Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Nursing & Rehab C during CMS and state inspections, most recent first.
Failure to Notify Physician of Weight Deviations: A resident with renal failure, DM2, HTN, CKD with HF, and dialysis had repeated weight gains exceeding the physician’s notification threshold, but the chart contained no documentation that the MD was notified as ordered. RN and ADON both verified the lack of documentation, and the facility policy required immediate notification of the attending physician and the resident’s advocate for significant changes.
A resident with multiple chronic conditions, moderate cognitive impairment, and a care plan for constipation had no documented BM for six days, and the record showed no evidence the facility addressed the missed documentation or implemented the bowel protocol during that time. The DON verified the lack of BM monitoring and documentation, and stated the issue was only discussed later at a clinical meeting after staff spoke with the resident.
Failure to Obtain Ordered Weights for Weight Monitoring: The facility failed to obtain ordered weights for a resident with cerebral infarction, COPD, and HTN. The resident had physician orders to monitor weekly weights and report significant gains or losses, but the record showed multiple gaps with no documented weights over several months, and the ADON verified the missing documentation.
Undated Oxygen Tubing: A resident with COPD, chronic respiratory failure, and CHF was receiving O2 via nasal cannula at 3 L/min, but the tubing was not dated as required by the physician order and facility policy. The UM verified the tubing was undated during observation, and the resident had moderately impaired cognition.
Failure to Monitor Side Effects for Anticoagulant and Antianxiety Medications: A resident with autistic disorder, Asperger's syndrome, CKD stage 4, HF, and type 2 DM was prescribed Xarelto for atrial fibrillation and buspirone for anxiety, but the record showed no evidence that staff monitored for side effects of either medication. The DON confirmed there was no documentation of side effect monitoring, despite the care plan and facility policies calling for monitoring of psychoactive and anticoagulant therapy.
A resident with Parkinson's disease and dementia received an incorrect, higher dosage of ropinrole due to a medication order entry error. The resident developed symptoms such as hypertension, headache, hallucinations, increased anxiety, and dizziness while receiving the wrong dosage. Despite these changes, the physician and family were not notified of the medication error or the resident's condition until the day after the error was discovered, contrary to facility policy requiring immediate notification.
A resident with moderate cognitive impairment and behavioral issues made multiple allegations of physical abuse by staff, which were witnessed and reported internally by nursing staff. Despite facility policy requiring immediate reporting of such allegations to the state survey agency, the administrator did not submit a report, citing the resident's history of making similar accusations. This resulted in a failure to comply with mandated abuse reporting procedures.
A resident with dementia and behavioral issues repeatedly accused staff of physical abuse, with several staff members witnessing or hearing concerning events and reporting them to supervisors. Despite these reports and the facility's policy requiring investigation, no formal inquiry was conducted, key witnesses were not interviewed, and the alleged perpetrator was not placed on leave.
A resident with Parkinson's disease and dementia was administered an incorrect, significantly higher dose of ropinrole after an LPN entered the order incorrectly into the EMR. The error went unnoticed by pharmacy and management, resulting in the resident experiencing hypertension, headache, hallucinations, increased anxiety, and dizziness.
Failure to Notify Physician of Significant Weight Gains
Penalty
Summary
The facility failed to notify the physician of weight deviations in accordance with physician orders for one resident reviewed for weight. The resident was admitted with diagnoses including renal failure, type II diabetes mellitus, hypertension, hypertensive heart and chronic kidney disease with heart failure with stage five chronic kidney disease, disorder of the kidney and ureter, and peripheral vascular angioplasty with implants and grafts. The MDS dated 03/31/26 indicated the resident had no cognitive impairment and received dialysis treatments. The care plan directed that the resident be weighed at the same time of day and recorded as ordered, and a physician order dated 03/03/26 required daily weights for three days with notification of the physician for weight gains of 3 lbs. in 24 hours or 5 lbs. in one week. Review of the weight record from 02/26/26 through 04/13/26 showed multiple weight gains of more than 3 lbs. in 24 hours, including gains of 3.2 lbs., 5.5 lbs., 5.6 lbs., 8.2 lbs., 4.3 lbs., 11.1 lbs., 7.5 lbs., and 3.8 lbs. Review of progress notes for the same period found no documentation that the physician was notified of these weight deviations. RN #501 and ADON #359 both verified they could not locate documentation showing the physician was notified of the resident's weight gains as ordered. The facility policy titled Change of Status Notification stated the facility would notify the attending physician and the resident's advocate immediately of any significant change in the resident's medical condition.
Failure to Monitor Bowel Movements and Follow Bowel Protocol
Penalty
Summary
The facility failed to adequately monitor bowel movements and implement the bowel protocol as needed for one resident. The resident was admitted with diagnoses including spinal stenosis, paroxysmal atrial fibrillation, hypertensive chronic kidney disease, chronic kidney disease stage III, hyperlipidemia, hypothyroidism, fibromyalgia, and dysphagia. The MDS dated 02/25/26 showed the resident was moderately cognitively impaired, required partial/moderate assistance with toileting, was occasionally incontinent of bladder, and was always continent of bowel. The care plan identified constipation related to decreased mobility, diminished appetite, and medication use/side effects, with interventions to record bowel movement patterns each day and follow the facility bowel protocol. Review of bowel tracking for the last 30 days showed no documented bowel movement from 03/31/26 through 04/06/26, and the medical record contained no evidence that the facility addressed the lack of bowel movements during that period. The DON verified the lack of documentation and stated the issue was discussed at the clinical meeting on 04/07/26, when staff spoke with the resident and determined she had recently had a bowel movement. The DON also verified the facility did not document or monitor the resident's bowel movements until there had been no documented bowel movement for six days.
Failure to Obtain Ordered Weights for Weight Monitoring
Penalty
Summary
The facility failed to obtain Resident #62’s weights as ordered to monitor for gains and losses. Resident #62 was admitted with diagnoses including cerebral infarction, COPD, and hypertension, and was assessed as cognitively intact on the MDS. The medical record included a physician order dated 10/28/24 to monitor, record, and report significant weight loss of 3 lbs. in one week, more than 5% in one month, more than 7.5% in 3 months, or more than 10% in 6 months. A later physician order dated 10/15/25 directed staff to weigh the resident weekly and notify the physician of any 3 lb. weight gain in a day or 5 lb. gain in a week, with the resident to be weighed every day shift every Saturday for weight monitoring. Review of the weight record summary showed multiple gaps with no documented weights across several date ranges from September 2025 through March 2026, and progress notes contained no evidence that the resident was weighed during those missing periods. The ADON verified that there was no documentation of the resident’s daily or weekly weights being obtained to determine gains or losses per the physician orders.
Undated Oxygen Tubing
Penalty
Summary
Supplemental oxygen tubing for Resident #40 was not properly labeled and dated. Resident #40 was admitted with diagnoses including COPD, chronic respiratory failure with hypoxia and hypercapnia, hypertensive heart disease with heart failure, and CHF, and her MDS showed moderately impaired cognition. A physician order dated 01/07/26 directed oxygen via nasal cannula at 3 liters per minute and required the oxygen tubing to be changed and dated weekly on Monday during night shift for infection prevention. During observation on 04/13/26 at 2:05 P.M., Resident #40 was seated in her wheelchair with oxygen in use via nasal cannula connected to an oxygen concentrator set at 3 liters per minute, and the oxygen tubing was not dated. The Unit Manager verified that the resident was receiving oxygen at 3 liters per minute and acknowledged that the tubing was not dated. The facility policy stated that disposable oxygen-related items, including oxygen tubing, are to be changed weekly on Mondays and dated on the day they are changed.
Failure to Monitor Side Effects for Anticoagulant and Antianxiety Medications
Penalty
Summary
The facility failed to establish adequate monitoring of medication side effects for Resident #3, who was reviewed for unnecessary medications. Resident #3 was admitted with diagnoses including autistic disorder, Asperger's syndrome, chronic kidney disease stage four, heart failure, and type two diabetes mellitus. The most recent MDS assessment identified the resident as cognitively intact. The care plan included use of antianxiety medications and interventions to monitor, document, and report any adverse reactions to antianxiety therapy. The resident had physician orders for Xarelto 20 mg by mouth daily for atrial fibrillation and buspirone 10 mg by mouth twice daily for anxiety. Review of the medical record revealed no evidence that facility staff monitored for side effects of either Xarelto or buspirone. The DON verified during interview that the resident did not have documentation of side effects being monitored for these medications. Facility policy stated that behavior documentation for psychoactive medications should include monitoring for effectiveness, side effects, and adverse effects, and that residents receiving anticoagulant therapy should be monitored daily for signs or symptoms of internal bleeding, bruising, hematuria, or changes in mental status.
Failure to Timely Notify Physician and Family of Medication Error and Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician and resident representative of a significant change in condition for a resident diagnosed with Parkinson's disease and dementia. The resident was admitted with intact cognition and had a physician order for ropinrole 0.5 mg three times daily. However, the medication order was incorrectly entered into the Medication Administration Record (MAR) as 5 mg four times daily, resulting in the resident receiving a much higher dosage than prescribed over several administrations. During the period the incorrect dosage was administered, the resident experienced symptoms including hypertension, headache, hallucinations, increased anxiety, and dizziness. Despite these symptoms and the discovery of the medication error, there was no evidence that the physician or the resident's family were notified of the error or the resident's change in condition until the following day. The facility's policy required immediate notification of the attending physician and resident advocate in the event of a significant change in medical condition, which was not followed in this instance.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment and a history of behavioral disturbances. The resident, who had diagnoses including dementia with agitation, major depressive disorder, and Alzheimer's disease, exhibited behaviors such as yelling, making accusations against staff, and threatening self-harm. On multiple occasions, the resident accused staff of physical abuse, including being hit and kicked by a nurse, and these allegations were witnessed and reported by certified nursing assistants and a registered nurse. Witness statements indicated that staff heard noises consistent with a possible physical altercation and observed the resident in distress immediately after interactions with the accused staff member. Despite these allegations and witness observations, the facility did not submit a Self-Reported Incident (SRI) to the state survey agency as required by their policy. The policy mandates immediate reporting of abuse allegations involving employees, but a review of the Certification and Licensure System showed no evidence of such a report being filed for this incident. Interviews with staff and administration confirmed that the incident was communicated internally, but the administrator decided not to report the allegation to the state due to the resident's history of making similar accusations. The facility's failure to report the abuse allegation was in direct violation of its own policy, which requires prompt notification of the state agency for any employee-related abuse allegations. The administrator acknowledged receiving the report from nursing staff but did not follow through with the mandated external reporting process. This omission was identified during a review of medical records, staff interviews, and facility documentation.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident with moderate cognitive impairment, dementia, and behavioral issues. The resident, who was dependent on staff for several activities of daily living, made multiple accusations against staff, including being hit, kicked, and punched. On specific occasions, staff members heard noises and observed the resident yelling out in pain, with one CNA reporting hearing a 'smack' and the resident immediately accusing a nurse of hitting her. Multiple staff members documented the resident's repeated claims of being struck by a staff member, and these incidents were reported to supervisory staff. Despite these allegations, the facility did not initiate a formal investigation as required by its own policy. Witness statements were collected by some staff and left for the Administrator, but key steps were omitted: the alleged perpetrator was not placed on leave, no skin assessment was performed on the resident, and other potential witnesses were not interviewed. Staff who reported the incident or wrote statements were not interviewed about the event, and the Administrator confirmed that no investigation was conducted due to the resident's history of making false allegations. The facility's policy required that all allegations of abuse be investigated, including securing the resident, assessing for injury, identifying the alleged perpetrator, notifying appropriate parties, and obtaining interviews or statements from all involved. These procedures were not followed in this case, resulting in a failure to respond appropriately to the alleged violations as required.
Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease and dementia was prescribed ropinrole HCl 0.5 mg three times daily, but the order was incorrectly entered into the electronic medical record as 5 mg four times daily. As a result, the resident received significantly higher doses of the medication over multiple administrations. The error was not detected by the pharmacy or management, and the medication was administered as entered in the system. Following the administration of the incorrect dosage, the resident experienced adverse symptoms including hypertension, headache, hallucinations, increased anxiety, and dizziness. The error was confirmed through interviews with the Director of Nursing and the LPN responsible for entering the order, both of whom acknowledged the mistake and the lack of system alerts or oversight that could have prevented the error.
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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 Wauseon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ayden Healthcare Of Wauseon | 0.7 mi | ★★★★★ | 5 | 0 |
| Fairlawn Haven | 8.7 mi | ★★★★★ | 0 | 0 |
| Northcrest Rehab And Nursing Center | 9.6 mi | ★★★★★ | 1 | 0 |
| Lutheran Home | 11.2 mi | ★★★★★ | 0 | 0 |
| Embassy Of Swanton | 12.3 mi | ★★★★★ | 4 | 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.