C M Tucker Jr Nursing Care Center Fewell and Stone

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 252 beds and averages 57.9 residents a day — about 23% occupied, or roughly 194 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.79 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.32 hrs/resident/day on weekends vs 5.56 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.27 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 17 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings include:Review of the facility policy titled Freedom From Abuse, Neglect…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-07-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The IJ was related to 42 CFR 483.25 - Quality of Care. On 07/15/24 at approximately 4:45 PM, the facility provided an acceptable IJ Removal Plan. The survey team…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-01-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. He then went to [NAME] 122 and informed the charge nurse that he smelled smoke and that the residents needed to be evacuated, and at that time the Charge Nurse (CN) stated that the residents on their unit…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-01-12 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 01/11/2024 at 5:30 PM, the survey team provided the Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled, Protection from Harm Policy last revised, November 2024 revealed A significant aspect of residents' rights is the right to be free from abuse/neglect. The facilities of C. M. [NAME], Jr. Nursing Care Center have a 'zero tolerance' for any type of abuse. A. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: Review of the facility's policy, titled Fall Prevention & Management Program, reviewed 06/20, revealed the purpose was to provide guidelines for falls and repeat fall preventive intervention. Review of the policy revealed that for all residents, Individualize equipment specific to resident's needs. Review of R12's hard-copy medical record included a Face Sheet, which indicated R12 had diagnoses including Alzheimer's disease, dementia, spondylosis, osteoporosis and lack of coordination. R12's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/21 revealed the resident was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-10-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: Review of R26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/21, revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating the resident had significant cognitive impairment. The assessment identified the resident had diagnoses including dementia and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The MDS documented R26 required set up assistance from staff for meals, weighed 147 pounds (lbs) at the time of the assessment, and had sustained a weight loss of five percent (%) or greater in the last 30 days or 10% or greater in the last six months.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: During a dining observation on 05/13/25 at approximately 11:25 AM, both independent and dependent residents were observed being brought into the main dining room, located outside the main kitchen, along with facility staff. The Dining Services Supervisor (DSS) and a Dietary Aide (DA) transported retherm carts into the dining room. The DA opened one of the retherm carts and removed six individual covered meal trays that had not been served. These trays were untouched and were removed directly from the hot box compartment of the cart. The DA then transported these six trays to the soiled area of the kitchen. The trays were placed one by one on a two-tiered metal cart located near the dishwasher, two soiled trash cans and a bucket containing a soiled mop and dirty mop water. The DA then…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled Clean Dressing Change effective April 2024, states, 1. Every resident has the right to privacy. No one should enter a resident's room without first knocking on the door, waiting for a response and only entering with permission. If there is no response, then knock again, and announce your name and the reason for entering the room. Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE], with diagnoses including but not limited to: injury at T7-T10 of thoracic spinal cord, pressure ulcer of unspecified site, stage 4, paraplegia, pressure ulcer of right buttock, stage 4, and pressure ulcer of left buttock, unstageable. Review of R36's Quarterly Minimum Data…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of facility policy, observation and interview, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. Findings include: Review of an undated facility policy titled Storage of Medication on Units states, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility policy titled Medication Administration: Oral effective October 2024, states, Procedure: . Key Points/Rationale: No medications or scissors should be on Top of medication cart when nurse steps away. During an observation on 05/14/25 at 8:22 AM, Registered Nurse (RN)1 walked away from the medication cart on Hall 122 with Metoprolol (a blood pressure medication) sitting on top of the cart. RN1 then leaves and enters a residents room. During an interview on 05/15/25, RN1 stated, It is not my regular…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-01-12 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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: Review of the facility's policy titled, Storage of Medications On Units revised October 2022, revealed, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and returned to pharmacy if appropriate or disposed of on the units. Observation on 01/10/24 at 12:36 PM of Medication Cart #1 on [NAME] 122 revealed 1 expired…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-12 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of a facility policy titled Resident Council Policy and Procedure Directive, revised April 2022, revealed, Policy Statement: This directive establishes a written plan for administration of the Resident Council and delineates the guidelines for the coordination of the facility wide program. Resident Council Format A 1. The Resident Council provides residents with a mechanism for voicing grievances and for participating in the decision-making process while residing at the E. [NAME] Stone Jr., Veterans Home. 2. It provides a method of communication wherein issues and concerns affecting the welfare of the residents can be discussed and solutions and recommendations pursued. Review of Resident Council meeting…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-12 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. During an observation and interview on 01/09/24 at 9:12 AM during medication administration, it revealed that Licensed Practical Nurse (LPN)1 drew up 23 units of Lantus insulin for Resident (R) 46 instead of the ordered 24 units. When asked about the amount drawn, LPN1 then stated, Yeah, see it's 23 units. LPN1 did not realize that she had drawn up the incorrect amount until…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled, Infection Control for Laundry, with an effective date of January 2023 revealed, Hand Hygiene and Personal Protective Equipment: #2, Good Hand hygiene consists of a 20 second scrub with soap and water or application of hand cleansing gel according to hand hygiene procedure. Handwashing cleansing gels may be used when frequent, casual contact occurs when hands are not visibly soiled, #3, a. states, Before and after contact with each resident on in-use resident device. Review of the facility policy titled, Infection Control with an effective date of October 2023 revealed, Purpose is To identify types and management of transmission-based precautions. Page 4, #3 d states, Remove gloves before leaving the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-12 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: Review of a facility policy titled, Resident Care Conference: The Development and Review of Resident Health Care and Care Plans, with an effective dated 02/ 2023, revealed Purpose Statement: Resident Care Conferences (RCC) are hereby established for the purpose of providing he most effective utilization of available resources in the planning and re-evaluation of an individualized care and treatment plan which is based on a comprehensive assessment. The RCC of each unit shall meet weekly. Special reviews ae scheduled as needed. All staff engaged in any aspect of the care of residents ae considered members of the RCC. The RCC team is responsible for evaluation of goals and approaches at quarterly, annual, and significant…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's Shaving the Resident policy, revised 09/22 revealed, Purpose: To safely shave the resident in order to promote cleanliness and provide skin care. Responsible staff: CNA, RN, LPN. Document procedure and any pertinent observations in the Electronic Health Record (EHR) on: Time and date that the procedure was performed. How resident tolerated procedure or any changes in the resident's ability to participate in procedure. Any complaints of discomfort. If resident refuses therapy, the nurse will explore the reasons for the resident's refusal, clarify, and educate the resident as to the consequences of refusal, offer alternative treatments, and continue to provide all other services. If the resident has refused treatment. The care plan reflects CMT's efforts…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: On 1/9/2024 at 11:09 am, an observation of R258 revealed him asleep in bed. His bilateral lower extremities were hanging off the foot of the bed to the left. He was not wearing Prevalon Boots and his feet were bare. On 1/11/2024 at 8:40 am, an observation of R258 revealed him asleep in bed. Prevalon Boots were not on his feet. His feet were uncovered with the blanket above his feet and were bare. Record review of the Physician orders for R258 dated 11/29/2023 revealed Prevalon Boots for Venous Insufficiency. Review of January 2024 Treatment Administration Record (TAR) for R258 revealed Prevalon Boots all 3 shifts, Day, Evening, and Night Shift signed as administered. Review of the Care Plan dated 11/30/2023 for R258 revealed he is at risk for skin breakdown and an intervention dated 1/10/2024 was added for Prevalon Boots. During an interview with Licensed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$239,350 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $10,361 — penalty dated 2025-12-18
• $53,196 — penalty dated 2025-05-15
• $10,036 — penalty dated 2024-07-15
• $165,757 — penalty dated 2024-01-12
• Medicare payment denial — starting 2025-06-14 for 16 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in SC