Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 C M Tucker Jr Nursing Care Center Fewell And Stone during CMS and state inspections, most recent first.
A CNA physically abused a resident by pinching the resident's nose after being subjected to verbal abuse, resulting in facial injuries. The incident was initially disclosed in a joking manner to an LPN, who delayed reporting the event. The resident, who had significant cognitive and physical impairments, was found with bruising and discoloration on the face. The facility's policy required immediate reporting and intervention, but there was a delay in both recognizing and addressing the abuse.
A CNA physically abused a resident with severe cognitive impairment by lifting the resident's legs to hip level and dropping them after the resident exhibited aggressive behaviors. Multiple staff witnessed the incident, and the CNA admitted to the actions, which were not in line with the facility's zero-tolerance policy for abuse. The resident was assessed and found to have no injuries following the event.
Staff removed untouched meal trays from a retherm cart and placed them in a soiled area of the kitchen near trash cans and dirty mop water, rather than keeping them in the retherm cart until it was confirmed whether any residents needed extra trays. This practice was acknowledged by dietary and nursing leadership as not meeting expectations for preventing cross-contamination.
A resident with paraplegia and multiple stage 4 pressure ulcers had their privacy compromised when laundry staff entered the room during a dressing change without waiting for permission, despite nursing staff announcing that patient care was in progress. The staff member left the door open while retrieving laundry, contrary to facility policy requiring privacy during care.
A RN left Metoprolol unsecured on top of a medication cart and walked away, contrary to facility policy requiring medications to be secured and inaccessible to unauthorized individuals. The RN later acknowledged the error, and the DON confirmed the RN was filling in for a shift.
A resident with a history of wandering and moderate cognitive impairment eloped from the facility due to inadequate supervision. Despite having a wander guard, the resident exited by holding a door open for 15 seconds, as indicated by a sign. Staff failed to associate an alarm with the resident's elopement, leading to the resident being found outside with minor abrasions. Surveillance footage confirmed the sequence of events.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident by pinching the resident's nose, resulting in visible injuries including bruising and discoloration to the nose, forehead, and above the right eyebrow. The incident took place during morning activities of daily living (ADL) care, after the resident verbally abused the CNA with racial slurs. The CNA admitted to pinching the resident's nose and also reported that the resident hit his head on the bed rail during care. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, restlessness, agitation, and vascular dementia, was rarely or never understood and had not exhibited physical or verbal behaviors during the look-back period according to the Minimum Data Set (MDS). The licensed practical nurse (LPN) was present outside the resident's room during the incident and was informed by the CNA about the verbal abuse. The LPN offered the CNA the option to switch assignments, but the CNA declined and stated she had something for the situation. After the incident, the CNA told the LPN in a joking tone that she had pinched the resident's nose. The LPN initially responded that she was not doing any incident reports that day, but later, upon noticing the resident's facial injuries during wound care, decided to report the incident to the supervisor. The CNA attempted to provide a cream to cover up the injury, but the LPN refused to apply it. The incident was not reported to administration until several hours later, after the RN supervisor was notified. The CNA was then removed from the unit and admitted to pinching the resident's nose, stating she was triggered by the resident's language. The resident was assessed and found to have multiple bruises on the face but denied knowing what happened and did not verbalize pain. The facility's policy required staff to be trained in abuse prevention and to report and remediate abuse immediately, but in this case, there was a delay in reporting and a failure to protect the resident from physical abuse.
Removal Plan
- The staff member who reported pinching the resident's nose was removed from care, a statement was obtained, and she was immediately put on administrative leave.
- A report was completed and provided to the authorities including Certification, Veterans Association, Ombudsman, VA contract monitor, Medical Director, and local authorities.
- The resident had a psychosocial visit completed by the Social Services Director.
- The resident was provided safety and interviewed for any feelings of fear or anxiety.
- The resident had pain monitored and was re-evaluated for side rail need; 1/4 rails were removed.
- The care plan was updated to reflect that staff should discontinue care and report to the nurse when a resident's physical or verbal behaviors escalate.
- Other residents cared for by the accused staff member were interviewed or had body checks completed by a licensed nurse; no concerns or skin issues were noted.
- Interviews were completed with other staff members providing care on that unit; no unusual findings or discoloration on the resident's nose were identified.
- The resident's responsible party was notified and the occurrence explained in full.
- A review of risk reports, grievance process, and resident council minutes was completed; no concerns related to potential abuse were identified.
- A root cause analysis was conducted, determining that the involved staff member did not follow protocol regarding residents who are combative or abusive.
- The QAPI committee determined that re-education was warranted on the abuse policy, which was started.
- All staff were re-educated on the abuse policy, including types of abuse, what and when to report abuse, and what to do when a resident is abusive verbally/physically.
- Policy and procedure were reviewed and updated with emphasis on removing self from a resident with escalating behaviors and notifying the nurse for assistance/guidance.
- Hiring practices were reviewed to include background and reference checks and orientation that includes abuse prevention.
- The accused staff member's file was reviewed and found complete as per practice.
- The accused staff member was immediately placed on administrative leave and, following investigation, employment was terminated.
- Questionnaires (audits) testing staff knowledge of abuse prevention and handling escalating behaviors will be completed randomly, with results reviewed in the QAPI process until compliance is attained and maintained.
CNA Physically Abuses Resident by Lifting and Dropping Legs
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident with severe cognitive impairment. The resident, who had dementia, depression, and a history of behavioral issues, was observed on surveillance video attempting to headbutt, punch, and kick the CNA. In response, the CNA moved in front of the resident, who then tried to trip her. The CNA then grabbed the resident's legs, lifted them to her hip level, held them briefly, and dropped them back down while speaking to the resident in a stern tone. Multiple staff interviews confirmed the sequence of events. The physical therapist witnessed the resident's aggressive behavior and the CNA's response, noting the CNA's stern voice and the act of lifting and dropping the resident's legs. The LPN on duty also observed the CNA forcibly move the resident's wheelchair, followed by the resident's attempts to strike the CNA, and then the CNA lifting and dropping the resident's legs while speaking loudly and with aggravation. The CNA herself admitted to lifting the resident's legs and releasing them, stating she did not want to bend over to place them on the ground. The facility's policy clearly states a zero-tolerance approach to abuse, defining physical abuse as actions such as hitting, slapping, or inappropriate handling of residents. The administrator and DON reviewed the incident and agreed that the CNA's actions were unnecessary and not in accordance with facility policy. The resident was assessed after the incident and found to have no injuries, but the act of lifting and dropping the resident's legs constituted physical abuse as defined by the facility's policy.
Unsanitary Handling of Extra Meal Trays in Kitchen
Penalty
Summary
During a dining observation, both independent and dependent residents were brought into the main dining room, and staff transported retherm carts containing meal trays. A Dietary Aide (DA) removed six untouched, covered meal trays from the hot box compartment of a retherm cart and transported them to the soiled area of the kitchen. These trays were placed on a two-tiered metal cart near the dishwasher, two soiled trash cans, and a bucket containing a soiled mop and dirty mop water. The DA then returned to the dining room, performed hand hygiene, and assisted with passing out meal trays to residents. The Dining Services Supervisor (DSS) confirmed that the trays placed in the soiled area were extras and would be discarded if not needed, but acknowledged that meals potentially for consumption should not be stored in that area. The Dining Services Manager (DSM) stated that her expectation was for extra or substitution trays to remain on the retherm cart to prevent cross-contamination and not be placed in soiled work areas if there was a potential for consumption. The Director of Nursing (DON) also stated that trays should remain in the retherm cart until it is confirmed that no residents need additional trays, after which they can be discarded.
Failure to Protect Resident Privacy During Patient Care
Penalty
Summary
The facility failed to protect a resident's privacy during patient care, as required by facility policy. During a dressing change, laundry staff entered the resident's room after knocking but without waiting for permission to enter, despite nursing staff repeatedly announcing that patient care was in progress. The laundry staff left the door wide open while retrieving laundry, further compromising the resident's privacy. The resident involved had a history of significant medical issues, including thoracic spinal cord injury, paraplegia, and multiple stage 4 pressure ulcers. The resident was cognitively intact, as indicated by a perfect BIMS score. Facility policy clearly states that staff must knock, wait for a response, and only enter with permission, but this protocol was not followed during the incident.
Medication Left Unsecured on Medication Cart
Penalty
Summary
A registered nurse (RN) left Metoprolol, a blood pressure medication, unsecured on top of a medication cart and walked away to enter a resident's room, leaving the medication accessible to unauthorized staff and residents. Facility policy requires that medications be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The policy also specifically states that no medications should be left on top of the medication cart when the nurse steps away. During interviews, the RN acknowledged the lapse, stating it was not their regular procedure and that they thought they had taken the medication with them. The Director of Nursing confirmed the RN was filling in for a shift and was nervous during the incident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision to prevent a resident's elopement, which was determined to constitute Immediate Jeopardy. The resident, who was moderately cognitively impaired and had a history of wandering and exit-seeking behaviors, managed to leave the facility unsupervised. The resident was admitted with diagnoses including wandering, lack of coordination, and a history of falling, and was equipped with a wander guard. Despite these precautions, the resident was able to exit the facility by holding a door open for 15 seconds, as indicated by a sign on the door. On the night of the incident, the resident was last seen in the common area near the nurse's station before rolling down the hallway and attempting to enter a secured unit. The resident then accessed a canteen room with an exit leading outside. Staff members discovered the resident outside after hearing an alarm but initially did not associate the sound with an elopement. The resident was found outside on his knees, with minor abrasions, and was brought back inside without apparent serious injury. Interviews with staff revealed a lack of awareness regarding the resident's exit-seeking behavior and the significance of the alarm sound. The facility's surveillance footage confirmed the sequence of events leading to the resident's elopement. The incident highlighted a failure in supervision and monitoring, as well as a lack of immediate response to the alarm, which allowed the resident to leave the facility unsupervised.
Removal Plan
- Resident was assessed for injury and was returned to unit for further evaluation and close observation Line of Sight.
- The resident will be placed on a secure unit for additional evaluation and stay.
- Resident has a wander guard safety monitor.
- Education was completed with working staff on situational awareness, leadership was contacted, and the film was reviewed.
- The facility has provided education regarding elopement and reporting.
- Policy on Code [NAME] and Elopement was shared.
- Training was provided by the Director of Nursing and lead nursing staff.
- Residents residing on the open units were assessed for elopement additionally.
- Residents are assessed for elopement risk quarterly.
- An additional assessment was done considering this event.
- Fire and Life Safety staff evaluated door to determine that it was functioning properly.
- Facility entrance codes will be changed to ensure integrity of security or as needed.
- The measures associated with this infraction will be included in the facility's monthly Quality Assurance Performance Improvement Meeting report.
- The report will include the updated CMS definition of elopement.
- The report will include updates regarding monitoring of quarterly assessments for elopement reports.
- The facility mitigation plan will be fully completed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| C M Tucker Jr Nursing Care Center Roddey Pavilio | 0 mi | ★★★★★ | 0 | 0 |
| Pruitthealth- Columbia | 1.2 mi | ★★★★★ | 0 | 0 |
| Forest Acres Post Acute | 1.3 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Columbia | 1.8 mi | ★★★★★ | 2 | 0 |
| Midlands Health & Rehabilitation Center | 1.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.