Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fulton Nursing & Rehab during CMS and state inspections, most recent first.
Staff failed to complete physician-ordered weekly skin assessments for three residents who were cognitively impaired, at risk for pressure ulcers, or had existing stage 3 pressure ulcers. Despite orders for weekly assessments and the expectation that licensed nurses perform these assessments even when a resident is under wound care, multiple scheduled assessment dates over several months lacked documentation of completion in the EHR. In interviews, the interim DON confirmed that weekly skin assessments are required and acknowledged that they were not being done, and the administrator similarly acknowledged awareness of the issue, attributing missed assessments to nurses being busy.
Surveyors found that the facility failed to update and revise comprehensive care plans to address aggressive and disruptive behaviors and did not complete required quarterly care plan reviews in conjunction with the MDS. Several severely cognitively impaired residents had documented incidents of threatening, hitting, kicking, slapping, yelling, and cursing at peers, yet their care plans either lacked any behavioral interventions or were not revised to include new interventions after these events. Staff interviews with an LPN, the DON, and the MDS Coordinator confirmed that care plans were expected to be updated after behavioral incidents and at regular intervals, but this did not occur, partly because the MDS Coordinator was solely responsible for revisions and had been absent for an extended period.
Staff did not consistently separate residents who tested positive for COVID-19 from those who tested negative, resulting in both groups sharing rooms and common areas without masks. Several residents were not consulted about room changes despite their preferences, and staff interviews revealed confusion about which residents were COVID-positive and a lack of proper signage and PPE disposal. Leadership acknowledged that while a list of positive residents was available, not all staff were aware of it or following infection control protocols.
Facility staff did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, as required. Staffing records showed multiple days without proper RN coverage, and interviews with the DON, administrator, and ADON revealed they were unaware of the specific lapses. The administrator attributed the deficiency to recent RN staff losses and challenges in scheduling, particularly on weekends.
Facility staff did not notify a resident's DPOA following a significant change in condition that led to a hospital transfer for psychiatric evaluation. Despite facility policy requiring immediate notification of family or legal representatives, the family only learned of the transfer after contacting the facility themselves. Staff interviews revealed confusion about responsibility for ensuring notification and documentation.
A resident with lower extremity impairment and using a manual wheelchair was subjected to physical abuse when a floor technician aggressively pulled the wheelchair, causing the resident to fall to the ground. Multiple staff witnessed the technician yelling and roughly handling the resident, who reported both physical pain and emotional distress as a result.
Two residents with impaired cognition were involved in an incident of inappropriate touching, where one resident raised their shirt and another touched their chest. The event was witnessed by a CMT and reported to an RN. Despite facility policies to prevent abuse, the incident highlights a lapse in monitoring and preventing inappropriate interactions between residents.
Facility staff failed to use appropriate infection control procedures during medication administration for two residents and did not ensure TB screening for three employees. Observations showed lapses in hand hygiene and handling of medications, and interviews confirmed non-compliance with facility guidelines. Additionally, the facility lacked a policy for catheter care, affecting the quality of care for residents with indwelling catheters.
Facility staff failed to maintain bathroom doorframes, sink counters, and floors in good repair, resulting in brown stains, broken sink counters, and rusted door frames in resident-occupied rooms. Staff were aware of the issues but cited difficulties in obtaining support for materials needed for repairs.
Facility staff failed to provide written information of the bed hold policy at the time of hospital transfer for three residents. Interviews revealed a lack of awareness among staff regarding the responsibility for completing bed hold notifications.
The facility staff failed to perform a significant change in status MDS assessment for two residents who experienced significant changes in their conditions. One resident elected hospice care, and another had a decline in their ability to perform ADLs. Despite the facility's policy requiring timely completion of these assessments, they were not done. Observations confirmed the residents' dependence on staff for care, and interviews revealed a lack of a full-time MDS nurse and unfamiliarity with the MDS process.
The facility staff failed to develop comprehensive care plans for four residents, leading to deficiencies in meeting their medical and nursing needs. Care plans were outdated and did not reflect significant changes in residents' conditions, such as the need for mechanical lifts, increased assistance, and hospice care. Interviews with staff confirmed that care plans should be comprehensive and updated regularly, but this was not adequately done.
Facility staff failed to obtain hydration orders for a resident with a gastric tube, did not complete required weight monitoring for multiple residents, and did not properly document falls and follow-up for a resident. These lapses indicate non-compliance with professional standards of care and facility policies.
Facility staff failed to provide appropriate personal hygiene for three dependent residents. One resident was observed with long facial hair and disheveled hair despite preferring to be clean-shaven. Another resident was observed with long facial hair multiple times, and a third resident reported having only one bath in a month and was observed with disheveled hair and food crumbs on clothing. Staff interviews confirmed that personal hygiene practices were not consistently followed.
Facility staff failed to ensure a safe environment by not using foot pedals during wheelchair propulsion, improperly using mechanical lifts, and not safely storing medications in a resident's room. These actions were confirmed through observations and staff interviews, highlighting a lack of adherence to safety protocols.
Facility staff failed to ensure residents' drug regimens were free from unnecessary drugs by not attempting GDR for psychotropic medications for four residents. Despite pharmacy recommendations, the medical records lacked completed GDRs, and the process for handling these recommendations was not followed.
Facility staff failed to monitor and store medication safely, resulting in expired medications in the storage room and unsecured medication on top of the cart. Interviews confirmed that CMTs and nurses are responsible for monitoring medication storage, but expired medications were still found. Additionally, an unsecured plastic box with resident medications was left on top of the medication cart, posing a safety risk.
Facility staff failed to designate a qualified Dietary Manager (DM). The DM's personnel record lacked documentation of food service experience or certification. The DM admitted to not being certified and not knowing all requirements. Both the DON and the administrator confirmed the necessity of certification, with the DON highlighting potential risks to residents.
Facility staff failed to protect residents' personal information by leaving EHR screens unlocked and unattended in public hallways. Observations showed a CMT and a CNA leaving EHR screens with resident information visible while administering medication. Interviews with staff confirmed that EHR screens should always be locked when unattended to protect residents' privacy.
Facility staff failed to complete the required Comprehensive MDS within the mandated timeframe for two residents. The facility lacked a full-time MDS nurse, and efforts to fill the role temporarily with a corporate nurse and the DON were insufficient to meet the required assessment deadlines.
Facility staff failed to complete the required Quarterly MDS assessments within the mandated timeframe for two residents. The facility lacks a full-time MDS nurse, and the current staff, including a corporate nurse and the new DON, are trying to manage the MDS assessments until the position is filled. Staff are expected to use the RAI manual as a guide to complete and submit the MDS data timely.
Facility staff failed to correctly assess a resident receiving an anticoagulant and another resident for their preferences and oral/dental status. The facility lacked a full-time MDS nurse, and the DON was new and unfamiliar with the MDS process. The corporate nurse and DON were assisting with MDS assessments until a floor nurse could fill the role full-time.
Facility staff failed to ensure that the three most recent years of survey results were posted and readily accessible to residents, family members, or representatives. Observations on multiple dates confirmed the absence of the survey results, and an LPN and the administrator were unable to locate them.
The facility staff failed to complete required neurological checks and fall follow-up documentation for three residents who experienced falls and did not perform weekly skin assessments for two residents. Interviews revealed a lack of clarity and accountability among staff, exacerbated by the absence of a DON.
Failure to Complete Ordered Weekly Skin Assessments for At-Risk and Wounded Residents
Penalty
Summary
Facility staff failed to provide ordered weekly skin assessments for three residents who were cognitively impaired or had existing pressure ulcers, despite physician orders and facility expectations. One resident, assessed on a quarterly MDS as severely cognitively impaired and at risk for developing pressure ulcers, had physician orders in February and March 2026 for weekly skin assessments. Review of the weekly skin assessment documentation showed no evidence that staff completed these assessments on multiple ordered dates, specifically 2/20/26, 2/27/26, 3/13/26, 3/20/26, and 3/27/26. A second resident, assessed on a comprehensive MDS as cognitively intact with two stage 3 pressure ulcers, also had physician orders in January, February, and March 2026 for weekly skin assessments, but the record lacked documentation of completion on 1/20/26, 2/3/26, 2/24/26, 3/3/26, 3/10/26, and 3/17/26. A third resident, assessed on a quarterly MDS as moderately cognitively impaired and at risk for developing pressure ulcers, had physician orders for weekly skin assessments over the same three-month period, yet the weekly skin assessment records did not show completion on 1/1/26, 1/8/26, 1/22/26, 1/29/26, 2/5/26, 2/12/26, 2/27/26, 3/6/26, 3/13/26, and 3/20/26. In interviews, the interim DON stated that weekly skin assessments should be done for all residents, including those under wound care, and acknowledged that they were not being completed, attributing this to heavy workload. The administrator also acknowledged awareness that weekly skin assessments were not being done, stating that nurses get busy and the assessments are not completed.
Failure to Update Behavioral Care Plans and Conduct Timely Quarterly Reviews
Penalty
Summary
The deficiency involves the facility’s failure to develop, update, and revise comprehensive, individualized care plans to address residents’ aggressive and behavioral symptoms, and to review and update care plans at least quarterly in conjunction with the MDS. Facility policy required an individualized comprehensive care plan with measurable goals and time frames, ongoing assessment with revisions as changes occur, and periodic review and updating by the interdisciplinary team when significant changes or other care-impacting changes occur. Despite this, three residents with severe cognitive impairment had documented aggressive or disruptive behaviors that were not reflected in their care plans, and two residents’ care plans were not updated on a quarterly basis as required. One resident, assessed on a quarterly MDS as severely cognitively impaired and without physical behavioral symptoms toward others during the look-back period, had no care plan directions or interventions for aggressive behaviors despite three documented altercations with other residents, including threats with a knife and hitting and slapping peers. A second resident, also severely cognitively impaired and assessed on a quarterly MDS as not exhibiting physical behavioral symptoms toward others, had no care plan guidance for aggressive behavior after kicking another resident in the dining room, and the care plan was not updated quarterly. A third severely cognitively impaired resident had a care plan listing multiple behaviors such as attempting to hit peers and staff, rummaging, making sexual comments, shouting, and refusing care, but no new intervention was added after an altercation involving yelling and cursing at another resident. In interviews, an LPN, the DON, and the MDS Coordinator each stated that new interventions should be added after behavioral incidents and that care plans should be updated quarterly, annually, and after significant changes, but acknowledged that care plans were not consistently updated, in part because the MDS Coordinator was the only person revising care plans and had been out sick for an extended period.
Failure to Cohort and Isolate COVID-19 Positive Residents
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, specifically in the management of residents who tested positive for COVID-19. Despite having a policy that directs staff to isolate or cohort residents with confirmed or suspected SARS-CoV-2 infection, staff did not consistently separate residents who tested positive from those who tested negative. Multiple observations showed that residents with positive COVID-19 test results were housed in the same rooms as residents with negative results, and neither group consistently wore masks. Additionally, COVID-positive residents were observed in common areas, such as hallways and dining rooms, in close proximity to other residents and staff. Interviews with residents and their representatives revealed that several residents were not asked if they wanted to move rooms when their roommate tested positive for COVID-19, despite expressing a preference not to share a room with an infected individual. Staff interviews indicated a lack of clear communication and awareness regarding which residents were COVID-positive. Some staff members, including a Certified Medication Technician and the Assistant Director of Nursing, were unaware of the COVID status of residents or the absence of appropriate signage and PPE disposal materials in affected rooms. The Infection Preventionist acknowledged that interventions such as room trays, some room changes, and mask usage had been implemented, but also noted that many residents refused to wear masks outside their rooms. Leadership interviews highlighted inconsistencies in staff education and communication regarding infection control protocols. While a list of COVID-positive residents was reportedly posted at the nurse's station, several staff members were unaware of it or did not know which residents required isolation or specific PPE. The Director of Nursing and Infection Preventionist were identified as responsible for ensuring compliance, but gaps in implementation and staff knowledge were evident throughout the facility.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. Record review showed that the facility did not have a policy regarding RN services, and the Facility Assessment indicated the need for at least one RN for eight hours daily. Staffing assignment records for September and October revealed multiple days where there was no documentation of RN coverage for the required period. Specifically, there was no RN coverage for eight consecutive hours on several dates in both months. Interviews with the Director of Nursing (DON), administrator, and Assistant Director of Nursing (ADON) confirmed awareness of the requirement but also revealed a lack of awareness regarding the specific days when coverage was not met. The administrator cited recent RN staff losses and difficulty in providing daily RN coverage, especially on weekends, and stated that efforts to hire more RNs were ongoing. The ADON, who had recently taken over scheduling, was also unaware of the missed coverage on the identified dates.
Failure to Notify Responsible Party of Resident Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party following a significant change in the resident's condition that resulted in a hospital transfer. The facility's policy requires immediate notification of the resident, physician, and legal representative or family member when there is a significant change in the resident's status or a decision to transfer or discharge. In this case, a resident with severe cognitive impairment, multiple psychiatric diagnoses, and an active Durable Power of Attorney (DPOA) was transferred to a psychiatric center for evaluation due to agitation and physical behaviors. Documentation showed that the family was not informed of the transfer at the time it occurred. The resident's family member, who was the active DPOA, only learned of the transfer after calling the facility the following morning. Interviews with facility staff, including the Social Service Director, DON, and administrator, confirmed that nurses are expected to notify families and document such notifications, but there was uncertainty and lack of clarity regarding responsibility for ensuring this process was completed. The LPN involved stated that they may have forgotten to document the notification, and the DON acknowledged responsibility for oversight of this process.
Resident Physically Abused During Wheelchair Transfer by Floor Technician
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a floor technician aggressively pulled the resident's wheelchair, resulting in the resident falling out of the wheelchair and onto the ground. The resident, who was cognitively intact but had impairment to both lower extremities and used a manual wheelchair, was involved in a verbal altercation with the floor technician. Multiple staff interviews confirmed that the floor technician yelled at the resident, refused to allow the resident to smoke, and then forcefully moved the wheelchair, causing the fall. The resident reported feeling hurt and emotionally distressed by the incident, stating it made them not want to go outside anymore. Witnesses, including a CNA, a housekeeper, and the dietary manager, observed the floor technician's rough handling and lack of assistance after the resident fell. The resident was assisted back into the wheelchair by other staff members. The incident was reported to the facility administrator, and the resident was assessed for injury. The floor technician stated that the resident was cursing and claimed the resident threw themselves to the ground, but this account was not supported by other staff interviews.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility staff failed to protect two residents from sexual abuse when one resident raised their shirt, and another resident touched their chest inappropriately. This incident occurred in a facility with a census of 34 residents. The event was witnessed by a Certified Medication Technician (CMT) who reported it to a Registered Nurse (RN). Both residents involved were assessed to have impaired cognition, with one resident having diagnoses of Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, and the other having Unspecified Dementia, anxiety disorder, and Alzheimer's Disease. The facility's policy on abuse, neglect, and misappropriation emphasizes the prevention of abuse by providing information on reporting concerns and establishing a safe environment. However, the policy also requires staff to identify, assess, and monitor residents with behaviors that include sexually aggressive behavior. In this case, the staff observed one resident with their shirt raised and another resident touching them inappropriately, indicating a failure to adequately monitor and prevent such interactions between residents with cognitive impairments. The incident was documented in the facility's investigation summary, which noted that both residents had cognitive impairments and did not recall the incident. Interviews with staff members, including the administrator, Director of Nursing (DON), and the CMT who witnessed the event, confirmed the inappropriate touching and the immediate separation of the residents. Despite the facility's policies, the incident highlights a lapse in monitoring and preventing inappropriate interactions between residents with cognitive impairments.
Infection Control and TB Screening Deficiencies
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during medication administration for two residents. Specifically, staff did not perform hand hygiene between administering medication to different residents, handling medication bottles, and administering eye drops. Observations showed that a Certified Medication Technician (CMT) did not perform hand hygiene after administering medication, using a keyboard, and preparing medication before administering it to another resident. Additionally, a Certified Nurses Aide (CNA) was observed removing Tylenol tablets from a bottle with bare hands and placing them into a medication cup, and the same CMT did not perform hand hygiene or wear gloves before administering eye drops to a resident. Interviews with the Director of Nursing (DON) and the administrator confirmed that these actions were against the facility's guidelines and infection control policies, which were found to be lacking in specific instructions for hand hygiene during medication administration and eye drop instillation. The facility also failed to ensure that all employees were screened for Tuberculosis (TB) as per policy and state law. Three employees, including a Dietary Aide, a CNA, and a CMT, did not have documented two-step purified protein derivative (PPD) tests completed and recorded in their personnel files. The facility's guidelines and Missouri state regulations require that all employees undergo a two-step TB test within one month prior to or after starting employment, with annual follow-up tests. Interviews revealed that the facility did not have a designated MDS coordinator responsible for overseeing the TB testing process, leading to lapses in documentation and compliance. Additionally, the facility did not provide a policy for catheter care, which is crucial for residents with indwelling catheters. One resident was assessed to have an indwelling catheter and a diagnosis of benign prostatic hyperplasia, which requires careful monitoring and management. The absence of a catheter care policy indicates a gap in the facility's infection prevention and control program, further compromising the quality of care provided to residents.
Failure to Maintain a Homelike Environment
Penalty
Summary
Facility staff failed to provide a comfortable and homelike environment for residents by not maintaining bathroom doorframes, sink counters, and floors in good repair. Observations revealed multiple instances of brown stains, broken sink counters, rusted door frames, and excessive caulking around toilet bases in various resident-occupied rooms. The facility's policies did not include a specific policy regarding the environment, and the housekeeping and maintenance job descriptions, dated May 2006, outlined expectations for cleaning and minor repairs that were not met. Interviews with staff indicated awareness of the issues but highlighted a lack of timely action to address them. Housekeeping staff reported cleaning the bathrooms daily and notifying maintenance of needed repairs, while maintenance staff acknowledged the damage but cited difficulties in obtaining support for materials. The Director of Nursing confirmed that maintenance is responsible for repairs and emphasized that damage should be repaired quickly. Despite these acknowledgments, the deficiencies persisted, compromising the residents' right to a safe, clean, and comfortable environment.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
Facility staff failed to provide written information of the facility's bed hold policy at the time of transfer to the hospital to the resident and/or resident's representative for three residents. The facility's Bed Hold Guidelines state that notification should be given at the time of transfer, but this was not documented for Residents #14, #24, and #45. Resident #14 was transferred to the hospital and returned over a month later, Resident #24 was transferred and returned within a week, and Resident #45 was transferred and remained hospitalized at the time of the report. None of their medical records contained documentation that the bed hold policy was communicated at the time of discharge. Interviews with facility staff revealed a lack of awareness and clarity regarding the responsibility for completing bed hold notifications. The administrator indicated that the charge nurse is responsible for completing bed holds but believed that the licensed nursing staff were not aware of this requirement. An LPN confirmed that bed holds should be given to residents sent to the hospital but could not explain why they were not completed. The DON, who was new to the position, acknowledged knowing about the form but was unsure who was responsible for completing it.
Failure to Perform Significant Change in Status Assessments
Penalty
Summary
The facility staff failed to perform a significant change in status Minimum Data Set (MDS) assessment for two residents who experienced significant changes in their conditions. One resident elected hospice care, and another resident had a decline in their ability to feed themselves, transfer, and perform toilet hygiene. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, mandates that a significant change in status assessment (SCSA) must be completed within 14 days of determining a significant change in a resident's condition. However, this was not done for the two residents in question. Resident #14, who was cognitively impaired and diagnosed with dementia, experienced a decline in their ability to perform activities of daily living (ADLs) such as eating, transferring, and toilet hygiene. The resident was discharged to the hospital and returned with orders for nothing by mouth (NPO) and artificial nutrition via a gastric tube. Despite these significant changes, the facility did not complete or submit an SCSA for this resident. Observations confirmed the resident's dependence on staff for transfers and hygiene, as well as the administration of nutrition through a gastric tube. Resident #37, who was cognitively impaired and diagnosed with dementia and stroke, was admitted to hospice care. The facility's records did not contain an order for hospice, a care plan for hospice, or a completed/submitted SCSA when the resident elected hospice services. Interviews with the facility's administrator and Director of Nursing (DON) revealed that the facility did not have a full-time MDS nurse, and the current staff were not familiar with the MDS process. The administrator acknowledged that the staff should use the RAI manual as a guide to complete and submit the MDS data timely.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop a comprehensive person-centered care plan for four of six sampled residents, leading to deficiencies in meeting the residents' medical and nursing needs. Resident #14's care plan did not reflect significant changes, such as the need for a mechanical lift for transfers, increased assistance for toileting, and a change to gastric tube feeding. Despite physician orders and observations confirming these needs, the care plan remained outdated and incomplete. Resident #20's care plan lacked directions for fall risk, pressure injury risk, nutrition for pressure injury risk, and communication needs, despite the resident's history of falls, cognitive impairment, and other medical conditions. After an unwitnessed fall, the care plan was not updated with new interventions to prevent future falls. Similarly, Resident #35's care plan did not address facial hair preferences, contracture management, or changes to diet and required assistance, even though observations and physician orders indicated these needs. Resident #37's care plan did not include directions for hospice care, despite the resident being admitted to hospice. Interviews with facility staff, including the LPN assuming the role of MDS nurse and the Director of Nursing, confirmed that care plans should be comprehensive and updated regularly to reflect the residents' needs. However, the care plans for these residents were not adequately maintained, leading to deficiencies in their care.
Deficiencies in Hydration Orders, Weight Monitoring, and Fall Documentation
Penalty
Summary
Facility staff failed to meet professional standards of care in several instances. For Resident #14, the nursing staff did not obtain a physician's order for water flushes for the gastric tube, despite the resident receiving all hydration via the tube. The LPN administered water flushes based on instructions from another nurse, but there was no documented order for this procedure. The Director of Nursing (DON) confirmed that an order should have been obtained to prevent dehydration, but was unaware that the record lacked this order. The facility also failed to complete resident weights as required by their policy. Resident #6 had an order for weekly weights, but weights were only documented sporadically. Resident #29 had an order for monthly weights, but no weight was documented for April. Resident #35, who had a Stage III pressure wound, did not have weekly wound assessments or measurements documented for specific weeks, and weights were missing for several weeks following a hospital readmission. The Restorative Aide responsible for obtaining and documenting weights was unaware of the missing entries, and the DON acknowledged that missing weights could lead to negative outcomes for residents. Additionally, the facility did not properly document falls and follow-up for Resident #2. The resident experienced falls on two occasions, but staff did not complete the required Event Report forms. The DON and the administrator both confirmed that an Event Report should be filled out for each fall, and a 72-hour neuro check should be initiated if the fall is unwitnessed. These deficiencies indicate lapses in adherence to facility policies and procedures, potentially compromising resident care and safety.
Failure to Provide Appropriate Personal Hygiene
Penalty
Summary
Facility staff failed to provide appropriate personal hygiene for three residents who were dependent on staff for their daily care needs. Resident #28, who was moderately cognitively impaired and diagnosed with debility, heart disease, lung disease, and dementia, was observed multiple times with long facial hair, disheveled hair, and an unkempt appearance. Despite the resident's preference to be clean-shaven and clean-looking, staff did not provide the necessary grooming. Similarly, Resident #35, who was cognitively impaired and dependent on staff for personal hygiene, was observed with long facial hair on multiple occasions. The care plan for Resident #35 did not include facial hair preferences, and staff interviews revealed that dependent residents should be shaved on bath/shower days and in between if noticed, but this was not consistently done. Resident #251, who had diagnoses including cancer, hypertension, benign prostatic hyperplasia, dementia, and schizophrenia, was observed with disheveled hair and food crumbs on clothing on multiple occasions. The resident reported having only one bath in a month and feeling unclean. Staff interviews indicated that residents are scheduled to get showers twice a week, and personal hygiene should be documented in progress notes and shower sheets. However, the observations and resident's statements indicated that these practices were not consistently followed. The Director of Nursing and the administrator confirmed that dependent residents should be showered twice a week and that refusals should be documented, but this was not reflected in the care provided to Resident #251.
Failure to Ensure Safe Environment and Proper Medication Storage
Penalty
Summary
Facility staff failed to ensure a safe environment for residents by not adhering to proper wheelchair propulsion protocols. Specifically, three residents were observed being propelled in wheelchairs without foot pedals, causing their heels to touch the floor. This was confirmed through interviews with staff, who acknowledged that residents should never be pushed without foot pedals as it could cause injury. The Director of Nursing and the administrator both confirmed that staff are trained to use foot pedals during wheelchair propulsion, and there are no exceptions to this rule. Additionally, the facility staff did not follow proper procedures for mechanical transfers. Two residents were observed being transferred using a mechanical lift with the legs of the lift closed, contrary to the facility's policy that requires the legs to be open for stability. Interviews with the staff involved revealed that they were trained incorrectly, and the Director of Nursing and the administrator confirmed that the legs of the lift should remain open during transfers to prevent potential injuries. Furthermore, the facility failed to safely store medications in a resident's room. One resident was found to have various medications, including nasal spray, an inhaler, and tablets, in their room without a physician's order or proper assessment for self-administration. The resident admitted that other residents sometimes enter their room and access their belongings. Interviews with staff and the Director of Nursing confirmed that residents should be assessed for safety and have a physician's order to keep medications at bedside. The lack of proper assessment and storage poses a risk of medication misuse or access by other residents.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
Facility staff failed to ensure all residents' drug regimens were free from unnecessary drugs by not attempting gradual dose reductions (GDR) for psychotropic medications for four residents. The facility's Drug Review guidelines require monthly medication reviews, interdisciplinary care plans, and physician consultations for GDR attempts. However, the medical records for the four residents did not contain completed GDRs despite pharmacy recommendations for review and reduction of psychotropic medications. These residents had various diagnoses, including depression, anxiety, Alzheimer's Disease, psychosis, schizophrenia, bipolar disorder, and dementia, and were on multiple high-risk medications such as Fluoxetine, Buspirone, Quetiapine, Haloperidol, Divalproex, Trazodone, Phenytoin, Sertraline, and Clonazepam. Interviews with the Director of Nursing (DON) and the administrator revealed that the process for handling pharmacy recommendations was not followed. The DON stated that physicians should review and document their agreement or disagreement with the recommendations, sign the pharmacy recommendation sheet, and have the nurse document the review and decision. However, this process was not adhered to, as evidenced by the lack of completed GDRs in the residents' medical records. The administrator confirmed that pharmacy recommendations should be reviewed and signed by the physician, with documentation of the reasoning if the physician disagrees, but this was not done in these cases.
Medication Storage and Monitoring Deficiency
Penalty
Summary
Facility staff failed to monitor and store medication in a safe and effective manner, leading to the presence of expired medications and unsecured medication storage. Observations revealed that the medication room contained expired medications, including extra strength Acetaminophen/diphenhydramine HCI, Therma-M, mucus relief, Zinc, and Cranberry 450 mg. Interviews with Certified Medication Technicians (CMTs) and the Director of Nursing (DON) confirmed that out-of-date medications should be destroyed or returned to the pharmacy, and that CMTs and nurses are responsible for monitoring medication storage rooms and carts. Despite these protocols, expired medications were found in the medication storage room, indicating a lapse in adherence to the facility's Storage of Medications policy. Additionally, observations showed that a CMT left an unsecured box containing residents' medications on top of the medication cart while passing medications to residents. Another observation noted an unattended plastic container with multiple drawers of resident medication on top of the 100 hall medication cart. The plastic container could not be locked and was left on top of the cart at all times. Interviews with the CMTs and the administrator highlighted that the unsecured plastic box posed a risk to residents and should be removed for their safety. The administrator acknowledged that the box was used for regularly used medications and extra storage, but its unsecured state was a safety concern.
Unqualified Dietary Manager
Penalty
Summary
Facility staff failed to designate a person to serve as the Dietary Manager (DM) with the appropriate qualifications. The facility census was 44. Review of facility policies showed staff did not provide a policy related to the qualifications of kitchen staff. Review of the DM's personnel record showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview, the DM stated he/she was not certified yet but was currently working on the certification and was about halfway done. The DM also mentioned not knowing all of the requirements. The Director of Nursing (DON) and the administrator both confirmed that the DM should be certified, with the DON noting that lack of certification could lead to residents not receiving the correct food or having allergic reactions, which could cause harm.
Failure to Protect Residents' Personal Information
Penalty
Summary
Facility staff failed to ensure residents' personal information was protected when staff left residents' Electronic Health Records (EHR) open and unattended in public hallways. The facility census was 44. The facility's Medication Administration Guidelines did not contain directions for the protection of residents' privacy. Multiple observations on 04/30/24 showed a Certified Medical Technician (CMT) and a Certified Nursing Assistant (CNA) leaving EHR screens unlocked in the hallway with resident information visible while administering medication to residents in their rooms. Additionally, an unsecured box with drawers containing residents' medications was left on the medication cart. Interviews with staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the facility administrator, confirmed that EHR screens should always be locked when unattended to protect residents' privacy. The CMT also acknowledged that screens on the carts should be locked when unattended to provide privacy. These actions and inactions led to a violation of residents' rights to privacy and confidentiality of their personal and medical records.
Failure to Complete MDS Assessments Timely
Penalty
Summary
Facility staff failed to complete the required Comprehensive Minimum Data Set (MDS) within the mandated timeframe for two residents. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, requires that an Admission (Comprehensive) MDS be completed no later than the 14th calendar day of the resident's admission and submitted within 14 calendar days from the care plan completion date. Additionally, an Annual (Comprehensive) MDS must be completed no later than 366 calendar days from the previous comprehensive assessment or 92 days following the previous OBRA quarterly assessment. However, the records for two residents showed that their Annual comprehensive assessments were not completed within the required timeframe. During interviews, the facility administrator and Director of Nursing (DON) revealed that the facility did not have a full-time MDS nurse. The administrator mentioned that a floor nurse was lined up for the MDS position once a floor nurse position was filled, and a corporate nurse was trying to fill in between their other duties. The DON, who was new and unfamiliar with the MDS process, stated that the MDS nurse would be trained by the corporate nurse once the position was filled full-time. The administrator confirmed that the corporate nurse and the DON would help complete the MDS assessments until the floor nurse could assume the role full-time. Despite these efforts, the required MDS assessments for the two residents were not completed on time, leading to the deficiency noted in the report.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
Facility staff failed to complete the required Quarterly Minimum Data Set (MDS) assessments within the mandated timeframe for two residents. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, requires that Quarterly MDS assessments be completed no later than 14 calendar days after the Assessment Reference Date (ARD) and at least every 92 days following the previous OBRA assessment. However, for Resident #18, the record did not contain a completed Quarterly assessment on or before the required date. Similarly, for Resident #30, the record did not contain a completed Quarterly assessment on or before the required date. The facility census was 44 at the time of the survey. Interviews with the facility's administrator and Director of Nursing (DON) revealed that the facility does not currently have a full-time MDS nurse. The administrator mentioned that a floor nurse is lined up for the position once a floor nurse position is filled, and a corporate nurse is currently trying to fill in between their other duties. The DON, who is new and not familiar with the MDS process, stated that the MDS nurse would be trained by the corporate nurse once the position is filled full-time. The administrator also mentioned that the corporate nurse and the DON would help complete the MDS assessments until the floor nurse can assume the role full-time. Staff are expected to use the RAI manual as a guide to complete and submit the MDS data timely.
Failure to Accurately Assess Residents
Penalty
Summary
Facility staff failed to correctly assess one resident who was receiving an anticoagulant medication and another resident for their preferences and oral/dental status. Specifically, Resident #2, who had a diagnosis of atrial fibrillation and was prescribed Eliquis, an anticoagulant, was not assessed for taking a high-risk medication under the category of anticoagulant in their Quarterly MDS. Additionally, Resident #12's Quarterly MDS did not include assessments for Preferences for Customary Routine and Activities (Section F) and Oral/Dental Status (Section L). The facility census was 44 at the time of the survey. Interviews revealed that the facility did not have a full-time MDS nurse, and the Director of Nursing (DON) was new and unfamiliar with the MDS process. The administrator mentioned that a nurse from the corporate office was trying to fill in between their other duties, and the corporate nurse and DON would help complete the MDS assessments until a floor nurse could fill the role full-time. The facility's policy was to use the most current CMS MDS Resident Assessment Instrument (RAI) manual as a guide for completing and submitting MDS data timely.
Failure to Post Survey Results
Penalty
Summary
Facility staff failed to ensure that the three most recent years of survey results were posted and readily accessible to residents, family members, or representatives of residents. The facility census was 44. Review of the facility's policies showed that staff did not provide a policy for required postings or survey posting. Observations on multiple dates revealed that the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. During an interview, an LPN stated that they were not sure where the survey was posted. The administrator mentioned that the past survey results should be on the shelf by the front entrance door, but they were unable to locate them.
Failure to Complete Neurological Checks and Skin Assessments
Penalty
Summary
The facility staff failed to complete required neurological checks and fall follow-up documentation for three residents who experienced falls. Specifically, the medical records for these residents did not contain the necessary 72-hour follow-up documentation as mandated by the facility's Fall Champion Program. Interviews with various staff members, including the administrator, LPNs, and RNs, revealed a lack of clarity and accountability regarding who was responsible for ensuring these checks and documentation were completed. The absence of a Director of Nursing (DON) further contributed to this oversight, as staff were unsure about the location of necessary forms and who should oversee the process. Additionally, the facility staff failed to perform weekly skin assessments for two residents as required by the facility's wound care prevention strategies. The medical records for these residents showed incomplete documentation of weekly skin assessments over several months. Interviews with the new DON and nursing staff indicated that while there was an expectation for weekly skin assessments, these were not consistently performed due to staff being too busy and a lack of oversight. The deficiencies highlight significant lapses in the facility's adherence to its own protocols for fall follow-up and skin assessments. The lack of proper documentation and follow-up care for residents who experienced falls and those requiring skin assessments points to systemic issues in staff training, accountability, and resource management within the facility.
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What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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) |
|---|---|---|---|---|
| Kingdom Care Senior Living | 0.5 mi | — | 2 | 0 |
| Fulton Manor Care Center | 0.6 mi | — | 2 | 0 |
| Riverview Nursing Center | 12.8 mi | — | 0 | 0 |
| Lenoir Health Care Center | 18.9 mi | — | 0 | 0 |
| Neighborhoods Rehabilitation And Skilled Nursing B | 19.3 mi | — | 1 | 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 August 2026) and official state health department websites.