Inspection Reports for
Fulton Nursing &Amp; Rehab
1510 BLUFF ST, FULTON, MO, 65251-2345
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
260% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
68% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 1
Date: Jan 14, 2026
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically focusing on whether care plans were updated to address resident behaviors and revised quarterly in conjunction with the federally mandated Minimum Data Set (MDS).
Findings
The facility failed to update care plans to address aggressive behaviors for three sampled residents and did not update care plans at least quarterly as required. Staff documented multiple incidents of resident altercations, but care plans lacked corresponding interventions. Interviews revealed staffing and workload issues impacting timely care plan updates.
Deficiencies (1)
Failure to address and update care plans to address behaviors for three residents and failure to update care plans at least quarterly in conjunction with the required Minimum Data Set (MDS).
Report Facts
Residents Affected: 3
Facility Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding expectations for care plan updates after behavioral incidents | |
| Director of Nursing (DON) | Interviewed regarding responsibility for verifying care plan updates and interventions | |
| MDS Coordinator | Interviewed regarding responsibility for updating care plans and challenges due to workload and absence |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Dec 31, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain an infection prevention and control program to prevent the spread of COVID-19 among residents.
Complaint Details
Complaint #2697930 triggered the investigation. The complaint involved failure to separate COVID-19 positive residents from negative residents and inadequate infection control practices. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to separate residents who tested positive for COVID-19 from those who tested negative, placing negative residents at increased risk of exposure. Staff did not consistently follow infection control practices, including proper use of masks and PPE, and communication about COVID-19 positive residents was inadequate among staff.
Deficiencies (1)
Failure to maintain an infection prevention and control program to prevent the spread of COVID-19, including failure to separate COVID-19 positive residents from negative residents.
Report Facts
Facility census: 68
COVID-19 positive residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician D | Certified Medication Technician | Mentioned in relation to lack of knowledge about COVID-19 positive residents and improper mask use |
| Director of Nursing | Director of Nursing | Responsible for resident placement during COVID-19 outbreak and educating nurses on PPE use |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for ensuring staff compliance with PPE requirements and aware of lack of signage and PPE disposal issues |
| LPN B | Licensed Practical Nurse | Mentioned regarding knowledge of COVID-19 positive resident list and PPE use |
| Infection Preventionist | Infection Preventionist | Responsible for interventions to contain COVID-19 and posting list of positive residents |
| Administrator | Administrator | Responsible for educating nurses on PPE use and posting list of COVID-19 positive residents |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a registered nurse on duty for at least eight consecutive hours per day, seven days a week.
Complaint Details
Complaint #2644523 regarding failure to have an RN on duty for eight consecutive hours daily was substantiated by staffing records and interviews.
Findings
The facility failed to provide RN coverage for eight consecutive hours on multiple days in September and October 2025. Interviews with the Director of Nursing, Assistant Director of Nursing, and administrator confirmed awareness of the requirement and staffing challenges due to recent RN losses.
Deficiencies (1)
Failure to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week.
Report Facts
Census: 67
Dates without RN coverage: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN coverage requirements and staffing |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding nursing schedule and RN coverage |
| Administrator | Administrator | Interviewed regarding staffing challenges and RN coverage |
Inspection Report
Routine
Census: 62
Capacity: 100
Deficiencies: 12
Date: Jun 27, 2025
Visit Reason
Routine inspection of Fulton Nursing & Rehab to assess compliance with regulatory requirements including resident care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of resident code status, failure to complete significant change assessments for hospice residents, incomplete and outdated care plans, inadequate fall documentation and neurological assessments, improper respiratory care including oxygen tubing and CPAP management, lack of dialysis communication and documentation, failure to post nurse staffing information, incomplete infection prevention and control program including lack of water management and antibiotic stewardship, failure to designate a qualified infection preventionist, and failure to provide and document resident immunizations.
Deficiencies (12)
Failed to consistently document resident code status (DNR or Full Code) across care plan, physician orders, and face sheets for multiple residents.
Failed to complete Significant Change in Status Assessments (SCSA) for hospice residents.
Failed to develop and implement comprehensive, individualized care plans addressing all resident needs and triggered care areas.
Failed to review and revise care plans timely when resident conditions changed.
Failed to document required fall documentation and neurological assessments for multiple residents after falls.
Failed to provide safe and appropriate respiratory care including undated oxygen tubing and lack of CPAP orders and maintenance.
Failed to maintain ongoing communication with dialysis facility and document dialysis care for a resident receiving dialysis.
Failed to post required nurse staffing information daily and maintain staffing records for 18 months.
Failed to develop and implement a complete infection prevention and control program including water management, use of Enhanced Barrier Precautions (EBP), and annual policy review.
Failed to implement an antibiotic stewardship program to monitor antibiotic use and resistance.
Failed to designate a qualified infection preventionist with required education and training.
Failed to educate and provide influenza and pneumococcal vaccinations to residents and document immunization status.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 10
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 18
Residents affected: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN W | Registered Nurse, Infection Preventionist | Stepped down from IP role, incomplete CDC training, unable to perform IP duties |
| LPN Q | Licensed Practical Nurse | Responsible for oxygen tubing changes and fall documentation; reported inconsistent neurological assessment practices |
| DON | Director of Nursing | New to facility, responsible for care plans, fall documentation, infection control oversight |
| Administrator | Facility Administrator | Responsible for overall facility compliance and oversight of infection control and staffing |
| SSD | Social Services Designee | Responsible for code status documentation and EBP signage placement |
| RN F | Registered Nurse | Transferred resident without PPE despite resident requiring Enhanced Barrier Precautions |
| LPN B | Licensed Practical Nurse | Provided wound care without PPE, reported PPE not readily accessible |
| CNA K | Certified Nurse Aide | Provided catheter care without PPE, forgot to wear gown and gloves |
| CNA G | Certified Nurse Aide | Unaware of EBP requirements and PPE availability |
| RA L | Restorative Aide | Did not wear PPE during catheter care, PPE not readily available |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: May 14, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's responsible party after a change in condition and failure to protect a resident from physical abuse by staff.
Complaint Details
The complaint investigation found that Resident #3's family was not notified of the resident's hospital transfer on 1/30/25 despite an active Durable Power of Attorney. For Resident #1, floor technician E was found to have roughly moved the resident's wheelchair causing a fall on 4/22/25; the technician was suspended and later terminated.
Findings
The facility failed to notify the responsible party of Resident #3's hospital transfer and failed to keep Resident #1 free from physical abuse when a floor technician aggressively moved the resident's wheelchair causing a fall. The facility took corrective actions including suspension and termination of the employee involved.
Deficiencies (2)
Facility staff failed to contact Resident #3's responsible party after a change in condition and hospital transfer.
Facility staff failed to keep Resident #1 free from physical abuse when floor technician E aggressively pulled the resident's wheelchair causing a fall.
Report Facts
Facility census: 61
Facility census: 58
Date of hospital transfer: Jan 30, 2025
Date of abuse incident: Apr 22, 2025
Date of employee termination: Apr 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Documented physician order for psychiatric evaluation and discussed notification failure |
| Social Service Director | Documented family call and discussed notification procedures | |
| Director of Nursing | Director of Nursing | Stated nurses are responsible for notifying family of hospital transfers |
| Administrator | Administrator | Confirmed responsibility for family notification and employee discipline |
| Floor Technician E | Floor Technician | Involved in physical abuse incident causing resident fall; suspended and terminated |
| Certified Nurses Aide F | Certified Nurses Aide | Reported floor technician E's rough handling of resident |
| CNA A | Certified Nurses Aide | Witnessed abuse incident and assisted resident after fall |
| CNA D | Certified Nurses Aide | Witnessed floor technician E's aggressive behavior |
| Dietary Manager | Dietary Manager | Reported witnessing floor technician E yelling at resident |
| Housekeeper F | Housekeeper | Assisted resident back into wheelchair after fall |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where two residents were involved in inappropriate sexual contact in the facility.
Complaint Details
The complaint investigation found substantiated sexual abuse involving two residents with cognitive impairment. The facility staff witnessed the incident, intervened immediately, and notified appropriate parties. The Director of Nursing provided staff inservice on abuse prevention and monitoring.
Findings
The facility failed to ensure two residents remained free from sexual abuse when Resident #1 raised his/her shirt and Resident #2 touched Resident #1's chest inappropriately. Both residents had impaired cognition and neither recalled the incident. Staff intervened immediately, separated the residents, and implemented new monitoring and intervention protocols.
Deficiencies (1)
Failure to protect residents from sexual abuse when Resident #1 was touched inappropriately by Resident #2.
Report Facts
Residents affected: 2
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified and investigated the incident, separated residents |
| CMT B | Certified Medication Technician | Witnessed the incident and reported to RN A |
| CNA C | Certified Nurse Aide | Witnessed the incident and reported to RN A |
| Director of Nursing | Director of Nursing | Provided staff inservice on abuse prevention and monitoring |
| Administrator | Administrator | Notified of the incident and investigation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse between two residents at Fulton Nursing & Rehab.
Complaint Details
The complaint investigation was substantiated based on staff observations and interviews confirming inappropriate sexual contact between two residents with cognitive impairment.
Findings
The facility failed to prevent inappropriate sexual contact between two residents, as Resident #1 raised his/her shirt and Resident #2 touched Resident #1's chest inappropriately. Staff intervened and separated the residents, but the facility's Abuse, Neglect, and Misappropriation Policy was found to be outdated.
Deficiencies (1)
F 600: The facility failed to ensure residents were free from abuse and neglect. Resident #2 touched Resident #1's chest inappropriately, violating the requirement to prevent verbal, mental, sexual, or physical abuse.
Report Facts
Facility census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified and documented observations of the incident and investigation |
| CMT B | Certified Medication Technician | Witnessed the incident and reported to RN A |
| CNA C | Certified Nurse Aide | Documented observations and participated in investigation |
| Director of Nursing | DON | Involved in notification and investigation of the incident |
Inspection Report
Routine
Census: 44
Deficiencies: 16
Date: May 2, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication administration, environment safety, infection control, and staff qualifications.
Findings
The facility was found deficient in multiple areas including failure to post survey results, protect resident privacy, maintain a safe and homelike environment, complete required resident assessments and care plans timely, ensure proper medication management and storage, provide adequate personal hygiene care, ensure safe resident transfers, maintain infection control practices, and ensure staff tuberculosis screening and dietary manager certification.
Deficiencies (16)
Failed to post three most recent years of survey results accessible to residents and representatives.
Failed to protect resident privacy by leaving Electronic Health Records (EHR) screens unlocked and unattended.
Failed to maintain bathroom doorframes, sink counters, and floors in good repair.
Failed to notify residents or representatives in writing of bed hold policy at time of hospital transfer.
Failed to complete Comprehensive Minimum Data Set (MDS) assessments within required timeframes.
Failed to perform significant change in status MDS assessments when required.
Failed to complete Quarterly MDS assessments within required timeframes.
Failed to accurately assess residents' medication use and preferences in MDS.
Failed to develop comprehensive person-centered care plans reflecting residents' current needs and preferences.
Failed to meet professional standards of care including obtaining orders for water flushes for gastric tubes, completing resident weights as ordered, documenting wound measurements, and documenting fall events.
Failed to provide appropriate personal hygiene care including shaving and bathing for dependent residents.
Failed to ensure safe resident environment and transfers including proper wheelchair foot pedal use, mechanical lift leg positioning, and safe medication storage.
Failed to employ a qualified and certified Dietary Manager.
Failed to implement infection prevention and control program including hand hygiene during medication administration and ensuring all employees had required tuberculosis screening.
Failed to ensure drugs and biologicals were properly labeled, stored, and expired medications were removed.
Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications.
Report Facts
Residents affected: 44
Deficiency count: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse F | Licensed Practical Nurse | Named in findings related to privacy, bed hold policy, care plans, and medication administration |
| Certified Medical Technician A | Certified Medical Technician | Named in findings related to privacy and infection control |
| Certified Nursing Assistant E | Certified Nursing Assistant | Named in findings related to privacy, personal hygiene, and tuberculosis screening |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding deficiencies and corrective actions |
| Administrator | Administrator | Named in multiple interviews regarding deficiencies and corrective actions |
| Certified Medication Technician B | Certified Medication Technician | Named in medication storage and infection control findings |
| Nurse Aide J | Nurse Aide | Named in wheelchair safety and weight monitoring findings |
| Licensed Practical Nurse I | Licensed Practical Nurse | Named in findings related to feeding tube care and care plans |
| Certified Nurse Aide G | Certified Nurse Aide | Named in privacy findings |
| Certified Nurse Aide H | Certified Nurse Aide | Named in transfer safety and privacy findings |
| Housekeeper C | Housekeeper | Named in environment maintenance findings |
| Maintenance D | Maintenance Director | Named in environment maintenance findings |
| Certified Nurse Aide E | Certified Nurse Aide | Named in tuberculosis screening and personal hygiene findings |
| Certified Medication Technician P | Certified Medication Technician | Named in tuberculosis screening findings |
| Dietary Aide O | Dietary Aide | Named in tuberculosis screening findings |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 15
Date: May 2, 2024
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for Fulton Nursing & Rehab.
Findings
The facility was found deficient in multiple areas including posting of survey results, resident privacy and confidentiality, safe and homelike environment, bed hold policies, comprehensive assessments, medication management, infection control, and care planning. Facility staff failed to ensure proper documentation, resident safety, and adherence to regulatory requirements.
Deficiencies (15)
F577: Facility staff failed to ensure three most recent years of survey results were posted and accessible to residents and representatives.
F583: Facility staff failed to protect resident privacy by leaving Electronic Health Records unlocked and unattended in public hallways.
F584: Facility failed to provide a comfortable homelike environment; bathrooms and floors were stained and in disrepair.
F625: Facility failed to provide written information on bed hold policy at time of resident transfer to hospital for three sampled residents.
F636: Facility failed to complete comprehensive Minimum Data Set (MDS) assessments within required timeframes for sampled residents.
F637: Facility failed to perform significant change assessments timely for residents with decline in condition.
F638: Facility failed to complete required quarterly Minimum Data Set assessments within required timeframes for sampled residents.
F641: Facility failed to accurately assess one resident's anticoagulant medication and oral/dental status.
F656: Facility failed to develop and implement comprehensive person-centered care plans consistent with resident rights and needs.
F677: Facility failed to provide appropriate personal hygiene care for dependent residents.
F689: Facility failed to ensure residents' environment remained free from accident hazards including wheelchair safety and mechanical lifts.
F758: Facility failed to ensure residents' psychotropic drug regimens were free from unnecessary medications and properly documented.
F761: Facility failed to properly label and store drugs and biologicals, and failed to monitor medication storage and disposal.
F801: Facility failed to employ a qualified dietary manager and provide adequate food and nutrition services.
F880: Facility failed to establish and maintain an infection prevention and control program to prevent spread of communicable diseases.
Report Facts
Facility census: 44
Deficiencies cited: 13
Plan of correction completion date: Jun 10, 2024
Inspection Report
Life Safety
Census: 44
Capacity: 100
Deficiencies: 14
Date: May 2, 2024
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and related provisions.
Findings
The facility failed to meet several Life Safety Code requirements including egress door locking arrangements, illumination of means of egress, smoke detection, smoke barrier construction, smoking regulations, electrical equipment safety, oxygen storage, and fire alarm systems. Deficiencies were observed through direct observation, interviews, and record review.
Deficiencies (14)
K222 Egress Doors: The main entrance/exit door was not on a controlled egress and did not open easily when the bar was pushed, failing delayed egress locking requirements.
K281 Illumination of Means of Egress: The facility failed to provide adequate emergency lighting at front and back exits, affecting evacuation safety.
K347 Smoke Detection: Smoke detection was missing in one room open to the corridor, risking delayed fire notification and evacuation.
K372 Smoke Barrier: The facility failed to maintain smoke barrier walls free of openings, including a 16 inch by 6 foot section missing in the dining room hallway.
K741 Smoking Regulations: The facility failed to ensure proper disposal of smoking materials and lacked a policy for maintenance of smoking areas.
K920 Electrical Equipment: The facility allowed improper use of power strips and extension cords in resident rooms, risking electrical hazards.
K923 Oxygen Storage: Oxygen cylinders were stored unsecured and the oxygen storage location was not secured against unauthorized entry.
A1133 Electrical System: The facility failed to test and certify the entire electrical system per the National Electrical Code requirements.
A2010 Oxygen Storage: The facility failed to comply with NFPA 99 standards for oxygen storage, including securing cylinders and proper storage conditions.
A2026 Smoke Detectors: The facility failed to have interconnected smoke detectors in all corridors and spaces open to corridors as required.
A2041 Door Locks: Door locks did not meet NFPA 101 requirements for egress, allowing only one lock per door and requiring manual release.
A2050 Emergency Lighting: Emergency lighting was insufficient to provide safety for residents and staff during power outages or emergencies.
A2054 Smoke Section Walls/Doors: Smoke sections were not properly separated by one-hour fire-rated walls and doors as required.
A2057 Ashtrays Noncombustibles/Safe Disposal: The facility failed to properly dispose of smoking materials in designated ashtrays made of noncombustible material.
Report Facts
Facility census: 44
Facility capacity: 100
Inspection Report
Routine
Census: 41
Deficiencies: 2
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in the nursing facility, specifically focusing on neurological checks and fall follow-up documentation after resident falls, as well as weekly skin assessments.
Findings
The facility failed to complete neurological checks and 72-hour fall follow-up documentation for three residents who experienced falls, and failed to complete weekly skin assessments for two residents. Interviews revealed staff awareness of required procedures but lack of completion and unclear responsibility for ensuring tasks were done.
Deficiencies (2)
Failure to complete neurological checks and fall follow-up documentation for three residents after falls.
Failure to complete weekly skin assessments for two residents as required by the facility's wound care prevention strategies.
Report Facts
Residents affected: 3
Residents affected: 2
Facility census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Admitted not completing neurological checks and follow-up fall charting |
| RN C | Registered Nurse | Stated nurses are responsible for neurological and follow-up fall charting but unclear who ensures completion |
| RN F | Registered Nurse | Responsible for ensuring neurological and follow-up fall charting but unsure why not completed |
| LPN D | Licensed Practical Nurse | Acknowledged responsibility for neurological and follow-up charting but unaware why not completed |
| LPN G | Licensed Practical Nurse | Stated nurses are in charge of weekly skin assessments but unsure why they are not completed |
| Director of Nursing | Director of Nursing | New DON who expects weekly skin assessments to be completed but unsure why they were not done previously |
| Administrator | Administrator | Stated nurses are responsible for neurological checks and skin assessments but unclear why tasks are incomplete |
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 2
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to neurological checks, fall follow-up documentation, and weekly skin assessments for residents at Fulton Nursing & Rehab.
Findings
The facility failed to complete neurological checks and fall follow-up documentation within 72 hours for several residents who experienced falls. Additionally, weekly skin assessments were not consistently completed as required, and care plans lacked appropriate interventions for pressure ulcers and skin care.
Deficiencies (2)
F658: The facility did not complete neurological checks and fall follow-up documentation within 72 hours for residents who had falls. Weekly skin assessments were incomplete for residents, and care plans lacked pressure ulcer or skin care interventions.
A4075: Nursing care per resident condition was not provided in accordance with acceptable nursing practice, as referenced by F658.
Report Facts
Facility census: 41
Completion date for plan of correction: Apr 2, 2024
Inspection Report
Census: 46
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to assess compliance with federally mandated quarterly Minimum Data Set (MDS) assessments for residents, ensuring that assessments are completed at least once every three months as required by OBRA regulations.
Findings
The facility failed to complete and submit the required quarterly MDS assessments for seven residents, with assessments either incomplete, in progress, or missing signed/printed documentation. Validation reports confirmed the absence of these assessments in the facility's records.
Deficiencies (1)
Failure to ensure quarterly Minimum Data Set (MDS) assessments were completed and submitted for seven residents as required.
Report Facts
Residents affected: 7
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding expectations for MDS completion and submission | |
| MDS coordinator | Interviewed about scheduling and completion of MDS assessments |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 2
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to assess compliance with quarterly Minimum Data Set (MDS) assessments and clinical record requirements at Fulton Nursing & Rehab.
Findings
The facility failed to complete required quarterly MDS assessments for seven residents, with assessments either incomplete, unsigned, or missing completion dates. Clinical records did not contain sufficient information to reflect ongoing assessments and interventions.
Deficiencies (2)
F638 Quarterly Assessment at Least Every 3 Months was not met as the facility failed to ensure seven residents were assessed using the quarterly Minimum Data Set (MDS) as required. Assessments were incomplete, unsigned, or missing completion dates.
A4108 Clinical Records - assessment/interventions regulation was not met as clinical records lacked sufficient information to reflect initial and ongoing assessments and interventions by involved disciplines.
Report Facts
Resident census: 46
Number of residents with incomplete MDS assessments: 7
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The visit was conducted to address a deficiency related to misappropriation and exploitation of resident property, specifically concerning missing resident funds.
Findings
The facility failed to prevent misappropriation of at least $150 from a resident's account and lacked a policy for monitoring resident funds deposited into a Resident Trust Account. The Administrator identified missing funds, conducted an investigation, replaced the missing funds, and implemented corrective actions including staff education and new procedures.
Deficiencies (1)
F 602: The facility did not have systems in place to prevent misappropriation of resident funds, resulting in a missing payment of $150 from a resident's account. The facility also lacked a policy for monitoring deposits into Resident Trust Accounts.
Report Facts
Resident census: 48
Missing payment amount: 150
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of at least $150.00 from one resident's (Resident #1) personal funds.
Complaint Details
The complaint investigation was substantiated with findings of misappropriation of Resident #1's funds. The Administrator conducted an investigation, reimbursed the resident, and implemented corrective actions.
Findings
The facility failed to have adequate systems in place to prevent misappropriation of Resident #1's money, resulting in missing funds. The investigation identified that four staff members had access to the safe, but the alleged perpetrator could not be determined. The facility reimbursed the resident and implemented corrective actions including setting up a Resident Trust Account and staff education.
Deficiencies (1)
Failure to protect resident's personal funds from misappropriation, resulting in missing $150.00 from Resident #1's account.
Report Facts
Missing funds amount: 150
Facility census: 48
Number of staff with safe access: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Conducted investigation, reimbursed resident, and implemented corrective actions | |
| Business Office Manager (BOM) | In-serviced on procedures for handling resident funds; current and prior BOM interviewed regarding missing funds |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 11
Date: Apr 13, 2023
Visit Reason
Annual inspection of Fulton Nursing & Rehab to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including unsafe environment conditions, inadequate maintenance, failure to provide proper resident care and documentation, and lack of compliance with infection control and medication management standards.
Deficiencies (11)
F584 Safe Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment, with issues such as chipped tiles, rust-colored spots, missing caulk, and damaged bathroom fixtures observed in multiple resident rooms.
F623 Notice Before Transfer/Discharge: The facility failed to provide written notice to residents or their representatives regarding transfers or discharges as required by regulation.
F658 Professional Standards: The facility failed to meet professional standards of quality in care plans and physician orders, including failure to follow physician orders and inadequate documentation of resident assessments.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate assistance with activities of daily living for dependent residents, including bathing and personal hygiene.
F680 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including failure to conduct required testing and training.
F689 Accidents: The facility failed to ensure the resident environment was free of accident hazards, including unsecured chemicals and unlocked medication carts.
F698 Tuberculosis Screening: The facility failed to provide required tuberculosis screening and documentation for residents.
F732 Nurse Staffing Information: The facility failed to maintain and post accurate nurse staffing information as required.
F758 Psychotropic Drugs: The facility failed to ensure psychotropic drugs were administered appropriately and with proper documentation.
F761 Storage of Drugs and Biologicals: The facility failed to store medications securely and in accordance with regulations, including unlocked medication carts and unsecured medications.
F882 Infection Preventionist Qualifications/Role: The facility failed to ensure the infection preventionist had completed required specialized training and certification.
Report Facts
Facility census: 50
Plan of correction completion date: May 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joannine Guyton | Administrator | Named in plan of correction signature and interview |
Inspection Report
Routine
Census: 50
Deficiencies: 12
Date: Apr 13, 2023
Visit Reason
Routine inspection of Fulton Nursing & Rehab to assess compliance with regulatory standards including resident care, environment, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including environmental maintenance, resident notification of transfers, medication administration and documentation, personal hygiene assistance, activities program qualifications, safety hazards, nurse staffing postings, psychotropic medication management, medication storage security, dialysis care communication, tuberculosis screening, and infection preventionist designation.
Deficiencies (12)
Facility staff failed to maintain a clean, comfortable and homelike environment with issues such as floor discolorations, missing toilet bolt covers, and damaged bathroom cabinets.
Facility staff failed to provide written notification to residents or representatives regarding hospital transfers and bed hold policies.
Facility staff failed to meet professional standards of care including failure to weigh residents as ordered, check Depakote levels, take blood pressure prior to medication, and document advance directives and physician medication orders.
Facility staff failed to provide assistance with personal hygiene for dependent residents, with inconsistent showering and grooming.
Activities program was not directed by a qualified professional; Activity Director lacked certification or formal training.
Facility failed to ensure razors/sharps and hazardous chemicals were stored safely and failed to maintain hot water temperature below 120 degrees Fahrenheit in resident rooms.
Facility staff failed to provide orders for dialysis and maintain communication with dialysis clinic for a resident receiving dialysis.
Facility failed to post nurse staffing information daily as required.
Facility failed to limit PRN psychotropic medication orders to 14 days without clinical rationale and failed to perform gradual dose reductions on psychotropic medications.
Facility failed to ensure medications were stored safely and medication carts were locked when unattended.
Facility staff failed to ensure residents were screened for tuberculosis with a two-step PPD test as per facility policy.
Facility failed to designate a qualified infection preventionist with specialized training for the infection prevention and control program.
Report Facts
Facility census: 50
Loose pills found: 2
Hot water temperature: 126.4
Hot water temperature: 125.6
Hot water temperature: 124.3
Hot water temperature: 121.3
PRN psychotropic medication stop date limit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding medication administration, dialysis communication, shower schedules, and medication cart security |
| CNA I | Certified Nurse Assistant | Interviewed regarding shower schedules and resident hygiene |
| Administrator | Interviewed regarding facility policies, deficiencies, and staff responsibilities | |
| Quality Assurance Nurse | Interviewed regarding facility deficiencies and policies | |
| Maintenance Director | Interviewed regarding water temperature monitoring | |
| Activity Director | Interviewed regarding qualifications and certification | |
| RN C | Registered Nurse | Interviewed regarding dialysis communication and medication orders |
| NA F | Nurse Assistant | Interviewed regarding shower room security |
| CMT B | Certified Medication Technician | Interviewed regarding medication cart management and loose pills |
| ADON | Assistant Director of Nursing | Interviewed regarding infection preventionist role and dialysis communication |
Inspection Report
Life Safety
Census: 50
Capacity: 100
Deficiencies: 18
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Fulton Nursing & Rehab.
Findings
The facility failed to meet several Life Safety Code requirements including sprinkler system maintenance, smoke barrier integrity, fire drills, electrical system testing, and safe storage of oxygen cylinders. Multiple deficiencies were identified that could affect the safety of all facility occupants.
Deficiencies (18)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to inspect, test, and maintain the wet pipe sprinkler system and replace or recalibrate sprinkler system gauges every five years.
K372 Smoke Barrier Construction: Facility staff failed to maintain five smoke barrier walls free of openings, including an unsealed hole in a wall allowing potential smoke and fire spread.
K500 Building Services - Other: Facility staff failed to maintain the back of gas-fired dryers free of lint buildup, increasing fire risk.
K712 Fire Drills: Facility staff failed to conduct fire drills quarterly on each shift at varying times and conditions, and records lacked documentation of simulated conditions.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to provide complete and verifiable documentation for inspection and testing of non-rated door assemblies.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to assess electrical receptacles in resident care rooms for physical integrity and grounding at least annually.
K918 Electrical Systems - Essential Electric System Maintenance: Facility staff failed to inspect main and feeder circuit breakers annually as required.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to secure oxygen cylinders against unauthorized access and failed to separate full and empty cylinders to prevent confusion.
K925 Gas Equipment - Respiratory Therapy Sources of Ignition: Facility staff failed to eliminate respiratory therapy sources of ignition near residents receiving oxygen therapy.
A1065 Drinking Fountains: Facility staff failed to provide drinking fountains accessible to residents in wheelchairs in or near the lobby, recreation area, and nursing units.
A1132 Night-lights-Required Locations: Facility staff failed to provide night-lights in 18 resident rooms and adjacent toilet and shower rooms.
A1133 Electrical System-Test/Certify per Code: Facility staff failed to ensure a qualified electrician tested and certified the entire electrical system as required.
A2003 No Fire Hazard: Facility staff failed to maintain fire safety by allowing accumulation of lint and unsecured oxygen storage.
A2010 Oxygen Storage: Facility staff failed to store oxygen cylinders in accordance with NFPA 99 requirements.
A2034 Sprinkler System-Test/Maintain: Facility staff failed to inspect, maintain, and test sprinkler systems as required.
A2054 Smoke Section Walls/Doors: Facility staff failed to maintain smoke barriers with required fire resistance ratings and self-closing doors.
A2061 Fire Drill Requirements, Evacuation: Facility staff failed to conduct required fire drills annually on each shift and include simulated resident evacuation.
A3030 Electrical Wiring & Equipment Maintained: Facility staff failed to maintain electrical wiring and equipment in accordance with code requirements.
Report Facts
Facility census: 50
Facility capacity: 100
Inspection Report
Life Safety
Census: 38
Capacity: 100
Deficiencies: 8
Date: May 12, 2021
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including staff access to all areas, delayed egress locking devices not functioning properly, failure to maintain smoke barriers and fire drills, and inadequate maintenance of sprinkler and fire alarm systems. The facility census was 38 with a capacity of 100.
Deficiencies (8)
K100: Facility staff failed to ensure staff had access to all areas of the facility at all times, potentially delaying emergency response in locked areas.
K222: Facility staff failed to ensure two of eleven exit doors opened within 15 seconds of manual actuation, delaying evacuation.
K321: Facility staff failed to maintain self-closing, positive latching doors to hazardous areas, preventing containment of smoke and fire.
K347: Facility staff failed to provide smoke detection in two resident lounges open to corridors, delaying fire notification and evacuation.
K353: Facility staff failed to maintain sprinkler systems free from obstruction, paint, and foreign materials, risking system failure.
K372: Facility staff failed to maintain four of five smoke barrier walls free of openings to provide required fire resistance rating.
K712: Facility staff failed to conduct fire drills at various times and shifts quarterly, risking delayed emergency response.
K918: Facility staff failed to provide complete and verifiable documentation of weekly and monthly emergency generator inspections and testing.
Report Facts
Facility census: 38
Total capacity: 100
Date of survey: May 12, 2021
Plan of correction completion date: Jun 13, 2021
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19.
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
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related 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
Deficiencies: 0
Date: Jun 2, 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 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 7
Date: Jul 29, 2019
Visit Reason
The inspection was the annual survey of Fulton Nursing & Rehab to assess compliance with federal and state regulations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper notice requirements before transfer or discharge, comprehensive person-centered care planning, behavioral health services, and food safety. Multiple deficiencies were cited related to environmental conditions, care planning, resident rights, and safety.
Deficiencies (7)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain residents' rooms in good repair, including dirty/discolored floors, peeling paint, and damaged fixtures.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the ombudsman of transfers or discharges to a hospital for sampled residents.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans within 48 hours of admission for sampled residents.
F657 Care Plan Timing and Revision: The facility failed to revise care plans in a timely manner for sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment remained free of accident hazards, including unsecured chemicals accessible to residents.
F740 Behavioral Health Services: The facility failed to provide adequate behavioral health services for one resident, including failure to provide non-pharmacological interventions.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to allow sanitized kitchenware to air dry prior to stacking and use to prevent cross-contamination of food.
Report Facts
Facility census: 52
Date of survey completion: Jul 29, 2019
Plan of correction completion dates: Various corrective actions scheduled for completion by 2019-09-07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Signed the inspection report and plan of correction | |
| Maintenance Director | Interviewed regarding maintenance issues and repairs | |
| Social Services Designee | Interviewed regarding ombudsman notifications | |
| MDS Coordinator | Interviewed regarding care plan completion and revisions | |
| Certified Medication Technician (CMT) | Interviewed regarding resident care and medication application | |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident assessments and medication | |
| Director of Nursing | Interviewed regarding care plan updates and resident care | |
| Dietary Manager/Designee | Interviewed regarding food safety and staff education | |
| Facility Social Services Director | Responsible for ombudsman notifications | |
| Facility Housekeeping Supervisor/Designee | Responsible for monitoring housekeeping compliance |
Inspection Report
Life Safety
Census: 52
Capacity: 100
Deficiencies: 18
Date: Jul 29, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and building construction standards at Fulton Nursing & Rehab.
Findings
The facility failed to maintain appropriate building construction and fire safety features, including sprinkler system deficiencies, unsecured doors, obstructed exit corridors, and incomplete fire alarm and emergency lighting systems. Multiple deficiencies were identified related to fire barriers, smoke partitions, exit door hardware, and fire alarm system maintenance.
Deficiencies (18)
K161: The facility failed to maintain a one-hour rated ceiling and proper fire-rated construction in the attic space, with multiple unsealed openings and exposed wooden studs.
K211: The facility failed to maintain exit corridors free of obstruction and unsecured furniture, and failed to secure exit doors properly.
K222: The facility failed to maintain delayed-egress exit doors with proper signage, locking mechanisms, and timely door release.
K271: The facility failed to maintain clear and unobstructed exit pathways, including repair of sidewalk gaps and securing exit doors.
K281: The facility failed to provide adequate illumination of means of egress and emergency lighting.
K321: The facility failed to maintain smoke barrier walls and doors, with multiple unsealed openings, missing self-closing devices, and damaged doors.
K341: The facility failed to maintain a complete fire alarm system, including missing audible alarms and incomplete documentation.
K345: The facility failed to maintain the sprinkler system, including missing sprinkler heads, improper installation, and lack of testing documentation.
K353: The facility failed to maintain fire sprinkler system components, including accumulation of lint on sprinkler heads and missing sprinkler heads in storage areas.
K363: The facility failed to maintain corridor doors with proper latching and smoke containment, with multiple gaps and damaged doors.
K372: The facility failed to maintain smoke barriers with unsealed openings and holes, compromising fire resistance ratings.
K712: The facility failed to conduct required fire drills quarterly and maintain documentation of fire drills.
K761: The facility failed to maintain fire doors and assemblies, with multiple gaps, damaged doors, and missing latching mechanisms.
K781: The facility failed to prohibit the use of portable space heaters in resident areas, increasing fire risk.
K914: The facility failed to maintain electrical receptacles in resident care areas, lacking proper documentation and testing.
K918: The facility failed to maintain emergency generator inspections and documentation, with incomplete records and testing.
K920: The facility failed to maintain electrical wiring and surge protectors, with use of non-rated extension cords and improper power strips.
K923: The facility failed to properly store combustible oxygen cylinders and maintain oxygen storage areas free of hazards.
Report Facts
Facility census: 52
Facility capacity: 100
Deficiencies cited: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Miller | Maintenance Director | Named in relation to door inspection and maintenance deficiencies |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 9
Date: Aug 3, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations and to investigate allegations of deficient practices related to resident care and facility policies.
Findings
The facility was found to have multiple deficiencies related to resident rights, abuse prevention, care planning, infection control, medication administration, and food safety. Corrective actions were planned and documented in the plan of correction.
Deficiencies (9)
F550 Resident Rights: The facility failed to ensure residents received dignified care, including proper clothing, privacy, and respect for preferences. Multiple residents were observed inappropriately dressed or without privacy measures.
F600 Abuse Prevention: The facility failed to prevent resident abuse and neglect, including verbal altercations among residents and inadequate staff response to aggressive behaviors.
F620 Admission Policies: The facility failed to ensure proper admission policies and consents were maintained and followed, including documentation of resident agreements and consents.
F637 Comprehensive Assessment: The facility failed to complete timely and accurate comprehensive assessments for residents with significant status changes.
F655 Care Planning: The facility failed to develop and implement comprehensive, person-centered care plans reflecting resident needs and preferences.
F656 Services Provided Meet Professional Standards: The facility failed to follow physician orders and provide care according to professional standards, including catheter care and medication administration.
F658 Food Procurement, Storage, Preparation, Service and Sanitation: The facility failed to ensure food safety and sanitation, including improper handwashing and food handling by staff.
F880 Infection Prevention and Control: The facility failed to maintain an effective infection control program, including improper use of gloves and hand hygiene by staff.
F697 Pain Management: The facility failed to provide adequate pain management, including assessment, documentation, and monitoring of residents' pain.
Report Facts
Facility census: 60
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Apr 3, 2018
Visit Reason
The inspection was conducted following a complaint alleging physical abuse of a resident by a staff member at Fulton Nursing & Rehab.
Complaint Details
The complaint investigation substantiated that a staff member physically abused Resident #1 by slapping the resident's hand. The abusive employee was suspended during the investigation and terminated after confirmation of abuse.
Findings
The facility failed to ensure a resident was free from physical abuse when a staff member slapped the resident's hand during care. The investigation confirmed the abuse, and the abusive employee was terminated.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent physical abuse when a staff member slapped a resident's hand during care.
A8023 Develop/Implement Abuse Policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents as required.
Report Facts
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named as the alleged abusive employee who slapped Resident #1 |
| CNA B | Certified Nurse Aide | Witness and reporter of the abuse incident |
| LPN C | Licensed Practical Nurse | Interviewed during investigation; provided information about staff directions and incident |
Document
Deficiencies: 0
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content related to facility inspection or compliance are present in the document.
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