Inspection Reports for
Fulton Manor Care Center

The complaint investigation found that the facility employed a CNA with a federal indicator for misconduct. The Social Service Director overlooked the federal indicator during background checks, and the administrator was unaware of the issue until the investigation.

The facility failed to prevent employing a Certified Nurse Aide (CNA A) who had a federal indicator for misconduct on the CNA Registry. Interviews revealed lapses in background check audits and oversight by the Social Service Director and administrator.

The facility failed to ensure call lights were placed within reach for four residents out of 16 sampled, posing a minimal harm or potential for actual harm. Observations and interviews confirmed that call light strings were often out of reach, and staff acknowledged the issue and the need for corrective action.

The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, privacy violations, failure to notify residents of bed hold policies, incomplete resident assessments and care plans, medication administration errors, inadequate infection control practices, insufficient staffing, lack of RN coverage for eight consecutive hours daily, incomplete nurse staffing postings, failure to maintain dishwashing equipment and ice machine properly, lack of an effective quality assurance program, and failure to implement an antibiotic stewardship program.

The complaint investigation found that Resident #2, with a history of aggression, was not properly monitored one on one as required after returning from the hospital. Staff left Resident #2 unattended while passing medications, leading to the incident. The administrator confirmed staff were directed to monitor Resident #2 one on one but communication failures occurred between shifts.

The facility failed to ensure Resident #1 remained free from physical abuse when Resident #2, who had a history of physical aggression, grabbed Resident #1's arm. Staff did not properly monitor Resident #2 one on one as required, and no staff were present at the nurse's station during the incident.

The complaint was substantiated. The CNA admitted to taking and depositing a $400 check from the resident. The facility reported the incident to the Department of Health and Senior Services, local police, and the resident's physician. The resident filed a grievance and was reimbursed $400 by the facility.

The facility failed to prevent the misappropriation of $400 from a resident by a CNA who cashed a check for personal use. The CNA was terminated, the resident was reimbursed, and all staff received in-service training on abuse, neglect, and misappropriation.

The complaint involved an allegation that PTA A made inappropriate comments related to oral sex to Resident #1 and was present in the resident's personal space against the resident's wishes. The facility was investigating the complaint, and the PTA was not suspended during the investigation.

The investigation found that the facility staff failed to implement the abuse policy by allowing PTA A, who was accused of abuse, to continue contact with residents during the investigation. The PTA denied the allegations, and the administrator was still investigating the complaint at the time of the visit.

The facility was found deficient in multiple areas including failure to timely refund resident personal funds, failure to post survey results, failure to maintain a homelike environment, failure to provide written grievance responses, incomplete care plans, improper catheter care and orders, inadequate assistance with activities of daily living, failure to prevent and treat pressure ulcers appropriately, unsafe wheelchair and lift use, unsecured chemicals and razors, incomplete bed rail assessments and consents, insufficient staff competency documentation, failure to post nurse staffing information properly, failure to limit psychotropic medication orders, improper medication storage, failure to maintain kitchen cleanliness and food safety, failure to perform hand hygiene and infection control practices, and failure to implement an antibiotic stewardship program.

Facility staff failed to assist five of twelve sampled dependent residents with grooming and bathing as required by their care plans. Observations and interviews revealed residents with unkempt, greasy hair and facial hair, and documentation showed missed showers. Staff and administration acknowledged showers should be done twice weekly but could not explain why they were missed.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, unsafe storage of hazardous chemicals and medications, improper use of mechanical lifts, lack of physician order for oxygen use, improper preparation and serving of pureed diets, and inadequate kitchen sanitation and hand hygiene practices.