Inspection Reports for
Fulton Manor Care Center
520 MANOR DR, FULTON, MO, 65251-2429
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
19.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
255% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
87% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Apr 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure that staff employed did not have a Federal Indicator for abuse, neglect, exploitation, or theft on the Certified Nurse Aide Registry.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility staff failed to ensure the facility did not employ or engage staff who had a Federal Indicator on the Certified Nurse Aide Registry.
Report Facts
Residents census: 45
Number of sampled employees: 4
Hire date of CNA A: Jan 31, 2025
CNA Registry date: Jan 30, 2025
Inspection Report
Annual Inspection
Census: 43
Capacity: 52
Deficiencies: 11
Date: Jan 30, 2025
Visit Reason
Annual inspection of Fulton Manor Care Center to assess compliance with emergency preparedness, life safety, medication room, electrical system, fire drills, and other regulatory requirements.
Findings
The facility was found deficient in emergency preparedness training, life safety code compliance including building construction and exit discharge maintenance, fire drills documentation, electrical receptacle maintenance, and medication room requirements. The facility census was 43 with a capacity of 52.
Deficiencies (11)
E037 Emergency Preparedness Training Program. The facility failed to provide training on emergency preparedness policies and procedures to all staff upon hire and at least annually, risking delayed emergency response.
K161 Building Construction Type and Height. The facility failed to maintain the Type V (111) protected wood-frame construction standard, allowing unsealed holes in ceilings that could permit smoke or flames to pass.
K271 Discharge from Exits. The facility failed to maintain exit discharge areas free of tripping hazards, including uneven sidewalks and ramps, risking delayed evacuation.
K712 Fire Drills. The facility failed to provide complete and verifiable documentation of fire drills conducted under varying conditions quarterly for all shifts, risking delayed emergency response.
K911 Electrical Systems - Other. The facility failed to maintain electrical receptacles in compliance with NFPA 70, including replacement with hospital grade receptacles, risking electrical hazards.
A1048 Medication Room Requirements. The facility failed to provide a medication preparation room next to nurses' station with required equipment and security, risking medication safety.
A1125 Electrical System Complies With Code. The facility failed to ensure the entire electrical system complies with the National Electrical Code and Life Safety Code.
A2061 Fire Drill Requirements, Evacuation. The facility failed to conduct required fire drills at least quarterly on each shift and document them properly.
A3001 Substantially Constructed/Maintained. The facility failed to maintain the physical plant in good repair, risking safety and compliance.
A4022 Employee Orientation/Continuing Education. The facility failed to provide in-service orientation and continuing education covering emergency protocols and infection control.
K926 Gas Equipment - Qualifications and Training. The facility failed to provide adequate training and education on medical gas safety and handling to staff.
Report Facts
Facility census: 43
Total capacity: 52
Deficiencies cited: 11
Inspection Report
Census: 43
Deficiencies: 1
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding reasonable accommodations for residents, specifically focusing on the accessibility and proper placement of call lights for residents.
Findings
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.
Deficiencies (1)
Facility staff failed to ensure call lights were placed within reach for four residents (Resident #4, #10, #48, and #295) out of 16 sampled residents.
Report Facts
Residents affected: 4
Sampled residents: 16
Facility census: 43
Call light string distance: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Certified Nursing Assistant (CNA) | Interviewed regarding call light accessibility for Resident #48 |
| H | Licensed Practical Nurse (LPN) | Interviewed regarding call light accessibility and expectations |
| K | Certified Nursing Assistant (CNA) | Interviewed about staff responsibilities to ensure call light placement |
| Director of Nursing (DON) | Director of Nursing | Interviewed about staff expectations for call light education and placement |
| Administrator | Administrator | Interviewed about staff expectations for call light education and placement |
| MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Interviewed about communication protocols for call light string length issues |
| Maintenance Director (MD) | Maintenance Director | Interviewed about call light string length and corrective actions |
Inspection Report
Routine
Census: 43
Deficiencies: 16
Date: Jan 30, 2025
Visit Reason
Routine inspection of Fulton Manor Care Center to assess compliance with regulatory requirements including resident care, medication administration, infection control, staffing, and safety.
Findings
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.
Deficiencies (16)
Failure to ensure call lights were placed within reach for four residents.
Failure to protect residents' personal and medical records privacy and bodily privacy during care.
Failure to provide written notification of bed hold policy to residents or representatives at time of transfer.
Failure to complete required Minimum Data Set (MDS) assessments within required time frames for three residents.
Failure to complete baseline care plans within 48 hours of admission for five residents.
Failure to develop comprehensive person-centered care plans addressing all resident needs for three residents.
Failure to follow professional standards in medication administration including lack of physician orders for water flushes, late medication administration, and unlicensed staff documenting medication administration.
Failure to provide care to meet basic hygiene needs for four residents.
Failure to obtain signed consents and complete side rail assessments for four residents.
Failure to provide sufficient nursing staff per facility assessment and failure to have RN coverage for eight consecutive hours daily.
Failure to post nurse staffing information daily including facility census and actual hours worked.
Medication error rate of 28.13% due to late administration and improper medication administration practices for one resident.
Failure to operate dishwashing machine according to manufacturer instructions and failure to maintain ice machine drain air gap.
Failure to develop and implement an effective Quality Assurance/Performance Improvement program.
Failure to ensure two-step tuberculosis skin tests were completed properly for six employees and failure to implement Enhanced Barrier Precautions for three residents.
Failure to complete regular inspections of bed frames, mattresses, and bed rails to identify entrapment risks for four residents.
Report Facts
Medication error rate: 28.13
Facility census: 43
Dishwasher wash temperature: 90
Dishwasher rinse temperature: 110
Sanitizer concentration: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Named in medication administration errors and failure to wear gown during Enhanced Barrier Precautions. |
| LPN H | Licensed Practical Nurse | Interviewed regarding medication administration, staffing, and Enhanced Barrier Precautions. |
| CNA K | Certified Nursing Assistant | Named in failure to provide privacy and failure to use Enhanced Barrier Precautions. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, care plans, medication errors, and infection control. |
| Administrator | Administrator | Interviewed regarding facility policies, staffing, and quality assurance. |
| Maintenance Director | Maintenance Director | Interviewed regarding bed rail maintenance and ice machine drain air gap. |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding MDS assessments and employee TB testing. |
| Corporate Nurse | Corporate Registered Nurse | Interviewed regarding Enhanced Barrier Precautions education and antibiotic stewardship. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Dec 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse and neglect involving physical altercations between residents.
Complaint Details
The complaint investigation substantiated that Resident #1 was physically abused by Resident #2 who had a history of aggression. Staff failed to monitor Resident #2 properly after returning from the hospital, contributing to the incident.
Findings
The facility failed to ensure a resident was free from physical abuse when another resident with a history of aggression grabbed the resident's arm. Staff did not properly monitor the resident after a hospital return, leading to an incident of aggression.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation was not met as staff failed to prevent physical abuse between residents and did not adequately monitor a resident at risk of harm.
A4074 Protective Oversight, Voluntary Leave was not met as the facility lacked adequate procedures for oversight and supervision of residents on voluntary leave.
Report Facts
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca B. Bey | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
The inspection was conducted following a complaint regarding a physical altercation between two residents, Resident #1 and Resident #2, where Resident #2 grabbed Resident #1's arm.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by Resident #2 who grabbed Resident #1's arm.
Report Facts
Residents affected: 2
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented the resident altercation and was responsible for monitoring Resident #2 during medication pass |
| CNA B | Certified Nurse Aide | Interviewed regarding monitoring Resident #2 and unaware of one-on-one monitoring requirement |
| CNA C | Certified Nurse Aide | Interviewed and stated off-going charge nurse notified incoming shift to monitor Resident #2 one on one |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Aug 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property and abuse at Fulton Manor Care Center.
Complaint Details
The complaint was substantiated as the investigation confirmed misappropriation of resident money by a CNA. The facility staff were found to be in-serviced on abuse, neglect, and misappropriation following the incident.
Findings
The facility failed to prevent misappropriation of money from a resident by a Certified Nurse Assistant (CNA). The CNA cashed a check from the resident for personal use, and the facility staff did not detect or prevent this until after the incident. The CNA was terminated and the resident was reimbursed.
Deficiencies (1)
F 602: The facility failed to protect the resident from misappropriation of money by a CNA who cashed a resident's check for personal use. The facility did not prevent or detect the abuse until after the incident occurred.
Report Facts
Resident census: 43
Amount misappropriated: 400
Dental bill amount: 394
Cash returned to resident: 6
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Aug 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of money from a resident's checking account by a Certified Nurse Assistant (CNA).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility staff failed to prevent the misappropriation of money from one resident's checking account by a CNA who cashed a check for personal use.
Report Facts
Amount misappropriated: 400
Census: 43
Date of misappropriation: Jun 22, 2024
Date CNA terminated: Jul 27, 2024
Date staff in-serviced: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Assistant | Admitted to misappropriating $400 from resident by cashing a check; terminated on 07/27/24 |
| CNA C | Certified Nurse Assistant | Reported the misappropriation to the administrator after resident complaint |
| CNA B | Certified Nurse Assistant | Witnessed CNA I admit to taking the money on speaker phone and reported knowledge of policy |
| Social Service Director | Social Service Director | Filed grievance on behalf of resident and described resolution of funds |
| Assistant Director of Nursing | Assistant Director of Nursing | Described staff training on abuse, neglect, and misappropriation |
| Administrator | Administrator | Notified of incident, conducted interviews, and reported to authorities |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse by a Physical Therapy Assistant (PTA) at Fulton Manor Care Center.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews indicating that the PTA was accused of abuse and the facility failed to protect residents by allowing continued contact with the PTA during the investigation.
Findings
The facility failed to implement its abuse prevention policy to ensure resident safety when staff allowed a PTA accused of abuse to continue contact with residents. The investigation included interviews, record reviews, and observations confirming the complaint and policy deficiencies.
Deficiencies (2)
F607: The facility failed to develop and implement policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents as required by federal regulations.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reporting to the department for any suspected abuse or neglect.
Report Facts
Facility census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca L. Bey | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to a complaint alleging abuse by a Physical Therapy Assistant (PTA A) towards a resident (Resident #1). The investigation focused on whether the facility staff properly implemented abuse prevention policies.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to implement policies and procedures to prevent abuse, neglect, and theft by allowing an accused staff member to continue contact with residents.
Report Facts
Residents present: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PTA A | Physical Therapy Assistant | Accused of abuse and involved in the complaint investigation |
| Administrator | Conducting the investigation and responsible for suspension decisions | |
| Social Service Worker | Reported resident's statement about PTA A |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 20
Date: Feb 9, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations, including review of resident care, environment, staffing, and policies.
Findings
The facility was found to have multiple deficiencies related to resident personal funds, survey result accessibility, safe environment, grievance procedures, comprehensive care plans, skin integrity, infection control, medication management, and staffing. Plans of correction were submitted to address these issues.
Deficiencies (20)
F569: Facility staff failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for nine residents discharged from the facility.
F577: Facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family members, and representatives of residents.
F584: Facility staff failed to provide a safe, clean, comfortable, and homelike environment, including failure to maintain temperature and repair door coverings.
F585: Facility staff failed to establish and implement a grievance policy that includes prompt resolution and written responses to grievances.
F656: Facility staff failed to develop and implement comprehensive, person-centered care plans for residents, including measurable objectives and timely updates.
F658: Facility staff failed to follow physician orders for indwelling catheters, including documentation and timely care, for multiple residents.
F677: Facility staff failed to assist five residents with grooming and bathing as needed.
F686: Facility staff failed to ensure prevention and treatment of pressure ulcers, including timely assessments, documentation, and wound care.
F689: Facility staff failed to provide safe mechanical lift transfers and maintain safe environment with locked doors and safe wheelchair use.
F690: Facility staff failed to obtain physician orders for urinary catheters and provide appropriate catheter care for residents.
F700: Facility staff failed to accurately complete entrapment assessments and obtain consents for bedrail use for four residents.
F726: Facility staff failed to maintain nursing staff competency evaluations and training documentation.
F732: Facility staff failed to post required nurse staffing information and maintain accurate staffing records.
F758: Facility staff failed to ensure psychotropic drug orders were limited to 14 days unless clinically justified and documented.
F761: Facility staff failed to store drugs and biologicals properly, including expired medications and unsecured storage.
F801: Facility failed to employ a qualified dietitian and provide adequate nutritional services and menu planning.
F803: Facility failed to post menus timely and provide adequate food service, including proper food temperatures and safe food handling.
F812: Facility failed to maintain kitchen cleanliness, proper food storage, and sanitation of equipment and utensils.
F880: Facility failed to establish and maintain an infection prevention and control program, including hand hygiene and wound care.
F881: Facility failed to implement an antibiotic stewardship program and track antibiotic use appropriately.
Report Facts
Facility census: 37
Number of discharged residents with personal funds issues: 9
Number of residents with catheter care deficiencies: 4
Number of residents with pressure ulcer issues: 3
Number of residents with grooming/bathing assistance deficiencies: 5
Number of residents with bedrail entrapment assessments missing: 4
Inspection Report
Life Safety
Census: 37
Capacity: 52
Deficiencies: 12
Date: Feb 9, 2024
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Fulton Manor Care Center.
Findings
The facility was found deficient in maintaining emergency preparedness training documentation and compliance with fire safety codes including building construction, hazardous area enclosures, fire alarm system maintenance, fire drills, electrical equipment safety, and gas equipment training. Several deficiencies were noted that could affect all facility occupants.
Deficiencies (12)
E037 Emergency Preparedness Training Program. The facility failed to provide complete and verifiable documentation for annual emergency preparedness training to all staff, risking delayed response in emergencies.
K161 Building Construction Type and Height. The facility failed to maintain the Type V (111) protected wood-frame construction standard due to holes and penetrations in ceilings.
K321 Hazardous Areas - Enclosure. Facility staff failed to ensure doors to hazardous areas were self-closing, positively latched, and smoke resistant, risking containment of smoke and fire.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to inspect, test, and maintain the fire alarm system properly and secure the alarm control panel against unauthorized access.
K712 Fire Drills. Facility staff failed to conduct fire drills at various times on each shift quarterly from January to December 2023, risking delayed emergency response.
K920 Electrical Equipment - Power Cords and Extensions. Facility staff failed to maintain electrical wiring and power strips properly, risking electrical fire hazards.
K926 Gas Equipment - Qualifications and Training. Facility staff failed to provide adequate education and training on handling medical gases and cylinders to all relevant personnel.
A2008 Hazardous Areas. Hazardous areas were not separated by at least one-hour fire-resistant construction and lacked self-closing doors.
A2019 Fire Alarm System - Test/Maintain. The facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72 requirements.
A2061 Fire Drill Requirements, Evacuation. The facility failed to conduct the required minimum of twelve annual fire drills with proper frequency and unannounced drills.
A3001 Substantially Constructed/Maintained. The building was not maintained in good repair as required by construction standards.
A4022 Employee Orientation/Continuing Education. The facility failed to provide adequate in-service orientation and continuing education on infection control, emergency protocols, and resident rights.
Report Facts
Facility census: 37
Facility capacity: 52
Fire drills conducted: 8
Fire drills required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Sey | Administrator | Named as signing official and involved in training and compliance discussions |
| Maintenance Director | Responsible for emergency preparedness training, fire alarm system control panel security, and fire drills | |
| Director of Nursing | DON | Responsible for oxygen training and nursing staff education |
Inspection Report
Routine
Census: 37
Deficiencies: 14
Date: Feb 9, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
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.
Deficiencies (14)
Failure to timely refund personal funds to discharged residents.
Failure to post most recent survey results accessible to residents and representatives.
Failure to maintain a safe, clean, comfortable and homelike environment including repair of door coverings, proper storage of commode lids and wash basins, cleaning of ice carts, and removal of cigarette butts.
Failure to provide residents with written responses to grievances.
Failure to develop and implement comprehensive person-centered care plans for residents including oxygen use and pressure ulcer care.
Failure to follow physician orders for indwelling urinary catheter care and failure to obtain appropriate catheter orders.
Failure to assist dependent residents with grooming and bathing, resulting in unkempt appearance.
Failure to update care plans and complete weekly skin assessments after pressure ulcer development; failure to notify physician and family and obtain wound care consult.
Failure to safely propel residents in wheelchairs with foot pedals, improper use of mechanical lifts, and unsecured chemicals and razors.
Failure to employ a qualified dietitian or clinically qualified nutrition professional full-time as Director of Food and Nutrition Services.
Failure to serve food according to menus and standardized recipes, failure to post menus, and failure to serve food at proper temperatures.
Failure to maintain kitchen cleanliness, proper food storage, and dish machine sanitation.
Failure to perform hand hygiene during wound care, perineal care, catheter care, and medication administration; failure to change and store oxygen tubing properly.
Failure to implement an antibiotic stewardship program with monitoring of antibiotic use.
Report Facts
Residents with personal funds held: 9
Facility census: 37
Deficiencies cited: 15
Medication documentation omissions: 15
Antibiotics without documentation: 11
Antibiotics without site documentation: 3
Antibiotics without onset documentation: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in catheter care and wound care hand hygiene deficiencies |
| CNA G | Certified Nursing Assistant | Named in perineal care hand hygiene deficiency |
| CNA F | Certified Nursing Assistant | Named in perineal care hand hygiene deficiency |
| DS | Dietary Supervisor | Named in food service and kitchen cleanliness deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including antibiotic stewardship, catheter care, hand hygiene, staffing, and bed rail assessments |
| Administrator | Facility Administrator | Named in multiple deficiencies including staffing, antibiotic stewardship, catheter care, and food service |
Inspection Report
Routine
Census: 37
Deficiencies: 1
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care and assistance requirements for residents unable to perform activities of daily living, specifically focusing on grooming and bathing.
Findings
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.
Deficiencies (1)
Failure to assist five residents with grooming and bathing as required by care plans.
Report Facts
Residents affected: 5
Sampled dependent residents: 12
Facility census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant M | Certified Nursing Assistant | Interviewed regarding bathing and hygiene care |
| Certified Medication Technician E | Certified Medication Technician | Interviewed about shower frequency |
| Nurse Aid N | Nurse Aid | Interviewed about shower schedule and missed showers |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed about shower frequency and shaving |
| Director of Nursing | Director of Nursing | Interviewed about shower schedule responsibility and documentation |
| Administrator | Administrator | Interviewed about shower schedule and staff instruction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
Submission of a plan of correction in response to prior inspection findings.
Findings
The document outlines corrective actions planned by the facility to address previously identified deficiencies.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 5
Date: Dec 16, 2022
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility regulations and standards.
Findings
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.
Deficiencies (5)
Failed to develop a comprehensive care plan for two residents.
Failed to ensure razors/sharps and hazardous chemicals were stored safely and failed to provide safe mechanical lift transfers for two residents.
Failed to obtain a physician order for the use of oxygen for one resident.
Failed to prepare pureed food according to recipes, ensure residents received all menu items, and serve pureed food at appropriate consistency.
Failed to maintain kitchen equipment in a clean and sanitary manner and to perform hand hygiene as necessary to prevent cross-contamination.
Report Facts
Facility census: 32
Number of residents affected by care plan deficiency: 2
Number of residents affected by unsafe storage and mechanical lift issues: 2
Number of residents affected by oxygen order deficiency: 1
Number of residents affected by pureed diet issues: 2
Number of residents affected by kitchen sanitation and hand hygiene issues: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Mentioned in relation to unsafe storage of chemicals and medication room, oxygen use, and mechanical lift observations |
| NA G | Nursing Assistant | Mentioned in relation to unsafe storage of chemicals and mechanical lift observations |
| LPN B | Licensed Practical Nurse | Mentioned in relation to medication storage and mechanical lift procedures |
| CNA E | Certified Nursing Assistant | Mentioned in relation to mechanical lift use and oxygen use |
| RN A | Registered Nurse | Mentioned in relation to oxygen order oversight |
| Director of Nursing | Director of Nursing (DON) | Mentioned in relation to care plan responsibility, medication storage, mechanical lift, and oxygen order oversight |
| Administrator | Facility Administrator | Mentioned in relation to care plan oversight, chemical storage, oxygen orders, dietary monitoring, and kitchen sanitation |
| Dietary Manager | Dietary Manager | Mentioned in relation to pureed diet preparation and kitchen sanitation |
| [NAME] I | Cook | Mentioned in relation to pureed food preparation and hand hygiene |
Inspection Report
Life Safety
Census: 32
Capacity: 52
Deficiencies: 15
Date: Dec 16, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain means of egress free of obstructions and unsecured furniture, failed to maintain exit doors equipped with delayed-egress locking systems, and failed to inspect and test fire alarm and sprinkler systems as required. Multiple deficiencies related to fire safety and egress were identified, posing potential risks to occupants.
Deficiencies (15)
K211 Means of Egress - General: The facility staff failed to maintain two means of egress corridors free of obstruction and unsecured furniture, reducing clear unobstructed egress width below required standards.
K222 Egress Doors: Facility staff failed to maintain five exit doors equipped with delayed-egress locking systems to ensure doors opened within 15 seconds of manual actuation.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to inspect and test the fire alarm system annually as required, and failed to maintain documentation of inspections and tests.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to inspect and test the dry pipe sprinkler system as required, including failure to conduct a full flow trip test of the dry pipe valve.
K363 Corridor Doors: Facility staff failed to inspect, test, and maintain non-rated door assemblies located within means of egress, resulting in gaps, loose door knobs, and doors not self-closing or latching properly.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Facility staff failed to maintain two of three fire barrier walls free of openings and gaps, compromising smoke tightness and fire resistance.
K712 Fire Drills: Facility staff failed to conduct fire drills at required times and frequencies, and failed to maintain documentation of fire drills conducted.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect, test, and maintain non-rated door assemblies located within means of egress in accordance with NFPA 101 Life Safety Code requirements.
A1088 Door No Louvre/Transom, Solid-Core Wood/Metal: Doors between rooms and corridors did not meet fire resistance requirements as required by regulation.
A2019 Fire Alarm System-Test/Maintain: Facility failed to maintain complete fire alarm systems and test them in accordance with NFPA 72 requirements.
A2034 Sprinkler System-Test/Maintain: Facility failed to inspect, maintain, and test sprinkler systems in accordance with regulatory requirements.
A2041 Door Locks: Door locks did not meet requirements for being operable from the inside and compliant with NFPA 101 standards.
A2046 Corridor Requirements: Facility failed to maintain corridors free of obstruction, equipment, or supplies, and doors to resident rooms improperly swung into corridors.
A2054 Smoke Section Walls/Doors: Smoke barriers were not properly maintained with required fire ratings and self-closing doors.
A2061 Fire Drills Requirements, Evacuation: Facility failed to conduct required fire drills annually with proper documentation and unannounced drills.
Report Facts
Facility census: 32
Facility capacity: 52
Exit doors with delayed-egress locking: 5
Fire drills conducted: 7
Fire drills required: 12
Inspection Report
Routine
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Census: 38
Deficiencies: 4
Date: Aug 29, 2019
Visit Reason
Routine inspection to assess compliance with quality of care and food safety regulations at Fulton Manor Care Center.
Findings
The facility failed to follow physician's orders for administering insulin to one resident and did not maintain food preparation and storage areas in a clean and sanitary manner, leading to potential contamination risks.
Deficiencies (4)
F684 Quality of care: Facility staff failed to follow physician's orders and administer long acting insulin (Lantus) for one resident as prescribed.
F812 Food safety: Facility staff failed to maintain food preparation and storage areas in a clean and sanitary manner, resulting in accumulation of dirt, food debris, trash, dead insects, and mold in multiple kitchen and storage areas.
A4074 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice; this regulation was not met as evidenced by F684.
A7015 Food protection and temperature control: Food shall be protected from contamination and held at required temperatures; this regulation was not met as evidenced by F812.
Report Facts
Facility census: 38
Inspection Report
Life Safety
Census: 38
Capacity: 52
Deficiencies: 3
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, specifically focusing on gas equipment and oxygen cylinder storage safety.
Findings
The facility failed to meet applicable provisions of the Life Safety Code related to the storage and handling of oxygen cylinders. Deficiencies included improper storage of oxygen cylinders in an unsecured area, failure to separate combustible materials within five feet of oxygen cylinders, and inadequate protection of cylinders from damage or dislocation.
Deficiencies (3)
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen cylinders in an enclosed area with proper ventilation and failed to separate combustible materials within five feet of oxygen cylinders. Staff also failed to secure portable oxygen cylinders to prevent damage or dislocation.
A1036 Oxygen Storage Room: The facility lacked an oxygen storage room surrounded by a one-hour rated construction with a powered or gravity vent to the outside, violating state regulations.
A2010 Oxygen Storage: Oxygen storage did not comply with NFPA 99, 1999 edition, including failure to use permanent racks or fasteners to prevent accidental damage or dislocation of oxygen cylinders.
Report Facts
Facility census: 38
Facility capacity: 52
Dates of survey: Survey completed on 08/29/2019; observations on 08/27/2019 and 08/28/2019
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Sep 13, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care and accommodations at Fulton Manor Care Center.
Findings
The facility failed to provide reasonable accommodations for resident needs and preferences, particularly regarding dining room table arrangements that hindered residents' ability to eat independently. Multiple observations showed residents struggling to reach food and drinks due to wheelchair positioning and table design.
Deficiencies (2)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to provide reasonable accommodations for residents' dining needs, resulting in residents being unable to reach food or drinks independently due to table and wheelchair positioning.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues cited under F558.
Report Facts
Facility census: 40
Inspection Report
Plan of Correction
Census: 40
Capacity: 52
Deficiencies: 4
Date: Sep 13, 2018
Visit Reason
The document is a Plan of Correction following a Life Safety Code survey conducted on 09/13/2018 at Fulton Manor Care Center. The plan addresses deficiencies found during the inspection related to fire safety systems, fire drills, door maintenance, and electrical systems.
Findings
The facility failed to meet several Life Safety Code requirements including maintenance and testing of the sprinkler system, conducting fire drills under varying conditions, inspection and testing of fire doors, and electrical receptacle testing. Deficiencies had the potential to affect all facility occupants.
Deficiencies (4)
K353: Facility staff failed to provide complete and verifiable documentation of sprinkler pendant testing, risking system failure in an emergency. The facility census was 40 with a capacity of 52.
K712: Staff failed to conduct fire drills under varying fire conditions from October 2017 through September 2018, potentially delaying response procedures. The facility census was 40 with a capacity of 52.
K761: Facility staff failed to inspect, test, and maintain fire doors and non-rated doors annually as required, risking equipment failure in an emergency. The facility census was 40 with a capacity of 52.
K914: Facility staff failed to assess electrical receptacles at resident bed locations for physical integrity, polarity, and grounding, increasing risk of fire and injury. The facility census was 40 with a capacity of 52.
Report Facts
Facility census: 40
Total capacity: 52
Fire drills reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Cannell | Maintenance Supervisor | Named in sprinkler system maintenance and fire door inspection plan of correction |
| Sharon Blakely | Safety Chairman and Fire Drill Chairman | Responsible for documenting fire drills and monitoring QA |
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