C M Tucker Jr Nursing Care Center Roddey Pavilio

In the surveyor’s words

From the most serious findings on record at C M Tucker Jr Nursing Care Center Roddey Pavilio, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Apr 18, 2025

  Based on observation, interview, and a review of facility policy, the facility failed to follow proper infection control protocol in 3 of 3 laundry rooms. Specifically, there was a lack of separation between the clean and soiled laundry room. Laundry staff did not adhere to manufacturer guidelines regarding the use of detergents and sanitizers. Additionally, heavily soiled clothing items were being rinsed out in areas such as resident bathroom toilets/sinks or the sinks in shared shower rooms. This failure had the potential to spread bacteria, viruses, and fungal infections. […]

• Immediate jeopardy, isolatedF600Mar 18, 2024

  Based on review of the facility policy, interviews, and record review, the facility failed to ensure Resident (R)1 was free from physical abuse by Certified Nursing Assistant (CNA)2. On 03/18/24 at 10:25 AM, the Administrator and the Director of Nursing were notified that the failure to ensure Resident (R)1 was free from physical abuse constituted Immediate Jeopardy (IJ) at F600. On 03/18/24 at 10:25 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/30/23. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 03/18/24 at 12:27 PM, the facility presented an acceptable plan of removal of the IJ. […]

• Immediate jeopardy, isolatedF689Sep 19, 2023

  Based on interview and record review, the facility failed to provide supervision to prevent the elopement of 1 of 7 residents reviewed. Resident (R) #7 eloped from the facility on 07/02/2023 at approximately 6:16 PM. This situation placed the resident at increased risk for severe harm and / or death. R7 was outside of a safe area without facility awareness, supervision, or permission, placing her increased risk of heat exposure, dehydration and / or other medical complications, or being struck by a motor vehicle. On 09/18/23 at 1:58 PM, the Administrator and the Director of Nursing (DON) were notified that Resident (R)7's successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. […]

• Actual harm, isolatedF689Apr 28, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident (R)12) of 4 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. Specifically, R12 did not have a chair alarm in use as required and sustained a fall on 02/21/2023, which resulted in a fractured clavicle. The facility developed an intervention that required staff to provide one on one supervision for the resident. However, on 03/29/2023, staff failed to provide supervision as required and there was no documented evidence the chair alarm was utilized. R12 sustained another fall, which resulted in an abrasion. […]

• No harm, potential for more than minimal, patternF880Jul 22, 2026

  Based on observation, interview, record review, and review of the facility policy, the facility failed to establish and maintain an effective Infection Prevention and Control Program (IPCP). Specifically, the facility failed to ensure staff followed appropriate hand hygiene during the administration of a gastrojejunostomy (G J) feeding tube flush for one sampled resident (Resident (R)25), and during medication administration for two of three residents reviewed for medication administration (R68 and R70).Findings Include: 1.Review of the policy titled, Infection Control Policy and Procedure, with a revision date of March 2026 revealed, Purpose: The purpose of this operational procedure is to establish infection control functions and responsibilities for Nursing Services at CM [NAME], Jr. […]