disease, adult failure to thrive, and aphasia following cerebrovascular disease, had a care plan that required checking for tube placement and gastric contents/residual volume per facility protocol. However, during an observation, a registered nurse initiated the tube feeding without checking the residual volume, which was a required step according to the resident's orders and facility protocol. The Director of Nursing confirmed that the proper procedure for checking G-tube placement included verifying orders, ensuring the feeding bottle had not expired, listening to bowel sounds, injecting air, listening for placement, and checking residual. Despite this, the registered nurse only injected air and listened for placement, neglecting to check the residual volume. This oversight was verified through staff interviews and record reviews, indicating a failure to adhere to the established protocol for G-tube feeding initiation.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy for a resident diagnosed with chronic obstructive pulmonary disease and acute respiratory failure. The resident, who had no cognitive impairment, was observed receiving oxygen via nasal cannula at four liters per minute on multiple occasions. However, a review of the resident's clinical record revealed no physician order for this oxygen administration. The Director of Nursing acknowledged that the oxygen order was only entered into the system after the surveyor's observation, despite the resident having used oxygen since their re-admission to the facility. The DON explained that oxygen orders are typically reactivated upon a resident's return to the facility after discharge, but this process was not followed in this case. The unit manager is responsible for auditing oxygen orders, but this oversight was not caught until the surveyor's investigation.
Failure to Ensure Full Visual Privacy in Shared Resident Bedrooms
Penalty
Summary
The facility failed to ensure that privacy curtains provided full visual privacy for three shared resident bedrooms. Observations revealed that room E44 had a privacy curtain missing several hooks, causing a large gap and not providing full privacy for the resident in the B bed. Room D5's privacy curtain also had missing hooks and could not be drawn for full privacy while providing care for the resident. Additionally, room B39-1 had hooks on the curtain track but no privacy curtain was observed to provide privacy for the resident during care. Interviews with staff confirmed the lack of a maintenance work order system at nursing stations and acknowledged the unacceptable conditions of the rooms needing immediate attention and repairs.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 426 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Operating Company Llc | 1.2 mi | ★★★★★ | 11 | 0 |
| Stone Mountain Run Of Journey Llc | 3.3 mi | ★★★★★ | 9 | 0 |
| Briarwood Health Center By Harborview | 3.6 mi | ★★★★★ | 1 | 0 |
| Pruitthealth - Lilburn | 3.8 mi | ★★★★★ | 0 | 0 |
| Pebblebrook Health Center At Park Springs | 5.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.