C M Tucker Jr Nursing Care Center Fewell and Stone

Inspectors wroteBased on a review of facility policy, record review, and interview, the facility failed to protect Resident (R)1 from physical abuse. Specifically, Certified Nursing Assistant (CNA)1 pinched the nose of R1, resulting in R1 suffering injuries to the face. On 12/17/25 at 7:28 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/19/25. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation. On 12/18/25 the facility provided an acceptable IJ Removal Plan. On 12/18/25 the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The SA is considering the IJ at Past Non-Compliance as of 09/19/25. [...]

Inspectors wroteBased on review of the facility policy, video footage, and interviews, the facility failed to ensure Resident (R)45 was free from physical abuse from Certified Nursing Assistant (CNA)1.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was handled in a sanitary manner to prevent cross-contamination in the main kitchen. This deficient practice had the potential to affect all residents who request alternative and/or extra trays from the kitchen.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to ensure the protection of Resident (R)36's privacy during patient care. Specifically, during a dressing change, Laundry Staff 1 entered the resident's room without requesting permission to enter.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents.

Inspectors wroteBased on interviews, record review, review of facility policy, and review of the facility's video surveillance the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. On 07/15/24 at 1:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 07/15/24 at 2:11 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 07/15/24 at 2:11 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/06/24. [...]

Inspectors wroteBased on review of the facility policy, documentation, and interviews, the facility failed to ensure residents on [NAME] 122, 1 of 2 Units, were free from neglect, when a nurse failed to follow emergency evacuation procedures during a fire emergency. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Abuse) at a scope and severity of J. The IJ began on 12/16/23 at approximately 12:45 AM when the facility fire alarm sounded, and a Code Red was called. Approximately 20 minutes after the alarm sounded the Public Safety Officer (PSO) arrived at [NAME] 120 and informed them they needed to evacuate. [...]

Inspectors wroteBased on review of the facility policy, record reviews, and interviews, the facility failed to have systems in place to control, account for, and reconcile controlled medications to prevent loss, diversion, or accidental exposure as evidenced by Resident (R)408 and R409, who received R40's prescribed morphine. On 01/11/2024 at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 01/11/2024 at 5:30 PM the Administrator and the Director of Nursing were notified that failure to facility failed to have systems in place to control, account for, and reconcile controlled medications to prevent loss, diversion, or accidental exposure at constituted Immediate Jeopardy (IJ) at F755. [...]

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure 2 expired medications were removed from storage with resident medications that were in use and failed to remove a cup of 11 unidentified pills, 3 loose small white round pills and 1 container of expired thick and easy iced tea from 3 of 5 medication carts. The facility further failed to remove 2 packages of Algisite M dressings, 5 packages of Optifoam gentle dressings, 5 packages of Telfa non-adherent pads, 3 packages of brown Coban dressings, and 1 bottle of Sterile Plain Packing Strips opened and no longer sterile from, 2 of 2 treatment carts. Findings Include: [...]

Inspectors wroteBased on facility policy review, record review, and interviews, the facility failed to address and resolve concerns of the resident council- related to food, and food substitutions/alternatives for 4 (Residents (R)3, R14, R17 and R19) of 10 residents reviewed for resident council.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure a medication error rate, during medication administration, was less than five (5) percent. The med error rate was 15.15 percent for 5 out of 33 opportunities for error. Findings Include: Review of the facility policy titled, Administration of Medication last revised December 2021, states Insulin will be verified by two medically licensed personnel (RN/LPN/LPP) for accuracy of the medication and dosage prior to administration. Furthermore, it states that The person administering medication must: 2. Be sure to have the right drug and dose for the right patient/resident, give at the right time and by the right route. [...]

Inspectors wroteBased on review of the facility policy, observations, and interview, the facility failed to follow Infection Prevention and Control procedures on 2 of 2 units for hand hygiene during distribution of meal trays and for a room identified with active COVID-19.

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to update and revise the comprehensive care plan for refusals to get out of bed (OOB) for 1 (Resident (R)48) of 3 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observations, record review, facility policy and interviews the facility failed to carry out activities of daily living necessary services to maintain good grooming, personal, and oral hygiene for Resident (R)45.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pressure relieving device was in place following physician order and plan of care for 1 of 1 resident reviewed, (Resident (R) 258.

Inspectors wroteBased on observation, interview and facility policy, the facility failed to follow physician order for pressure ulcer dressing change for 1 of 1 resident observed, (Resident (R) 26.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to identify and implement preventative measures for 1 of 1 resident with significant weight loss (Resident (R) 26.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly store Resident (R)22's respiratory device. R22's Continuous Positive Airway Pressure (CPAP) mask had no covering, when not in use.

Inspectors wroteBased on resident interview, staff interview, document review and the facility policy review, the facility failed to provide meals that were palatable, attractive, or appetizing in temperature for 3 (Residents (R)3, R14 and R19) of 3 residents reviewed for food/nutrition.

Inspectors wroteBased on resident interview, staff interview, and document review, the facility failed to provide residents with menus with meal substitutions/alternatives for 3 (Residents (R)3, R14 and R19) of 3 residents reviewed for dining.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure an assistive device was implemented to prevent injury for one (Resident (R)12) of three residents reviewed for falls out of a sample of eighteen residents. R12, who had a history of previous falls and orders for hip protectors, sustained a fall that resulted in a right hip fracture after the facility failed to provide this assistive device designed to prevent injury.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to effectively monitor weights and follow prescribed physician orders for nutritional supplement administration for one resident (Resident (R) 26) who sustained an apparent significant weight loss, out of six residents reviewed for nutritional status.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to store, distribute, and serve food at temperatures designed to prevent the spread of food-borne illness. Food that was received by the facility from a delivery truck was above the acceptable cold-temperature range. Foods that then went through a retherm process were either not heated sufficiently, or not cooled to the established safe temperatures. In addition, refrigerator/cooler temperatures were not consistently recorded. Staff stored personal food items with the resident's food items in the refrigerator in the facility's main dining area. These failures had potential to affect 48 out of 51 residents living at the facility, who received food from the kitchen; there were three of 51 residents who received their nutrition via tube feedings.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one of the facility's two dumpsters was consistently kept closed to keep pests out and/or to keep the garbage contained in the dumpsters.