Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fulton Manor Care Center during CMS and state inspections, most recent first.
Facility staff did not complete required Criminal Background Checks (CBCs) for three CNAs before they began working with residents, despite policies requiring background and criminal conviction checks for all direct-access employees. Review of personnel files showed no documentation that CBCs were requested or obtained for these CNAs. The administrator reported relying on verification through the Family Care Safety Registry (FCSR) and, when not registered, on requests to an external association for background checks, and acknowledged not requesting CBCs from the state highway patrol since assuming responsibility for this process.
A resident with severe cognitive impairment and psychiatric diagnoses was improperly restrained in a wheelchair by a CNA who tied a sheet around the resident’s upper body and secured it to the back of the chair to control the resident’s behavior, contrary to the care plan that called for assisted ambulation, safety devices, and simple instructions without restraints. Another CNA witnessed the tying and tightening of the sheet and reported it to an LPN, who found the resident in the dining area with a blanket draped over the chair that concealed the sheet and required several minutes to untie. The CNA later admitted the restraint was used to "teach a lesson" and to prevent the resident from getting up, despite prior training on abuse and neglect.
Facility staff did not prevent the employment of a CNA who had a federal indicator for misconduct on the CNA Registry. Despite policies requiring background checks and registry reviews, the responsible staff member overlooked the federal marker and the administrator was unaware of the issue, resulting in the CNA being hired.
Facility staff failed to ensure call lights were within reach for several residents, leading to unmet needs for assistance. Observations showed residents with cognitive impairments and assistance needs were unable to access call lights, resulting in them calling out for help. Staff interviews revealed a lack of awareness and communication regarding the accessibility of call lights, with some staff acknowledging the issue of short call light strings.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leaves. This issue affected four residents, and the facility lacked a bed hold policy. Interviews revealed that the DON and administrator were unaware of the bed hold requirements and processes.
The facility failed to complete baseline care plans within 48 hours for several residents, as required by policy. The Care Plan Coordinator and DON were unclear about the timeframe, leading to delays. The administrator incorrectly stated that care plans should be completed within seven days, contributing to the deficiency.
Facility staff failed to follow professional standards by not obtaining physician's orders for water flushes during G-tube medication administration for a resident. Medications were administered without necessary water flushes, and Levothyroxine was not given separately as required. Unauthorized documentation by CMTs on the MAR was also noted, with a lack of oversight due to the absence of a DON.
Facility staff failed to meet basic hygiene needs for four residents, as observations and interviews revealed inconsistent shower offers and documentation. A resident with mild cognitive impairment was observed with greasy hair despite documented showers, while another cognitively intact resident reported not having a shower in weeks. A newly admitted resident had no documented showers, and staff interviews indicated a lack of consistent care due to a temporary absence of a DON.
The facility failed to obtain signed consents and conduct necessary side rail assessments for four residents, as required by policy. Observations showed residents with bed rails in the upright position without proper documentation. Interviews with staff revealed confusion about responsibilities, leading to non-compliance with procedures.
The facility failed to provide adequate staffing as per their Facility Assessment, resulting in unmet hygiene needs for several residents. Observations and interviews revealed that residents were not receiving regular showers or personal hygiene assistance due to understaffing. The facility's reliance on fire code regulations instead of the Facility Assessment for staffing contributed to this deficiency.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, from July 2024 to January 2025. The RN staff schedule showed numerous days without adequate RN presence, and interviews with the DON and administrator revealed a lack of awareness of the regulatory requirements. Despite recognizing the importance of RN expertise, the facility did not ensure compliance with staffing regulations.
The facility failed to post required nurse staffing information, including the facility census and actual hours worked by licensed and unlicensed staff, in an accessible location. Observations and interviews revealed that the Director of Nursing and the administrator were unaware of the missing information, despite policy requirements. The responsibility for completing the daily staffing sheet was assigned to the charge nurses, but the deficiency persisted.
A resident in an LTC facility experienced a medication administration error, resulting in a 28.13% error rate. The LPN administered multiple medications via G-tube over two hours late, contrary to the facility's policy of administering within one hour of the prescribed time. The resident expressed concern about the delay, and the LPN admitted to forgetting the scheduled administration.
The facility failed to ensure proper operation of the dishwashing machine, resulting in inadequate sanitization of kitchen wares due to low temperatures and insufficient sanitizer concentration. Manual warewashing also showed deficiencies, with improper sanitizer concentration and insufficient sanitization time. Additionally, the ice machine lacked a required air gap, indicating a failure to adhere to sanitation standards.
The facility failed to implement an effective QA/QAPI program, as there was no policy in place and no documentation of quarterly meetings held by department heads to discuss facility issues and resolutions. The administrator was unaware of the need for documentation, affecting a facility with a census of 43.
The facility failed to follow its policy for TB testing, administering the second PPD test too soon for several employees. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) effectively, as staff were not educated or alerted about residents requiring EBP, and PPE was not readily available. Observations showed staff did not wear gowns during high-contact care activities, and interviews revealed a lack of awareness and training on EBP. The new DON acknowledged the oversight issues, but no corrective actions were taken at the time.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. Interviews with staff revealed a lack of awareness and adherence to regulations regarding bed rail safety, contributing to the deficiency in ensuring resident safety.
Facility staff failed to protect resident privacy by leaving computer screens with sensitive information open in public areas and not ensuring privacy during incontinence care. Two residents' medication information was exposed, and a resident was left visible to the parking lot during personal care. Staff interviews confirmed these actions were against facility policy.
The facility failed to complete the federally mandated MDS assessments within the required time frames for three residents. The MDS Coordinator was behind on completing assessments due to being pulled to work on the floor, and there was no system to ensure timely completion. The DON was unaware of the required time frames, contributing to the deficiency.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident on hospice care lacked hospice documentation in their care plan, another resident's use of bed rails was not documented, and a third resident with contractures had no interventions noted. Staff acknowledged these oversights, attributing them to the MDS/Care Plan Coordinator's responsibilities.
The facility failed to implement an Antibiotic Stewardship Program, lacking protocols and a system to monitor antibiotic use. The DON, new to the role, was unaware of any existing program, and the Corporate Nurse admitted that tracking and trending of antibiotic use had not been done. The administrator was unaware of the program's absence, indicating a lack of oversight.
A resident with a history of aggression grabbed another resident's arm, leading to a physical altercation. The aggressive resident was supposed to be monitored one-on-one after returning from the hospital, but was left unattended by an LPN who was not informed of the monitoring requirements. Surveillance footage showed no staff present during the incident, highlighting a failure in communication and supervision.
A CNA in a long-term care facility misappropriated $400 from a resident's checking account by cashing a check for personal use. The resident, who was moderately cognitively impaired, wrote the check after the CNA requested a loan to bail out a relative. The incident was reported over a month later, leading to an investigation and confirmation of the CNA's actions.
A facility failed to implement its abuse prevention policy when a PTA accused of inappropriate conduct was allowed to continue working with residents during an investigation. The policy requires immediate suspension and removal of alleged perpetrators, but the PTA remained unsupervised. The incident involved a cognitively intact resident with multiple diagnoses who reported feeling uncomfortable with the PTA's proximity and alleged inappropriate comments.
Failure to Complete Required Criminal Background Checks for Direct-Care Staff
Penalty
Summary
Facility staff failed to complete required Criminal Background Checks (CBCs) for three CNAs prior to their employment, contrary to Missouri DHSS requirements and the facility’s own policies. Record review showed that the Abuse, Neglect and Exploitation policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, with documentation maintained as proof of screening. The Background Screening Investigations policy further required that background and criminal conviction checks, including fingerprinting as required by state law, be initiated within two days of an employment offer and completed prior to employment for all applicants with direct access to residents. Review of personnel files revealed that CNA A, CNA B, and CNA C, each hired on different dates, had no documentation that a CBC was requested or received. During an interview, the administrator stated he/she was responsible for requesting CBCs on all potential staff prior to hire and explained that he/she typically verified whether applicants were registered with the Family Care Safety Registry (FCSR). If applicants were registered with the FCSR, the administrator did not request a CBC, and if they were not, he/she sent a request to the Missouri Association of Nursing Home Administrators (MANHA) for a background check. The administrator also stated that he/she had not requested a CBC from the Missouri State Highway Patrol (MSHP) since assuming responsibility for employee CBCs in April 2025.
Resident Physically Restrained in Wheelchair with Sheet as Discipline
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a CNA intentionally restrained the resident in a wheelchair using a sheet as a form of discipline and behavior control. The resident had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, anxiety disorder, and schizophrenia, and used a walker for ambulation. The resident’s care plan directed staff to assist with ambulation and transfers per therapy recommendations, use devices as appropriate for safety, provide clear, simple instructions, and offer re-orientation, but did not include the use of restraints. On the day of the incident, the CNA placed a sheet across the resident’s upper body, tied the sheet to the back of the wheelchair, and pushed the resident to the dining room. The CNA later admitted to tying the resident to the chair to “teach the resident a lesson” and to “trick the resident’s mind” so the resident would not keep getting up. The CNA acknowledged having received training on abuse and neglect, knowing it was not appropriate to restrain the resident, and understanding that the action constituted abuse, even though the CNA stated there was no intent to harm and the resident was not physically injured. Another CNA witnessed the first CNA tying the sheet around the resident and using a foot to tighten the sheet to the back of the wheelchair, and attempted to tell the CNA that the resident could not be restrained. This CNA reported the incident to an LPN. The LPN observed the resident in the dining room in a wheelchair with a blanket draped over the back, which concealed the sheet tied behind the chair, and it took the LPN several minutes to untie the knot. The facility’s investigation confirmed that the CNA had tied the resident to the wheelchair with a sheet and covered it with a blanket, constituting physical abuse and the use of an unauthorized restraint for discipline and staff convenience.
Failure to Screen and Prevent Employment of CNA with Federal Misconduct Indicator
Penalty
Summary
Facility staff failed to ensure that an employee with a federal indicator for misconduct on the Certified Nurse Aide (CNA) Registry was not hired or engaged to work. The facility's policies required screening of potential employees for any history of abuse, neglect, exploitation, or misappropriation of resident property, including checking the CNA Registry for federal indicators. Despite these policies, a review of one employee's personnel record showed that the individual was hired even though their CNA Registry indicated a federal marker for misconduct. Interviews revealed that the Social Service Director (SSD) was responsible for conducting background checks, including reviewing the CNA Registry. However, the SSD overlooked the section indicating the federal marker for misconduct, focusing instead on the active status of the CNA. The administrator was unaware of the federal indicator and acknowledged that no audits were being conducted to ensure compliance with hiring policies at the time.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodations to meet the needs of residents by not ensuring that call lights were within reach for four residents. The facility's policy requires that call lights be accessible to residents at all times, but observations showed that call lights were consistently out of reach for several residents. For instance, Resident #4, who has cognitive impairment and requires moderate assistance, was observed multiple times with the call light across the room, leading the resident to yell for help. Similarly, Resident #10, with severe cognitive impairment and needing maximal assistance, was found in situations where the call light was not within reach, causing the resident to express confusion and inability to call for help. Resident #48's call light was secured to a wall light pull-cord, making it difficult for the resident to reach, despite the resident's ability to use the call light if it were accessible. Interviews with staff confirmed that the call light string was too short, and the Maintenance Director was unaware of the issue until it was brought to their attention. Resident #295 also experienced issues with the call light being out of reach due to a short string. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed a lack of communication and awareness regarding the accessibility of call lights. The staff acknowledged the expectation that call lights should be within reach, but the deficiency persisted due to inadequate measures to ensure compliance with the facility's policy.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification to residents or their representatives regarding the bed hold policy during transfers to hospitals or therapeutic leaves. This deficiency was identified for four residents out of a sample of four, with the facility's census being 43. The facility's policies did not include a bed hold policy, and the medical records of the affected residents lacked documentation of notification about the bed hold policy at the time of their discharge and readmission. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the bed hold requirements and processes. The DON was unaware of the bed hold requirement, while the administrator acknowledged the existence of bed hold paperwork in the admission packet but was not familiar with the requirement or process for bed hold at the time of residents' transfer and discharge.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 16, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan should be developed to meet the resident's immediate needs within 48 hours of admission. However, the electronic medical records (EMRs) for Residents #20, #43, #45, #46, and #48 did not contain documentation of a completed baseline care plan within the specified timeframe. Interviews with the Care Plan Coordinator revealed uncertainty and delays in completing these plans, with attempts to gather information extending beyond the 48-hour requirement. The Care Plan Coordinator admitted to trying to complete the baseline care plans within the first week rather than the required 48 hours. The Director of Nursing (DON) was unaware of the specific timeframe for completing baseline care plans and acknowledged that there was no system in place to ensure timely completion. The facility administrator stated that the initial nurse should initiate the care plan, and the Care Plan Coordinator should complete it within seven days, contrary to the policy. This lack of clarity and oversight contributed to the deficiency in meeting the residents' immediate needs upon admission.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice by not obtaining physician's orders for water flushes during medication administration via G-tube for a resident. The facility's policy required a physician's order for such procedures, but the resident's Physician's Order Sheet did not include this order. Despite this, medications were administered without the necessary water flushes, as observed on multiple occasions. Interviews with staff revealed a lack of awareness and communication regarding the need for such orders, indicating a breakdown in protocol adherence. Additionally, the facility staff did not administer medications as directed by the physician and the Medication Administration Record (MAR). Specifically, Levothyroxine, which was ordered to be given on an empty stomach and separately from other medications, was administered alongside other medications. This was contrary to the instructions on the MAR and the facility's policy, which emphasized the importance of timing and separation of medication administration to enhance therapeutic effects. Staff interviews highlighted a lack of attention to these instructions, with one LPN admitting to not following the MAR directions. Furthermore, the facility staff failed to ensure that only licensed personnel documented medication administration via G-tube. The MAR showed documentation by Certified Medication Technicians (CMTs), who were not authorized to administer medications via G-tube. Interviews with staff, including the Director of Nursing (DON) and the facility administrator, revealed a lack of monitoring and auditing of MARs, leading to unauthorized documentation. This issue was compounded by the absence of a DON for a period, resulting in lapses in oversight and adherence to physician orders.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility staff failed to provide adequate hygiene care for four residents, resulting in unmet basic hygiene needs. The facility's Bath, Shower/Tub Policy, dated February 2018, requires staff to promote cleanliness, document shower/bath occurrences, and notify supervisors of refusals. However, observations and interviews revealed that residents were not receiving showers as scheduled, and documentation was inconsistent or missing. For instance, Resident #24, with mild cognitive impairment, was observed with greasy hair despite documented showers, indicating a lack of adherence to the care plan. Resident #32, who is cognitively intact and requires supervision for bathing, reported not having a shower in several weeks and feeling neglected. The care plan lacked specific directions for assistance with ADLs, and the shower sheets showed infrequent showers with no recent offers. Similarly, Resident #35, also cognitively intact, was observed with greasy hair and unclean fingernails, suggesting infrequent bathing despite documented showers. The care plan did not provide clear instructions for ADL assistance, contributing to the deficiency. Resident #48, newly admitted, had no documented showers since admission, and observations showed poor hygiene, including greasy hair and food debris on teeth. The resident expressed a need for assistance with bathing, which was not provided. Interviews with staff, including CNAs and an LPN, revealed a lack of consistent shower offers and documentation, partly due to the absence of a Director of Nursing (DON) for a period. The facility administrator acknowledged the expectation for regular showers and the lapse in monitoring during the DON vacancy.
Failure to Obtain Consent and Conduct Bed Rail Assessments
Penalty
Summary
The facility failed to obtain signed consents for the use of bed rails and did not complete necessary side rail assessments for four residents. The facility's policy requires an assessment of the resident's risk from using bed rails, obtaining informed consent, and a physician's order before installation. However, these steps were not followed for Residents #3, #15, #20, and #46, as their medical records lacked signed informed consents and bed rail assessments. Resident #3, who was assessed with severe cognitive impairment and required substantial assistance with toileting and transfers, was observed with the left side rail in the upright position on multiple occasions. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position over several days. Resident #20, who used side rails for bed mobility, and Resident #46 also had side rails in the upright position without the necessary consents or assessments. Interviews with facility staff, including an LPN and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy regarding bed rail assessments and consents. The staff were unsure about the responsibility for obtaining consents and completing assessments, leading to the deficiency in following the established procedures for bed rail use. The administrator acknowledged the oversight but was unsure why the assessments were not conducted quarterly as required.
Inadequate Staffing Leads to Unmet Hygiene Needs
Penalty
Summary
The facility failed to provide adequate staffing in accordance with their Facility Assessment, leading to unmet basic hygiene needs for several residents. The Facility Assessment outlined specific staffing requirements based on census numbers, but the employee schedules from August to December 2024 showed consistent understaffing across various shifts. This lack of sufficient staffing resulted in residents not receiving necessary care, such as showers and personal hygiene assistance, as documented in the observations and interviews with residents and staff. Resident #24, who was assessed with mild cognitive impairment and required partial assistance with personal hygiene, was observed with greasy hair on multiple occasions, indicating a lack of regular showers. Similarly, Resident #32, who was cognitively intact and required supervision for bathing, reported not being offered a shower for several weeks, leading to feelings of neglect. Resident #35, also cognitively intact and requiring assistance with personal hygiene, was observed with greasy hair and long, dirty fingernails, further highlighting the facility's failure to meet hygiene needs. Resident #48, who required assistance with ADLs, had not been documented as receiving a shower since admission, and was observed with greasy hair and food debris on teeth. Interviews with other residents and staff confirmed the perception of short staffing, with residents expressing dissatisfaction with the frequency of showers and staff acknowledging the lack of adequate assistance. The Director of Nursing and the administrator admitted to not following the Facility Assessment for staffing, instead relying on fire code regulations, which contributed to the deficiency in care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their policy. The review of the facility's RN staff schedule from July 2024 to January 2025 revealed numerous instances where the facility did not have an RN on duty for the required hours. Specifically, there were multiple days each month where the facility lacked RN coverage for the mandated eight consecutive hours, indicating a consistent pattern of non-compliance with the staffing requirement. Interviews conducted with the Director of Nursing (DON) and the facility administrator highlighted a lack of awareness and understanding of the regulatory requirements for RN coverage. The DON admitted to being unsure of the regulation and acknowledged the importance of having an RN for their expertise and knowledge. Similarly, the administrator was aware of the deficiency in RN coverage and recognized the significance of having an RN present for their advanced nursing knowledge. Despite this awareness, the facility failed to ensure adequate RN staffing, leading to the identified deficiency.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility staff failed to complete the required nurse staffing information, which included the facility census and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility's policy, dated July 2016, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care should be posted in a prominent location accessible to residents and visitors. However, reviews of the facility's daily staffing sheets from November 2024 to January 2025 showed that they did not contain the facility census or actual hours worked for licensed and non-licensed staff. Observations on multiple dates in January 2025 confirmed that the facility staff postings did not include the required information and were not readily accessible to residents and visitors. Interviews with the Director of Nursing (DON) and the administrator revealed that they were unaware of the missing information on the daily staffing sheets. Both acknowledged that the daily staff postings should include the facility census and actual hours worked and should be accessible to all residents and visitors. The responsibility for completing the daily staffing sheet was attributed to the charge nurses, specifically the night charge nurse, but the deficiency persisted due to a lack of awareness and oversight.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 28.13% error rate during the observation period. Out of 32 medication administration opportunities, nine errors were identified, affecting one resident. The errors were primarily due to the late administration of medications, which were given two hours and twenty minutes past the scheduled time. The facility's policy mandates that medications should be administered within one hour of their prescribed time, and any administration beyond this window is considered a medication error. The deficiency involved a resident who was supposed to receive multiple medications via a gastric tube during the morning medication pass. The medications included Levothyroxine, Midodrine, Vitamin D, Cyclobenzaprine, Eliquis, Fludrocortisone, Gabapentin, Fluoxetine, and Prenatal vitamins. The resident expressed concern about not receiving medications as scheduled, and the LPN responsible admitted to forgetting to administer them on time. The LPN acknowledged the error and the need to notify the Director of Nursing and the resident's physician, although this had not been done at the time of the interview.
Deficiencies in Dishwashing and Ice Machine Sanitation
Penalty
Summary
The facility staff failed to ensure the dishwashing machine operated according to the manufacturer's instructions, leading to inadequate sanitization of kitchen wares. Observations revealed that the dishwashing machine consistently failed to reach the required wash and rinse temperatures, with recorded temperatures as low as 90 degrees Fahrenheit for washing and 110 degrees Fahrenheit for rinsing. Additionally, the sanitizer concentration was below detection levels, as indicated by test strips that did not change color. Despite these issues, the Dietary Manager was unaware of the machine's failure to meet the necessary temperature and sanitizer concentration standards. The facility's manual warewashing process also demonstrated deficiencies. Staff were observed using a sanitizer concentration of 100 ppm, which was within the range stated by the Dietary Manager but not in accordance with the manufacturer's instructions, which required a concentration of 150-400 ppm. Furthermore, the sanitizing process was not consistently followed, with some items being removed from the sanitizer sink after only 30 seconds instead of the required one minute. The Dietary Manager admitted to not having read the sanitizer directions for use, indicating a lack of adherence to proper sanitization protocols. Additionally, the facility failed to maintain an air gap for the ice machine drain, which was directly connected to the floor drain without the necessary air gap. The maintenance director was unaware of this requirement, and the administrator confirmed that the maintenance director was responsible for the ice machine. This oversight further highlights the facility's failure to adhere to proper sanitation and safety standards, as the absence of an air gap can lead to potential contamination issues.
Lack of Effective QA/QAPI Program Documentation
Penalty
Summary
The facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program. The facility's policies did not include a policy for the QA/QAPI program. During an interview, the administrator stated that department heads meet quarterly to discuss various items within the facility, but there was no documentation available regarding these meetings, issues discussed, or resolutions made. The administrator was unaware that such information needed to be documented and maintained. The facility census at the time was 43.
Deficiencies in TB Testing and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own policy regarding the administration of the two-step purified protein derivative (PPD) skin test for tuberculosis (TB) for six employees. The policy required a second PPD test to be administered seven to 21 days after the first test if the initial result was negative. However, the second PPD tests for several employees were administered too soon, within five to six days after the first test, contrary to the policy. This discrepancy was attributed to the MDS Coordinator's misunderstanding of the policy and scheduling conflicts, as well as a lack of oversight from the Director of Nursing (DON) and the facility administrator. The facility also failed to implement its Enhanced Barrier Precautions (EBP) policy effectively. Staff were not educated or alerted about residents who required EBP, and appropriate personal protective equipment (PPE) was not placed in close proximity for residents with specific medical needs, such as feeding tubes and colostomies. Observations revealed that staff did not wear gowns when performing high-contact care activities, such as administering medications via G-tube or providing incontinence care, as required by the EBP policy. Interviews with staff indicated a lack of awareness and training regarding EBP requirements. The deficiencies in both TB testing and EBP implementation were compounded by inadequate communication and training from the facility's leadership. The new DON acknowledged the lack of oversight by the previous DON and the need for further education on EBP. The administrator also admitted that EBP precautions were not being followed and emphasized the importance of infection control. Despite these acknowledgments, the facility had not taken corrective actions to address these deficiencies at the time of the report.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. The policy required regular checks to ensure bed rails and mattresses were appropriately secured and did not pose entrapment risks. However, the facility did not adhere to these guidelines, as evidenced by the absence of entrapment risk assessments and maintenance inspections in the electronic medical records of the sampled residents. Resident #3, who had severe cognitive impairment and required substantial assistance with toileting and transfers, was observed multiple times with the left side rail in the upright position without any documented entrapment risk assessment or maintenance inspection. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position on several occasions, again without any documented assessments or inspections. Residents #20 and #46 also had side rails in the upright position without any documented entrapment risk assessments or maintenance inspections. Interviews with facility staff revealed a lack of awareness and adherence to regulations regarding bed rail safety. The Maintenance Director admitted to not conducting regular measurements of bed rails once installed and was unaware of any regulations requiring such measurements. The DON believed that the MDS coordinator was responsible for bed rail measurements but was not aware of specific regulations. The facility administrator was also unaware that entrapment assessments were not being conducted quarterly, as they believed was necessary. This lack of compliance with safety protocols and inadequate staff awareness contributed to the deficiency in ensuring resident safety.
Privacy Breaches in Resident Care and Information Handling
Penalty
Summary
The facility staff failed to protect the privacy and confidentiality of residents' personal and medical information. On two separate occasions, computer screens on medication carts were left open and unattended in public hallways, displaying sensitive medication information for two residents. This occurred despite the facility's policy requiring staff to lock or minimize computer screens when unattended. Interviews with staff, including the Care Plan Coordinator and an LPN, confirmed that the screens should have been secured to protect resident privacy. Additionally, during incontinence care for a resident, a CNA did not close the privacy curtain or window blinds, leaving the resident exposed to view from the parking lot. The resident expressed discomfort with the lack of privacy, and the CNA acknowledged the oversight, attributing it to nervousness. Interviews with the LPN and the Director of Nursing confirmed that staff are expected to ensure privacy by closing curtains and blinds during personal care activities.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility staff failed to complete the federally mandated Minimum Data Set (MDS) assessments within the required time frames for three residents out of a sample of six, with a total facility census of 43. The facility's policy, dated July 2017, outlines that the Assessment Coordinator or designee is responsible for ensuring timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system. However, the review of the MDS records for Residents #20, #24, and #48 revealed that the required assessments were not completed or submitted within the specified time frames as per the Resident Assessment Instrument (RAI) Manual guidelines. Interviews with the MDS Coordinator and the Director of Nursing (DON) highlighted issues contributing to the deficiency. The MDS Coordinator admitted to being behind on completing MDSs due to being frequently pulled to work on the floor, and acknowledged that there was no system in place to double-check the timely completion of MDSs. The DON, who was new to the facility, was unaware of the required time frames for MDS submissions. The administrator confirmed that the MDS Coordinator was responsible for completing the MDSs within the required time frames, while the DON was responsible for monitoring their completion. This lack of adherence to the required assessment time frames resulted in the deficiency noted by the surveyors.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #1, who was admitted on hospice care, did not have hospice services documented in their care plan, despite the facility's policy requiring such documentation. The Social Services Director and the MDS/Care Plan Coordinator acknowledged the oversight, noting that hospice directions should have been included in the resident's care plan. Resident #15, assessed as cognitively intact and independent in certain activities, had bed rails in use that were not documented in their care plan. Observations over several days confirmed the presence of bilateral U-Bars in the resident's bed, yet the MDS/Care Plan Coordinator mistakenly believed this was already included in the care plan. The absence of this information in the care plan was acknowledged as an oversight by the staff. Resident #16, with severe cognitive impairment and multiple diagnoses, had contractures in both upper and lower extremities that were not addressed in their care plan. Observations showed the resident in a broda chair with contracted hands, lacking any interventions. The MDS/Care Plan Coordinator admitted that interventions, such as placing washcloths in the resident's hands, were supposed to be documented but were not. The Director of Nursing and the facility administrator confirmed that the responsibility for these omissions lay with the MDS/Care Plan Coordinator, who was expected to update care plans regularly.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an Antibiotic Stewardship Program, which includes protocols and a system to monitor and track antibiotic use. The facility, with a census of 43, did not have a policy for antibiotic stewardship, and there was no process in place to track and trend antibiotic usage. Interviews revealed that the Director of Nursing (DON), who had been employed for only eight days, was unaware of any existing program. The Corporate Nurse admitted that the previous DON did not track and trend antibiotic use, and no one had been doing it. The administrator stated that the Infection Preventionist, who was the previous DON, was responsible for the program, but oversight was lacking, and she was unaware of the program's absence.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of physical aggression, grabbed the resident's arm. The incident involved two residents, one of whom was cognitively impaired and the other cognitively intact but with a history of aggressive behavior. The facility's policy defines abuse as the willful infliction of injury or intimidation resulting in harm, which includes resident-to-resident altercations. Resident #1, who was cognitively impaired, was involved in an altercation with Resident #2, who had a documented history of aggression and was assessed as cognitively intact. The care plan for Resident #2 included measures to reduce stimuli, monitor interactions, and intervene before agitation escalated. Despite these measures, Resident #2 was left unattended by LPN A, who was responsible for monitoring the resident one-on-one after returning from the hospital following a previous altercation. The incident occurred when Resident #1 propelled their wheelchair near Resident #2, who then grabbed Resident #1's arm. Surveillance footage showed no staff present at the time of the incident. Interviews revealed that LPN A was not informed of the need for continuous one-on-one monitoring, and there was a lack of communication among staff regarding the monitoring requirements for Resident #2. This failure to ensure proper supervision and adherence to the care plan led to the physical altercation between the residents.
Misappropriation of Resident Funds by CNA
Penalty
Summary
Facility staff failed to prevent the misappropriation of money from a resident's checking account when a Certified Nurse Assistant (CNA) cashed a check from the resident for personal use. The incident involved a resident who was assessed as moderately cognitively impaired with no behaviors. On June 22, 2024, the resident wrote a check for $400.00 to the CNA, who had asked to borrow the money to bail a relative out of jail, with the promise of repayment on the next payday. The resident kept the checkbook in their room and reported the incident to another CNA on July 27, 2024, after not being repaid. Upon discovery of the incident, the facility staff initiated an investigation and reported the misappropriation to the Department of Health and Senior Services, the local police department, and the resident's physician. The administrator conducted interviews with facility staff and residents, and it was confirmed that the CNA admitted to taking and depositing the check. The resident had also filed a grievance about the incident, and it was noted that a dental bill check had bounced around the same time the money was given to the CNA. The facility's policy on abuse, neglect, and exploitation mandates protection for residents' health, welfare, and rights, including the prevention of misappropriation of property. The policy requires immediate investigation of such allegations and reporting to the appropriate authorities. Staff are educated on these policies upon hire and annually, with additional training provided as needed. Despite these measures, the CNA involved in the incident admitted to knowing that accepting money from a resident was against policy.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy effectively, resulting in a deficiency related to resident safety. The policy, dated November 2017, mandates that any alleged perpetrator of abuse, neglect, or misappropriation of resident funds be immediately suspended from employment and removed from the property until the investigation is complete. However, the facility did not adhere to this policy when a Physical Therapy Assistant (PTA) accused of inappropriate conduct with a resident was allowed to continue working with other residents during the investigation. The administrator was aware of the allegation but did not suspend the PTA or ensure constant supervision as required by the policy. The incident involved a resident who was cognitively intact and had multiple diagnoses, including hypertension, end-stage renal failure, anxiety disorder, and a fracture. The resident reported feeling uncomfortable with the PTA's proximity and alleged that the PTA made inappropriate comments of a sexual nature. Despite these allegations, the PTA was observed in the facility without supervision, and the administrator admitted to not knowing if contracted staff should be treated the same as facility staff in such situations. This inaction led to a failure in protecting the resident and potentially others from further exposure to the alleged perpetrator.
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What surveyors actually found near you
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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 Fulton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fulton Nursing & Rehab | 0.6 mi | ★★★★★ | 4 | 0 |
| Kingdom Care Senior Living | 1.1 mi | ★★★★★ | 2 | 0 |
| Riverview Nursing Center | 13.3 mi | ★★★★★ | 0 | 0 |
| Lenoir Health Care Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Neighborhoods Rehabilitation And Skilled Nursing B | 19.4 mi | ★★★★★ | 4 | 2 |
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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.