Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to maintain
resident dignity by not dressing the resident and using the resident’s personal space for
staff convenience for one resident ( Resident #24) and by failing to properly cover two
residents (Resident #27 and Resident #54) urinary catheter bags. The facility census was
60.
1. Review of Resident #24’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 5/19/18, showed the following:
– Admission of 2/14/14;
– No speech;
– Severely impaired cognition;
– Resident is rarely/never understood;
– Resident/staff assessment of daily preferences not completed;
– Required total dependence of two or more staff for bed mobility, transfers, dressing,
personal hygiene, and bathing;
– Limitation in range of motion on both sides in upper and lower extremities;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].>- Feeding tube.
Review of the resident’s care plan, last reviewed on 4/17/18, showed the care plan did not
address activities of daily living or resident preferences.
Observation on 7/31/18 at 10:24 A.M. showed the resident lay in bed on his/her left side,
wore only a brief, and covered with a sheet on the lower half of his/her body. A
medication cart sat directly across from the resident’s bed, in the resident’s line of
sight. The resident’s could be seen from the hallway.
Observation on 8/1/18 at 9:41 A.M. showed the resident lay in bed on his/her right side,
wore only a brief, and covered with a sheet on lower half of body. The resident’s room
door was open.
Observation on 8/1/18 at 2:20 P.M. showed the resident lay in bed on his/her left side,
wore only a brief, covered with a sheet on lower half of body. A medication cart sat
directly across from the resident’s bed, in the resident’s line of sight. The resident’s
room door was open.
Observation on 8/2/18 at 9:42 A.M. showed the resident lay in bed on his/her left side,
wore only a brief, and covered with a sheet on lower half of body. A medication cart sat
directly across from the resident’s bed, in the resident’s line of sight. The resident’s
room door was open. Observation at 11:30 A.M. and 3:30 P.M. showed the resident lay in bed
on his/her right side, wore only a brief, and covered with a sheet on lower half of body.
During an interview on 8/3/18 at 11:44 A.M., LPN A said he/she is familiar with the
resident and sometimes passes medications to the resident. The medication cart is in the
resident’s room because it has all his/her feeding supplies in it. It is easiest for the
staff to keep the medication cart next to the resident’s bed.
During an interview on 8/3/18 at 11:55 A.M., CNA F said he/she is very familiar with the
resident. The resident never wears a gown or clothing, because the staff say he/she is too
hot. The facility staff turn the air conditioner in the resident’s room way up, and he/she
is worried that the resident will get pneumonia from not wearing clothes while lying in
the cold air. If the facility has clean gowns in stock then he/she will try to put one on
the resident after his/her shower. The medication cart has been sitting in the same spot
for the last ten months. The medication cart contains the resident’s tube feeding

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
supplies. The cart sits next to the resident’s bed, because it is easier for the nursing
staff.
During an interview on 8/3/18 at 2:55 P.M., Housekeeper T said he/she is responsible for
cleaning the halls and resident rooms. He/she goes into all resident rooms, and sometimes
the residents are in the rooms when he/she cleans them. Resident #24 is always in the room
when he/she cleans it. The resident never has on clothes when he/she goes into his/her
room. He/she is in the resident’s room almost every day. He/she has worked the day shift,
the evening shift, and the weekend shift. The resident is always in a brief with no other
clothes. The resident’s door is always open except when they do patient care. It is easy
to see the resident in only a brief and sheet from the hallway. The medication cart has
been sitting at the wall near the resident’s bed for at least three months. It used to be
near the entrance door, out of the resident’s view, but the nurses moved it closer to
where they work so they did not have to walk as far. The resident has to look at the
medication cart when he/she is in bed.
During an interview on 8/3/18 at 3:42 P.M., the Activity Director said she is very
familiar with the resident. She visits him/her daily. There is a Cardinals banner on the
wall of the resident’s room, because he/she was a Cardinal fan. Pictures on the wall would
be more stimulating than looking at the medication cart. There should be more pictures on
his/her wall. She typically visits the resident around 6:30 A.M. This week the resident
did not have a gown on, but he/she was covered with a sheet. He/she was naked at the top.
When she went into the resident’s room on Wednesday, he/she was only in a sheet with no
shirt and no pants.
During an interview on 8/3/18 at 6:00 P.M., the administrator and the Director of Nursing
(DON) said every resident should be dressed every day. No resident should be laying around
in only a brief all day.
During an interview on 8/3/18 at 7:24 P.M. the DON said the medication cart should not be
in the resident’s line of sight. He/she would benefit from pictures or other stimulating
items in that space. Those would be a better use of the space then a medication cart.
2. Review of Resident #27’s significant change MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood and understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– Required total dependence with transfers, toilet use, and bathing;
– Uses a catheter;
– [DIAGNOSES REDACTED].
– On hospice.
Review of the resident’s hospital discharge report, dated 6/20/18, showed the resident
discharged to the facility with a Foley catheter in place due to [MEDICAL CONDITION].
Review of the resident’s care plan, last reviewed on 7/26/18, showed the following:
– Resident has an indwelling urinary catheter;
– Resident will have catheter care managed appropriately;
– Position bag below level of bladder, place bag in privacy cover.
Observation on 8/2/18, at 11:31 A.M., showed the resident in bed with his/her catheter
unsecured and hung on side of the bed. The bag did not have a privacy cover and could be
seen from the hallway.
Observation on 8/3/18 at 10:00 A.M. showed the resident in bed with his/her catheter
unsecured and hung on side of the bed. The bag did not have a privacy cover and could be
seen from the hallway.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
3. Review of Resident #54’s readmission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with physical and verbal behaviors;
-Requires total physical assistance of one person for bathing;
-Requires extensive physical assistance of two persons for bed mobility, transfers,
dressing, toileting, and personal hygiene;
-Requires extensive physical assistance of one person for locomotion;
-Requires limited physical assistance of one person for eating;
-Impaired range of motion of the lower extremity on one side;
-Catheter;
-Always incontinent of bowel;
-[DIAGNOSES REDACTED].
-Almost constant pain rated 8 on a scale of 0 – 10 and uses pain medication as needed;
-Skin intact;
-During the seven day look back, took antidepressant medication for seven days, antibiotic
medication for seven days, and an Opioid for seven days.
Review of the resident’s Plan of Care, dated 06/28/18, showed the following:
-Staff are directed to see the POS for orders regarding changing the catheter,
-Keep the catheter system a closed system as much as possible. Don’t let any part of
tubing or bag touch the floor. Keep the bag below the bladder level and put in a privacy
bag.
Observation on 07/31/18 at 10:50 A.M., showed the resident lay in a low bed on his/her
left side with the catheter bag touching the floor without a dignity bag covering it.
Observation on 08/01/18 at 9:39 A.M., showed the resident in bed with the catheter bag
touching the floor without a dignity bag covering it.
During an interview on 08/01/18 at 9:45 A.M., CNA N said the catheter bag should not touch
the floor and should be in a dignity bag. The CNA said it is hard to keep it off the floor
when the resident is in a low bed but a dignity bag would provide a barrier.
During an interview on 08/03/18 at 6:15 P.M., the Administrator and Director of Nursing
(DON) said the catheter bag should always be covered with a privacy bag and the catheter
bag and tubing should never be allowed to touch the floor.

F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility staff failed to prevent a
resident to resident altercation for two resident’s (Resident #15 and Resident #33). The
facility census was 60.
1. Review of the facility’s Abuse Prohibition Policy, updated 11/2016, showed direction
for staff as follows:
– Purpose: To prohibit mistreatment, neglect, abuse, misappropriation of resident’s
property, and exploitation of any resident;
Physical abuse is defined as hitting, slapping, pinching, kicking, etcetera. It also
includes controlling behavior through corporal punishment;
– To assure that everything possible is being done to prevent abuse, the facility has
implemented the following seven component processes:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– Screening of potential employees;
– Training, initial and ongoing of employees;
– Prevention of abuse, neglect, or mistreatment or any of the types of abuse;
– Identification of suspicious events;
– Protection of residents during an investigation;
– Investigation of all alleged violations;
– Response and reporting of an abusive situation to necessary agencies.
2. Review of Resident #4’s annual Minimum Data Set (MDS), a federally mandated assessment,
dated 1/17/18, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Physical behavior directed toward others 1 to 3 days;
-Verbal behavior directed towards others 4 to 6 days;
-Behaviors put resident at risk for physical illness or injury, and interfere with the
resident’s care, activities, and social interaction;
-Behaviors intrude on the privacy or activity of others, and disrupts the living
environment;
-Wanders and intrudes on the privacy of activities of others 1 to 3 days.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented the
resident:
-Severe cognitive impairment;
-Physical behavior directed toward others 1 to 3 days;
-Verbal behavior directed towards others 4 to 6 days;
-Wanders 1 to 3 days.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented the
resident:
-Severe cognitive impairment;
-Physical behavior directed toward others 1 to 3 days;
-Verbal behavior directed towards others 4 to 6 days;
-Wanders 1 to 3 days.
3. Review of Resident #15’s quarterly MDS, dated [DATE], showed staff documented the
resident:
-Severe cognitive impairment;
-Limited assistance of one staff member for bed mobility, transfers, ambulation,
locomotion, and eating;
-Extensive assistance of one staff member for dressing, toilet use, hygiene, and bathing.
4. Review of Resident #33’s, quarterly MDS, dated [DATE], showed the staff documented:
-Cognition is moderately impaired;
-Limited assistance of two staff members for bed mobility, transfers, locomotion, and
hygiene;
-Extensive assistance of two staff members for dressing, toilet use,
-Dependent on two staff for bathing.
5. Observation on 8/2/18, at 12:34 P.M., showed certified nurse assistant (CNA) E walk
Resident #15 beside Resident #4’s chair. Additional observation showed Resident #4 strike
Resident #15 four times in the buttocks and strike CNA E and say shut up. CNA E said,
someone is in a bad mood and left Resident #15 at the table (square table that sits four)
beside Resident #4. Resident #27 sat on the other side of Resident #15 and said, be nice
to each other.
Observation on 8/2/18, at 12:37 P.M., showed Resident #4 continued to curse at and
threaten Resident #15, Resident #27, and Resident #33 (sitting on the side of the table
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
next to Resident #4 and Resident #27).
Observation on 8/2/18, at 12:40 P.M., showed Resident #4 curse and swing at Resident #33.
Nurse assistant (NA) P came to the table and moved Resident #33 over approximately a foot,
and Resident #4 struck NA P. CNA E said to Resident #4, don’t make me take you out of the
dining room, I know you are hungry, and he/she sat at the table with the residents between
Resident #27 and Resident #15.
Observation on 8/2/18, at 12:42 P.M., showed Resident #27 moaned and Resident #4 said,
shut the hell up.
Observation on 8/2/18, at 12:44 P.M., showed Resident #4 grab Resident #33’s silverware.
Resident #33 grabbed the silverware back, and Resident #4 cursed and said, I dare you to
Resident #33. Resident #33 told CNA E (who sat at the table with the residents), I don’t
want to sit by (Resident #4) anymore. The CNA replied, it will be ok.
Observation on 8/2/18, at 12:51 P.M., showed Resident #4 cursed at Resident #33 and said
I’ll kill you b****, and slapped Resident #33 on the arm. Resident #33 said, don’t hit me.
6. During an interview on 8/02/18, at 1:01 P.M., DHSS staff reported the incident to the
administrator (ADM). The ADM said staff did not report the incident to him/her. The ADM
said the incident is a resident to resident altercation and he/she will start an
investigation and ensure the resident is removed from the table.
During an interview on 8/2/18, at 2:00 P.M., the ADM said Resident #4 had two resident to
resident altercations in (MONTH) when the resident had a urinary tract infection. He/She
said he/she expects staff to remove the aggressor immediately if a resident to resident
altercation occurs, and to report it to him/her right after.
Review of the facility’s investigation showed staff documented Resident #4 was sent to an
acute geriatric psychiatric facility pending medical evaluation.
7. During an interview on 8/3/18, at 5:40 P.M., Licensed practical nurse (LPN) L said if
staff witness a resident to resident altercation, they are to separate the residents and
make sure they are safe. He/She said staff are expected to report it immediately to the
charge nurse, director of nursing (DON), or the ADM. He/She said if staff report an
incident to him/her he/she assesses the residents immediately and alerts the ADM
immediately.
During an interview on 8/3/18, at 6:11 P.M., the ADM said if staff witness a resident to
resident altercation they are to separate the resident’s and make sure they are safe.
He/She said staff are expected to report it immediately to the charge nurse, director of
nursing (DON), or the ADM.

F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a
condition of admission; and must tell residents what care they do not provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure the admission policy
did not require the resident to waive potential facility responsibility for loss or damage
to personal belongings for 15 out of 15 sampled residents (Residents #9, # 14, #15, #17,
#23, #27, #29, #30, #32, #33, #37, #43, #44, #50, and #54). This had the potential to
affect all facility residents. The census was 53.
1. Review of Resident #9’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/5/18, showed an admission date
of [DATE].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
Review of the resident’s Consents and Authorizations forms, showed the following:
-The resident will participate in supervised activities outside the Facility, but will
release the facility from responsibility for any accident or injury that may occur as a
result of these trips;
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the resident;
-Dated 4//24/18.
2. Review of Resident #14’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the resident;
-Dated 7/10/17.
3. Review of Resident #15’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the responsible party;
-Dated 2/6/14.
4. Review of Resident #17’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form,the Personal Laundry Agreement
form, and the Cable/Satellite Services form showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 4/19/18.
5. Review of Resident #23’s quarterly MDS, dated [DATE], showed an admitted 2.9.18.
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 6)
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the resident;
-Dated 2/23/18.
6. Review of Resident #27’s significant change MDS, dated [DATE], showed an admission date
of [DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the responsible party;
-Dated 5/14/18.
7. Review of Resident #29’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the responsible party;
-Dated 9/4/15.
8. Review of Resident #30’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form, the Personal Laundry Agreement
form and the Cable/Satellite Services form showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 4/18/18.
9. Review of Resident #32’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Cable/Satellite Services
form, showed the following:
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 11/2/15.
10. Review of Resident #33’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 7)
-Signed by the responsible party;
-Dated 11/1/12.
11. Review of Resident #37’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the responsible party;
-Dated 5/21/13.
12. Review of Resident #43’s annual MDS, dated [DATE], showed an admission date of [DATE].
Review of the resident’s Consents and Authorizations form, the Personal Laundry Agreement
form and the Cable/Satellite Services form showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
– The resident authorized payment for the facility to provide basic cable television
service, but released the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 6/30/15.
13. Review of Resident #44’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations form and the Personal Laundry
Agreement form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-Signed by the responsible party;
-Dated 8/31/15.
14. Review of Resident #50’s significant change MDS, dated [DATE], showed an admission
date of [DATE].
Review of the resident’s Consents and Authorizations forms, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 5/15/13.
15. Review of Resident #54’s discharge MDS, dated [DATE], showed an admission date of
[DATE].
Review of the resident’s Consents and Authorizations forms, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 8)
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 5/8/18.
16. During a group interview, on 8/2/18 at 9:29 A.M., with five residents identified by
the facility as alert and oriented, the residents said they had personal items or money go
missing while living at the facility, such clothing items and money. They tell staff and
staff look for it. The facility does not replace or reimburse them for the items.
17. Review of the facility’s Consents and Authorizations forms showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection.
18. Review of the facility’s Non-Liability Statement for Personal Property showed the
resident waived the facility’s responsibility for personal items brought into the facility
which were lost or damaged while residing at the facility.
19. During an interview on 8/3/18 at 2:20 P.M., the Social Worker said she is responsible
for reviewing the admission packet with the new residents and/or the responsible party.
She reviews the section labeled Social Services Section. The Consents and Authorization
page is part of the current admission . The form discusses facility staff doing the
resident’s laundry and asks the resident to release the facility from any responsibility
for damage to personal clothing. The facility is not responsible for damage to the
laundry. The form also discusses the facility providing basic cable television service and
asks the resident to release the facility from any responsibility for damage to the
personal television set as a result of the television cable installation and connection.
The facility is not responsible for the television, because they did not provide the item
for the resident. She said she did not know the residents could not be asked to waive the
facility’s responsibility for their personal belongings.
20. During an interview on 8/3/18 at 2:34 P.M. the Business Office Manager said she is
responsible for reviewing the Financial Section of the admission packet with the new
residents and/or responsible party. The Consents and Authorization page is part of the
current admission packet, but it is part of the Social Services section. She does not
review it with the residents. The Cable/Satellite Services form asks the resident to waive
the facility’s responsibility for damage to their television as a result of the cable or
satellite installation or connection. She does not discuss the waiving of responsibility
with the residents. She discusses the agreement to pay for cable services, if they want
it. The Personal Laundry Agreement asks the resident to waive the facility’s
responsibility for loss or damage of the resident’s personal belongings during the
laundering process. The facility is not responsible for lost, stolen, or damaged clothes
or personal items. That is what she was told. The facility policy is not to replace ay
items which have been lost, stolen, or damaged. Residents have complained of missing
items, but the facility did not replace or reimburse for those items. The facility only
looks for the items if they are missing. If they are not found then nothing else happens.
Staff will continue to keep an eye out for them item. She said she did not know the
residents could not be asked to waive the facility’s responsibility for their personal
items.
21. During an interview on 8/3/18 at 3:42 P.M., the Activity Director said she is
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 9)
primarily responsible for assisting residents with finding their lost items, especially
clothing. When residents report one of their clothing items is missing, she goes to the
laundry staff and lets them know. She and the laundry staff will search for the items. If
the clothing items have been messed up during the laundering process, she will get money
from the facility and replace the items. They do not do that if the clothing is just
missing. They look for missing clothes, but the facility does not replace them. They just
keep looking for the items.
22. During an interview on 8/3/18 at 6:00 P.M., the administrator and the Director of
Nursing (DON) said they did not know the residents could not be asked to waive the
facility’s responsibility for their personal belongings. The facility does not reimburse
or replace lost or missing personal property of money. The facility does not have the
money to do that. They facility staff make every effort to locate the items, but if they
cannot be found they are not replaced or reimbursed.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility staff failed to complete a
significant change in status (SCSA) Minimum Data set (MDS) for four resident’s (Resident
#9, #14, #30 and #58) with a significant change. The facility census was 60.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff
as follows:
-Comprehensive Assessments are required comprehensive assessments include the completion
of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as
care planning. Comprehensive assessments are completed upon admission, annually, and when
a significant change in a resident’s status has occurred or a significant correction to a
prior comprehensive assessment is required. They consist of:
-Admission Assessment
-Annual Assessment
-Significant Change in Status Assessment
-Significant Correction to Prior Comprehensive Assessment
-The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a
resident that must be completed when the interdisciplinary team (IDT) has determined that
a resident meets the significant change guidelines for either major improvement or
decline. It can be performed at any time after the completion of an Admission assessment,
and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s
determination was made that the resident had a significant change. A significant change is
a major decline or improvement in a resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered
self-limiting;
-Impacts more than one area of the resident’s health status; and
-Requires interdisciplinary review and/or revision of the care plan.
-Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the
assessment is complete.
o For required Comprehensive assessments, assessment completion is defined as completion

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
of the CAA process in addition to the MDS items, meaning that the registered nurse (RN)
assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item
V0200B) completion attestations. Since a Comprehensive assessment includes completion of
both the MDS and the CAA process, the assessment timing requirements for a comprehensive
assessment apply to both the completion of the MDS and the CAA process.
2. Review of Resident #9’s admission MDS, a federally mandated assessment, dated 5/5/18,
showed staff assessed the resident as:
-Cognitively intact;
-Admission to facility 4/24/18;
-[DIAGNOSES REDACTED].
-No signs or symptoms of depression;
-No behaviors or rejections of care;
-Weight 214 pounds (lbs);
-Supervision with one person physical assistance for bed mobility, and transfers;
-Limited physical assistance of one staff member for dressing, and hygiene;
-Extensive assistance of one staff member with toilet use, and bathing;
-Stage 4 wound;
-Indwelling catheter.
Review of the resident’s weight record showed staff documented:
-5/01/2018 214.2 lbs;
-6/01/2018 203.8 lbs (10.4 lb weight loss);
-7/01/2018 168.2 lbs (35.6 lb weight loss, 17% in 30 days, 45.9 lb weight loss, 21% in 60
days);
-7/20/2018 173.2 lbs;
-7/25/2018 173.4 lbs;
-8/01/2018 171 lbs.

Review of the resident’s Dietitian Note, dated 6/21/2018, showed the registered dietitian
(RD) documented:
-Wound Monitoring: Resident has lost 10 lbs/4.9% in the past 30 days;
-Current weight 203.8 lbs., body max index (BMI): 27.64- healthy weight;
-Tolerating regular diet with VHC (dietary supplement) one time per/day;
-Resident has stage 4 open wound on right ischium, foul order noted;
-5/7/18 [MEDICATION NAME] 10.5(Low);
-Recommend: discontinue VHC due to diet prescription meeting nutritional goals and add
double meat/eggs with breakfast. Prosource (dietary supplement for wound healing) 30
milliliters (ml) and [MEDICATION NAME] (dietary supplement to aide in wound healing) twice
a day. RD to continue monitoring weight and wound.
Review of the resident’s Dietitian Note, dated 7/11/2018, showed the RD documented:
-Wound & Weight Monitoring: Resident has lost 35 lbs/17.5% in the past 30 days;
-Current weight: 168.20 BMI: 22.81- healthy weight;
-Tolerating regular diet with double meat and eggs at breakfast;
-Wound to right ischium; receiving antibiotics due to wound infection;
-Receives [MEDICATION NAME] two times a day and prosource two times a day to aid with
wound healing;
-Current diet order plus supplements meeting nutritional goals;
-Recommend weekly weights for four weeks due to large weight variation;
-Continue to encourage good intake;
-RD to follow.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
Review of the resident’s monthly summary, dated 7/16/18, showed staff documented the
resident rejects care, is independent with hygiene, independent with grooming,and is
dependent on staff for toilet use.
Review of the resident’s physician’s orders [REDACTED].
During an interview on 8/01/18, at 10:26 A.M., the resident said he/she lost a lot of
weight since he/she came to the facility. He/She said he/she is having more anxiety and
depression than he/she has ever had, and no one is addressing it. He/She said that he/she
started losing weight when his/her wound became infected and he/she had such a foul odor
coming from the wound he/she felt bad and embarrassed for anyone to smell it. He/She said
it was hard for him/her to eat and would not go to the dining room because he/she would
not subject anyone to the smell and it was embarrassing.
Further review showed the record did not contain a significant change in status assessment
after documented changes in his/her ADL’s from the admission assessment to the monthly
summary, a significant infection, a significant weight loss, symptoms of depression, and
new behaviors.
3. Review of Resident #14’s significant change in status assessment (SCSA) MDS, dated
[DATE], showed staff documented:
-Cognition moderately impaired;
-Extensive assistance of one staff member for dressing, and eating;
-Extensive assistance of two staff member for bed mobility;
-Dependent on two staff members for transfers, and toilet use;
-Staff did not administer Opioid;
-One Stage 3 and one Stage 4 wound.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented:
-Cognition moderately impaired;
-Added [DIAGNOSES REDACTED].>-Limited assistance of one staff member for eating;
-Dependent on one staff member for dressing, and toilet use;
-Dependent on two staff members for transfers, and bed mobility;
-Opioid administration every day;
-One Stage 4 wound.
Further review showed the record did not contain a SCSA after the resident declined in
dressing, bed mobility, an improvement in eating, decrease in the amount of wounds, or the
increase in Opioid use.
4. Review of Resident #30’s, admission MDS, dated [DATE], showed the staff documented:
-Cognitively Intact;
-Limited physical assistance of one staff member for dressing, and bathing;
-Limited physical assistance of two staff members for toilet use;
-Extensive assistance of one staff member for locomotion;
-Extensive assistance of two staff members for bed mobility;
-Walking did not occur;
-Occasionally incontinent of bowel and bladder;
-Surgical wound;
-intravenous (IV) medications;
-No oxygen.
Review of the resident’s Quarterly MDS, dated [DATE], showed the staff documented:
-Cognitively intact;
-Independent needs set up only with walking in his/her room, locomotion, dressing, and
toilet use;
-Set up assistance with one staff members for bed mobility, and transfer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Extensive assistance of one staff member for bathing;
-Continent of bowel and bladder;
-No wounds;
-IV medications;
-No oxygen.
Further review showed the record did not contain a SCSA for the resident’s improvement in
walking, dressing, toilet use, locomotion, bed mobility, continence, surgical wound; or
the decline in the residence bathing, or new oxygen use.
Review of the resident’s Care Plan, dated 5/18/18, directed staff to:
-Minimal assistance with toilet use, and dressing.
The care plan did not contain directions to staff on set up assistance for walking,
locomotion, bed mobility, or transfers; extensive assistance for bathing, IV medications
or care of the resident’s peripherally inserted central catheter (PICC) line, or oxygen
use.
Observation on 7/31/18, at 11:24 A.M., showed the resident in bed with his/her nasal
cannula in the sheets beside him/her. The oxygen concentrator is set at 3.5 liters/minute
(L).
Observation on 8/1/18, at 11:52 A.M., showed the resident sat on the side of his/her bed
with a nasal cannula on. The resident’s concentrator is on at 2 L per nasal cannula.
5. Resident #58’s Admission Assessment MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Supervision with eating;
-Extensive assistance of two staff members for bed mobility, transfers, locomotion,
dressing, toilet use, and hygiene;
-Dependent with one staff members for bathing;
-Not steady only able to stabilize with human assistance during moving from seated to
standing, walking, turning around while walking, moving on and off toilet, and surface to
surface transfers;
-No limitations in range of motion;
-Did not have urinary appliances;
-Always incontinent of urine;
-No oxygen use.
Review of the resident’s Quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Extensive assistance of one staff member for locomotion, and bathing;
-Extensive assistance of two staff members for eating, bed mobility, transfers, dressing,
toilet use, and hygiene;
-Walking, turning around while walking, and moving on and off the toilet did not occur;
-Limited range of motion in one upper extremity;
-Indwelling urinary catheter;
-[MEDICAL CONDITION], and a Urinary tract infection;
-Frequent pain rated at a 5 on a 1-10 scale;
-Vomiting;
-Significant weight gain, not on a prescribed weight gain program;
-Oxygen use while a resident.
Further review showed the record did not contain a SCSA after the resident’s improvement
with bathing; decline in eating, range of motion, balance; the added use of oxygen;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
increase in pain; vomiting and [MEDICAL CONDITION]; significant weight change; and the use
of a catheter.
Review of the resident’s care plan, last updated 7/13/18, shows it directs staff to:
-Assist the resident with a shower two times a week;
-Incontinent care after each incontinence, wears a brief;
-Transfers with assist of two staff members;
-Total dependence with activities of daily living (ADL)’s.
The resident’s care plan did not contain specific amount of assistance for ADL’s, oxygen
use, respiratory monitoring, limited range of motion, or pain control.
6. During an interview on 8/3/18, at 7:07 P.M., the MDS coordinator (MDSC) said that
he/she completes a SCSA within 14 days of a significant change. He/She said a SCSA should
be completed when a resident goes on hospice, change in ADL’s, a [MEDICAL CONDITION], or
changes in two areas. He/She said he/she has missed some because he/she has been busy.
During an interview on 8/3/18, at 6:11 P.M., the director of nursing (DON) said that
he/she expects the MDSC to complete a SCSA if a resident has two or more changes in ADL’s,
two or more care areas, if a resident moves on or off the locked unit, or a resident
starts or stops hospice service. He/She expects the MDSC to follow the RAI manual.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility staff failed to complete a baseline care
plan within 14 days of admission, review the information with the resident/responsible
party, or provide a copy to the resident/responsible party for four resident’s (Resident
#9, #30, #57, and #58). The facility census was 60.
1. Review of the facility’s Temporary Care Plan policy, dated (MONTH) (YEAR), showed staff
are directed as follows:
-A temporary care plan will be implemented to meet the new resident’s immediate needs;
-Complete within 24 hours of admission;
-The interdisciplinary care plan team and/or admitting nurse will review the physician
orders [REDACTED].
-The temporary care plan will be used until the comprehensive assessment has been
completed and an interdisciplinary care plan has been developed according the the resident
assessment instrument (RAI) process.
2. Review of Resident #9’s medical record showed the resident was admitted to the facility
on [DATE]. Further review showed the record did not contain a baseline care plan.
3. Review of Resident #30’s medical record showed the resident was admitted to the
facility on [DATE]. Further review showed the record did not contain a baseline care plan.
4. Review of Resident #57’s medical record showed the resident was admitted to the
facility on [DATE]. Further review showed the record did not contain a baseline care plan.
5. Review of Resident #58’s medical record showed the resident was admitted to the
facility on [DATE]. Further review showed the record did not contain a baseline care plan.
During an interview on 8/03/18, at 2:36 P.M., the social service director (SSD) said the
baseline care plan is supposed to be done within 48 hours of admission and a copy given to
the resident/responsible party, and have them sign that the information was reviewed.
He/She said that he/she is responsible for the baseline care plans and he/she has not been

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
getting them done. He/She said that he/she wears many hats and has missed it.
During an interview on 8/3/18, at 2:37 P.M., the administrator (ADM) said the baseline
care plan is supposed to be done within 48 hours of admission. He/She said the SSD is
responsible to complete them and they have been missed.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility staff failed to develop
comprehensive care plans to direct the staff in the care of eight resident’s (Resident #9,
#14, #17, #24, #27, #33, #54, and #58). The facility census was 60.
1. Review of the facility’s Care Plan Comprehensive policy, dated (MONTH) (YEAR), showed
staff are directed to:
-Develop an individualized comprehensive care plan that includes measurable goals and time
frames to meet the resident’s highest practicable physical, mental and psychosocial
well-being;
-A well developed care plan will be:
a. Prevent avoidable declines in functioning or functional levels;
b. Managing risk factors to the extent possible or indicating the limits of such
interventions;
c. Address ways to build upon strengths;
d. Apply current standards of practice;
e. Evaluating treatment of [REDACTED].
f. Resident’s right to decline treatment;
g. Addressing additional care planning areas that are relevant to meeting the resident’s
needs in the long-term care setting.
2. Review of Resident #9’s admission Minimum Data Set (MDS), a federally mandated
assessment, dated 5/5/18, showed staff assessed the resident as:
-Cognitively intact;
-Admission to facility 4/24/18;
-[DIAGNOSES REDACTED].
-No signs or symptoms of depression;
-No behaviors or rejections of care;
-Weight 214 pounds (lbs);
-Supervision with one person physical assistance for bed mobility, and transfers;
-Limited physical assistance of one staff member for dressing, and hygiene;
-Extensive assistance of one staff member with toilet use, and bathing;
-Stage 4 wound;
-Indwelling catheter.
Review of the resident’s care plan, dated 6/6/18, directed the staff to:
-Offer assistance with bath;
-At risk for weight loss because the resident does not go to the dining room;
-Strong foul odor from the resident’s Stage 4 wound, pan of charcoal, room, fan, and
housekeeping to clean daily with odor fighting chemicals.
The care plan did not contain directions to staff to provide assistance with dressing,
hygiene, toilet use, or bathing.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
3. Review of Resident #14’s significant change in status assessment (SCSA) MDS, dated
[DATE], showed staff documented:
-Cognition moderately impaired;
-Extensive assistance of one staff member for dressing, and eating;
-Extensive assistance of two staff member for bed mobility;
-Dependent on two staff members for transfers, and toilet use;
-Staff did not administer Opioid;
-One Stage 3 and one Stage 4 wound.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff documented:
-Cognition moderately impaired;
-Added [DIAGNOSES REDACTED].>-Limited assistance of one staff member for eating;
-Dependent on one staff member for dressing, and toilet use;
-Dependent on two staff members for transfers, and bed mobility;
-Opioid administration every day;
-One Stage 4 wound.
Review of the resident’s care plan, last reviewed 7/31/18, directed the staff as follows:
-Two staff members to assist with hoyer lift;
-Assist with dressing, personal care, and a shower
-Pressure ulcer to the resident’s coccyx.
The care plan did not contain the amount of assistance needed with all activities of daily
living (ADL’s) or pressure ulcers.
4. Review of Resident #17’s MDS, dated [DATE], showed the staff documented:
-admitted [DATE];
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-History of two falls with no injury during the look back period;
-During the seven day look back period, took antipsychotic medication for seven days,
antidepressant medication for seven days, and antibiotic therapy for three days;
-A gradual dose reduction (GDR) was recommended on 06/01/18 and was clinically
contraindicated.
Review of the resident’s care plan, dated 04/13/18, showed the care plan did not contain
direction to staff on the use of psychoactive medications and signs and symptoms of
possible side effects.
5. Review of Resident #24’s quarterly MDS, dated [DATE], showed staff documented:
– Admission of 2/14/14;
– Required total dependence for bed mobility, transfers, dressing, and personal hygiene;
– Limitation in range of motion on both sides in upper and lower extremities;
– [DIAGNOSES REDACTED].>- At risk of developing pressure ulcers.
Review of the resident’s care plan, last reviewed on 4/17/18, showed the following:
– Problem start date: 5/17/15;
– Problem: The resident had contractures to all extremities;
– Goal: Prevention of further contractures;
– Approach: Sit the resident up in recliner two hours each day.
Observation on 7/31/18 at 10:24 A.M. showed the resident laid in bed.
Observation on 8/1/18 at 9:41 A.M. and 2:20 P.M. showed the resident laid in bed.
Observation on 8/02/18 at 9:42 A.M., 11:30 A.M., and 3:30 P.M. showed the resident laid in
bed.
During an interview on 8/3/18 at 11:44 A.M., LPN A said he/she has worked at the facility
since last April, (YEAR). He/she is familiar with the resident and sometimes passed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
medications to the resident. The nursing staff is responsible for getting him/her up. It
is not charted anywhere that the resident gets up. The resident usually gets up from 11:00
A.M. until 2:00 P.M. while his/her tube feeding is off. He/She does not get up every day.
There is no set schedule for getting the resident up.
During an interview on 8/3/18 at 11:55 A.M., Certified Nursing Assistant (CNA) F said
he/she has worked at the facility for 10 months. He/she was very familiar with the
resident. The staff try to get the resident up at lunch time. CNAs are responsible for
getting the resident up. They get him up a few times a week though it is supposed to be
two hours every day.
During an interview on 8/3/18 at 2:55 P.M., Housekeeper T said he/she has worked at the
facility since February, (YEAR). He/she is responsible for cleaning the halls and resident
rooms. Resident #24 is always in the room when he/she cleans it. He/she is in the
resident’s room almost every day. He/she has worked the day and evening shifts and the
weekend shift; but she has only seen the resident out of bed twice. He has never been out
of bed other than that. He/She sees him/her every day.
During an interview on 8/3/18 at 3:42 P.M., the Activity Director said she is very
familiar with the resident. She visits him/her daily. She sees the resident in his/her
recliner once a week. She considers it an activity when the resident gets out of bed and
sit in the recliner, but she does not chart it anywhere.
During an interview on 8/3/18 at 6:00 P.M., the administrator and the Director of Nursing
(DON) said resident care plans should be followed. If the care plan says the resident
should sit in his/her recliner for two hours every day then the staff should get the
resident up.
6. Review of Resident #27’s significant change MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood and understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– Required total dependence with transfers, toilet use, and bathing;
– Had a catheter;
– [DIAGNOSES REDACTED].
– On hospice.
Review of the resident’s care plan, last reviewed on 7/26/18, showed the following:
– Problem start date: 5/29/18;
– Problem: Resident at risk for falling;
– Goal: Resident will remain free from injury;
– Approach: Keep call light in reach at all times.
Observation on 8/2/18 at 9:50 A.M., showed the resident laid in bed on his/her back. The
resident called out for someone to help him/her. Four staff walked past the resident’s
door without assisting the resident. The resident’s call light was inside the drawer of
the bedside table and not accessible to the resident. The resident stated he/she was
hungry and wanted to eat.
Observation on 8/3/18 at 10:00 A.M., the resident laid on his/her back in bed. The
resident’s call light sat on the bed side table and was not accessible to the resident.
During an interview at 8/2/18 at 10:00 A.M., the Director of Nursing (DON) said if staff
are walking by a room and hear a resident calling out then it is expected for the staff to
stop and check on the resident. The resident’s call light should not be inside the bedside
table. The resident’s call light should always be accessible to the resident. If staff
move the call light to provide care then it is expected they place the call light back
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
into the resident’s reach after care is provided.
During an interview on 8/3/18 at 10:05 A.M., NA H said the call light should be within the
reach of the resident. The nurses move the call light during treatments but forget to put
it back. The call light should be placed within reach after the treatment.
7. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with hallucinations, delusions, and behaviors;
-[DIAGNOSES REDACTED].
-Weight loss;
–Medication use during the seven day look back period include seven days of insulin,
seven days of antipsychotic medications, and seven days of an Opioid.
-A Gradual Dose Reduction (GDR) was contraindicated on 06/01/18.
Review of the resident’s care plan, last reviewed 10/05/17, showed the care plan did not
contain direction for the following:
-Weight loss;
-Specific guidelines for direct care staff with direction for Activities of Daily Living
(ADL) care, such as how many staff are required to provide specific care and how the
resident is to transfer;
-Signs and symptoms of antipsychotic drug use and when to report to the charge nurse.
Further review showed antipsychotic medications were prescribed to be given as needed and
were not addressed in the care plan.
8. Review of resident #58’s admission MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Supervision with eating;
-Extensive assistance of two staff members for bed mobility, transfers, locomotion,
dressing, toilet use, and hygiene;
-Dependent with one staff members for bathing;
-Not steady only able to stabilize with human assistance during moving from seated to
standing, walking, turning around while walking, moving on and off toilet, and surface to
surface transfers;
-No limitations in range of motion;
-Did not have urinary appliances;
-Always incontinent of urine;
-No oxygen use.
Review of the resident’s Quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Extensive assistance of one staff member for locomotion, and bathing;
-Extensive assistance of two staff members for eating, bed mobility, transfers, dressing,
toilet use, and hygiene;
-Walking, turning around while walking, and moving on and off the toilet did not occur;
-Limited range of motion in one upper extremity;
-Indwelling urinary catheter;
-[MEDICAL CONDITION], and a Urinary tract infection;
-Frequent pain rated at a 5 on a 1-10 scale;
-Vomiting;
-Significant weight gain, not on a prescribed weight gain program;
-Oxygen use while a resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
Review of the resident’s care plan, last updated 7/13/18, directs staff to:
-Assist the resident with a shower two times a week;
-Incontinent care after each incontinence, wears a brief;
-Transfers with assist of two staff members;
-Total dependence with activities of daily living (ADL)’s.
The resident’s care plan did not contain specific amount of assistance for ADL’s, oxygen
use, respiratory monitoring, limited range of motion, or pain control.
During an interview on 8/3/18, at 7:07 P.M., the MDS coordinator (MDSC) said the
comprehensive care plan should include the resident’s, diagnosis, ADL’s, medications, and
follow the CAA’s to complete the care plan. He/She said that he/she is expected to include
equipment, oxygen needs, and resident’s preferences. He/She said the comprehensive care
plan is to direct staff on how to take care of the resident.
During an interview on 8/03/18 06:11 PM the director of nursing (DON) said the MDSC is
responsible to complete the comprehensive care plans. He/She said all of the resident’s
care needs should be on the comprehensive care plan to direct the staffs care.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility staff failed to update the
comprehensive care plan with changes in care for three resident’s (Resident #23, #30, and
#33). The facility census was 60.
1. Review of the facility’s Care Plan Comprehensive policy, dated (MONTH) (YEAR), showed
staff are directed to:
-Develop an individualized comprehensive care plan that includes measurable goals and time
frames to meet the resident’s highest practicable physical, mental and psychosocial
well-being;
-A well developed care plan will be:
a. Prevent avoidable declines in functioning or functional levels;
b. Managing risk factors to the extent possible or indicating the limits of such
interventions;
c. Address ways to build upon strengths;
d. Apply current standards of practice;
e. Evaluating treatment of [REDACTED].
f. Resident’s right to decline treatment;
g. Addressing additional care planning areas that are relevant to meeting the resident’s
needs in the long-term care setting.
-Assessment of each resident is a ongoing process and the care plan will be revised as
changes occur in the resident’s condition.
2. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 05/19/18, showed staff assessed the resident as follows:
-Cognitively intact with no behaviors;
-[DIAGNOSES REDACTED].
-One fall with no injury;
-Weight loss;
-Medication use during the seven day look back period include four days of an anxiolytic

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
(anti-anxiety), seven days of an antidepressant, and seven days of an anticoagulant
medications.
Review of the resident’s record showed a resident to resident altercation on 07/28/18.
Further review showed the resident’s care plan, dated 03/01/18, did not contain updated
interventions for behaviors.
3. Review of Resident #30’s, admission MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively Intact;
-Limited physical assistance of one staff member for dressing, and bathing;
-Limited physical assistance of two staff members for toilet use;
-Extensive assistance of one staff member for locomotion;
-Extensive assistance of two staff members for bed mobility;
-Walking did not occur;
-Occasionally incontinent of bowel and bladder;
-Surgical wound;
-Intravenous (IV) medications;
-No oxygen.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-Independent needs set up only with walking in his/her room, locomotion, dressing, and
toilet use;
-Set up assistance with one staff members for bed mobility, and transfer;
-Extensive assistance of one staff member for bathing;
-Continent of bowel and bladder;
-No wounds;
-IV medications;
-No oxygen.
Review of the resident’s care plan, dated 5/18/18, showed staff are directed to provide
minimal assistance with toilet use and dressing. Further review showed the care plan did
not contain directions to staff on set up assistance for walking, locomotion, bed
mobility, or transfers; extensive assistance for bathing, IV medications or care of the
resident’s peripherally inserted central catheter (PICC) line, or oxygen use.
Observation on 7/31/18, at 11:24 A.M., showed the resident in bed with his/her nasal
cannula in the sheets beside him/her with the concentrator set at 3.5 liters/minute
(L/min).
Observation on 8/1/18, at 11:52 A.M., showed the resident sat on the side of his/her bed
with a nasal cannula on with the concentrator set at 2 L/min.
4. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with hallucinations, delusions, and behaviors;
-[DIAGNOSES REDACTED].
-Weight loss;
–Medication use during the seven day look back period include seven days of insulin,
seven days of antipsychotic medications, and seven days of an Opioid.
-A Gradual Dose Reduction (GDR) was contraindicated on 06/01/18.
Review of the nurse’s notes showed:
-Fall on 12/03/17 resulting in a fractured right humerus;
-Fall on 12/22/17 with no injuries;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Fall on 01/14/18 with no injuries;
-Fall on 1/28/18 with no injuries.
Review of the resident’s care plan dated 10/05/17, showed the care plan did not contain
direction and intervention for falls.
5. During an interview on 8/3/18, at 7:07 P.M., the MDS coordinator (MDSC) said he/she is
responsible to update the care plans. He/She said that he/she communicates with therapy
about cushions or changes. He/She said when staff put an event in the electronic medical
record, it alerts him/her the care plan can be updated. He/She said he/she tries to update
with falls and changes to the resident’s care.
During an interview on 8/03/18 06:11 PM the Director of Nursing (DON) said the MDSC is
responsible to complete the comprehensive care plans. He/She said all of the resident’s
care needs should be on the comprehensive care plan to direct the care, and updated to
reflect the resident’s current care needs and interventions.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to follow
physician’s orders, and monitor placement of a peripherally inserted central catheter
(PICC) for one resident (Resident #30), failed to obtain oxygen orders for one resident
(Resident #27, and #30), failed to provide direction to the staff on oxygen use for one
resident (Resident #30, and #58), and failed to obtain urinary indwelling catheter orders
for two resident’s (Resident #27, and #54). The facility staff also failed to ensure
proper insulin dosage for three resident’s (Resident #32, #33, and #43). The facility
census was 60.
1. The facility did not provide a policy on care and maintenance of a Peripherally
Inserted Central Catheter (PICC).
2. Review of Resident #30’s, admission Minimum Data Set (MDS), a federally mandated
assessment tool used by staff to plan care, dated 4/26/18, showed the staff assessed the
resident as follows:
-Cognitively Intact;
-Limited physical assistance of one staff member for dressing, and bathing;
-Limited physical assistance of two staff members for toilet use;
-Extensive assistance of one staff member for locomotion;
-Extensive assistance of two staff members for bed mobility;
-IV medications;
-No oxygen.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented:
-Cognitively intact;
-Independent needs set up only with walking in his/her room, locomotion, dressing, and
toilet use;
-Set up assistance with one staff members for bed mobility, and transfer;
-Extensive assistance of one staff member for bathing;
-IV medications;
-No oxygen.
Review of the resident’s care plan, last updated 6/15/18, did not contain direction to the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
staff related to the resident’s infection, intravenous antibiotics, or the residents
peripherally inserted central catheter (PICC).
Review of the resident’s Physician’s Order Sheet (POS), dated 7/3/18-8/3/18, directed
staff to change the residents PICC line dressing weekly and as needed.
Review of the resident’s Medication Administration Record [REDACTED].
Review of the resident’s Treatment Administration Record (TAR), dated 7/1/18-8/3/18,
showed it did not contain a treatment order, placement checks, or monitoring of the PICC
insertion site.
Observation on 7/31/18, at 11:22 A.M., showed the resident in bed with intravenous
[MEDICATION NAME] 1.5 grams in 500 milliliters (ml) of normal saline running at 167
ml/hour. Additional observation showed the dressing covering the resident’s PICC line
insertion site dated 7/18/18.
Observation on 8/01/18, at 11:46 A.M., showed the resident in bed with intravenous
[MEDICATION NAME] 1.5 grams in 500 milliliters (ml) of Normal Saline running at 167
ml/hour. Additional observation showed the dressing covering the resident’s PICC line
insertion site dated 7/18/18.
During an interview on 8/3/18, at 5:40 P.M., licensed practical nurse (LPN) L said staff
are expected to change PICC line dressings weekly, and date the dressing. He/She said
staff should obtain an order from the physician for PICC line dressing changes and then
transcribe the order on the treatment administration record to keep track of the dressing
changes. He/She did not know if the catheter should be measured from the insertion site to
the end of the catheter.
During an interview on 8/3/18, at 6:11 P.M., the director of nursing (DON) said staff are
expected to change PICC line dressings every seven days. He/She said staff are expected to
get a physician’s order and document the dressing changes on the MAR indicated [REDACTED].
3. Review of the facility’s Catheter Care policy, dated (MONTH) 2012, directs staff to:
-Prevent infection and reduce irritation;
-Procedure to cleanse the insertion site;
-Secure catheter utilizing a leg band.
Review of the facility’s policy did not include required physician’s orders, indications
for use, general catheter precautions, and maintenance.
4. Review of the facility’s Oxygen Administration policy, dated (MONTH) 2012, shows it
directs staff to place a nasal cannula, face mask, or nasal catheter as ordered; and set
the flow meter to the rate ordered by the physician.
5. Review of Resident #27’s significant change MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood and understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– Required total dependence with transfers, toilet use, and bathing;
– Had a catheter;
– [DIAGNOSES REDACTED].
– Not on oxygen therapy;
– On hospice.
Review of the resident’s hospital discharge report, dated 6/20/18, showed the resident
returned to the facility with a Foley catheter due to [MEDICAL CONDITION].
Review of the resident’s care plan, last reviewed on 7/26/18, showed the following:
– Resident has an indwelling urinary catheter;
– Resident will have catheter care managed appropriately;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
– Position bag below level of bladder, place bag in privacy cover.
– The resident’s use of oxygen was not addressed in the care plan.
Review of the resident’s POS, dated 6/1/18 through 6/30/18 and 7/1/18 through 7/31/18,
showed it did not contain an order for [REDACTED].>Observation on 7/31/18 at 11:45
A.M., showed the resident’s oxygen at 2 L per nasal cannula, and the nasal cannula tubing
dated 7/22/18.
Observation on 8/1/18 at 4:05 P.M., showed the resident’s nasal cannula tubing dated
7/22/18.
Observation on 8/2/18, at 11:31 A.M., showed the resident’s oxygen at 1.5 L, and the nasal
cannula tubing dated 7/22/18. The resident lay in bed with his/her catheter unsecured and
hung on side of the bed. The bag did not have a privacy cover and could be seen from the
hallway.
Observation on 8/3/18, at 10:00 A.M. showed the resident lay in bed with his/her catheter
bag hung on the bottom rail of the bed. The bag did not have a a privacy cover and could
be seen from the hallway. Additional observation at 5:41 P.M., showed the resident’s nasal
cannula tubing dated 7/22/18.
6. Review of Resident #30’s, admission MDS, dated [DATE], showed the staff assessed the
resident as follows:
-Cognitively Intact;
-Limited physical assistance of one staff member for dressing, and bathing;
-Limited physical assistance of two staff members for toilet use;
-Extensive assistance of one staff member for locomotion;
-Extensive assistance of two staff members for bed mobility;
-No oxygen.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as follows:
-Cognitively intact;
-Independent needs set up only with walking in his/her room, locomotion, dressing, and
toilet use;
-Set up assistance with one staff members for bed mobility, and transfer;
-Extensive assistance of one staff member for bathing;
-No oxygen.
Review of the resident’s care plan, last updated 6/15/18, showed it did not contain
directions to the staff on oxygen use, or respiratory monitoring.
Review of the resident’s POS, dated 7/3/18-8/3/18, shows it did not contain orders for
oxygen use.
Review of the resident’s nurses notes, dated 7/3/18-8/3/18, showed it did not contain
documentation of oxygen use.
Observation on 7/31/18, at 11:24 A.M., showed the resident’s oxygen concentrator set at
3.5 L, and his/her nasal cannula tubing undated and wrapped in his/her blankets.
Observation on 8/1/18, at 11:52 A.M., showed the resident on the side of his/her bed with
his/her oxygen on at 2 L per nasal cannula. Additional observation showed staff did not
date the tubing.
Review of the resident’s Home to Hospital Transfer Form, dated 8/3/18, showed staff
documented the resident is on 2 liters (L)/minute of oxygen per nasal cannula tubing.
7. Review of Resident #58’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognition moderately impaired;
-Significant weight gain, not on a prescribed weight gain program;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Oxygen use while a resident.
Review of the resident’s POS, dated 7/3/18-8/3/18, directed staff to administer 2 liters
per minute of oxygen, as needed.
Review of the resident’s care plan, last updated 8/3/18, showed it did not contain
directions to staff on oxygen use or respiratory monitoring.
Review of the resident’s TAR, dated 7/1/18-8/3/18, showed it did not contain documentation
to show staff changed the resident’s oxygen tubing.
Observation on 7/31/18, at 11:12 A.M., showed the resident’s nasal cannula at 2 L and the
date on the tubing as 7/22/18.
Observation on 8/1/18, at 11:32 A.M., showed the resident’s nasal cannula tubing dated
7/22/18.
8. During an interview on 8/3/18, at 5:40 P.M., licensed practical nurse (LPN) L said if a
resident is in distress, a nurse can administer 2 liters of oxygen per minute until they
are able to get a physician’s order, otherwise oxygen can not be administered without a
physician’s order.
During an interview on 8/3/18, at 6:11 P.M., the director of nursing (DON) said staff are
expected to obtain a physician’s order prior to the use of oxygen.
9. Review of Resident #54’s readmission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with physical and verbal behaviors;
-Requires total physical assistance of one person for bathing;
-Requires extensive physical assistance of two persons for bed mobility, transfers,
dressing, toileting, and personal hygiene;
-Requires extensive physical assistance of one person for locomotion;
-Requires limited physical assistance of one person for eating;
-Impaired range of motion of the lower extremity on one side;
-Catheter;
-Always incontinent of bowel;
-[DIAGNOSES REDACTED].
-Almost constant pain rated 8 on a scale of 0 – 10 and uses pain medication as needed;
-Skin intact;
-During the seven day look back, took antidepressant medication for seven days, antibiotic
medication for seven days, and an Opioid for seven days.
Review of the resident’s current POS, showed it did not contain a written order for the
catheter.
During an interview on 08/03/18 at 10:11 A.M., Registered Nurse (RN) M said he/she expects
an order for [REDACTED].
During an interview on 08/03/18 at 6:15 P.M., the administrator and Director of Nursing
(DON) said they expect an order to be on the POS for the catheter and are not sure how it
was missed.
10. The facility provided the packet insert for the insulin pen as the policy and
procedure for staff to follow. Review of the insert showed it does not give step by step
direction for use of the insulin pen. The American Diabetes Association provides the
following direction regarding insulin pen use:
-Check the pen to ensure it contains the proper type of insulin and contains enough to
cover the full dose. Check to make sure the expiration date has not passed;
-Wash or sanitize hands. The hands should be clean;
-Gently stir intermediate or premixed insulin by turning the pen on its side and rolling
it between the palms of your hands. Clear (fast acting, long acting insulin generally does
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
not need to be mixed;
-Cleanse the rubber membrane on the end of the pen and attach a fresh pen needle and
remove the cap to expose the needle;
-Prime the pen by dialing two units on the pen and and press the plunger, repeating until
a drop appears at the end of the needle;
-Turn the dial to the prescribed dose;
-The needle should be embedded within the skin for five seconds after complete depression
of the plunger to ensure complete delivery of the insulin dose;
-Do not leave the needle on between injections. Remove the needle and replace the cap on
the syringe to protect the insulin from the light.
11. Observation on 08/01/18 at 11:19 A.M., showed RN D did not prime the insulin pen prior
to giving insulin to Resident #32 and Resident #33.
During an interview on 08/02/18 at 12:12 P.M., Certified Medication Technician (CMT) Q
said an insulin pen is always to be primed prior to giving the prescribed dosage.
Observation on 8/03/18, at 11:23 A.M., showed RN K prepare to administer insulin to
Resident #43. The RN pulled the cap off the insulin pen, dialed the dose selector to one,
and pointed the pen (without a needle on it) toward the trash can and pushed the plunger.
The RN dialed the insulin pen to five units and placed the pen without a needle on the
resident’s skin and depressed the plunger and said, you are all done. DHSS staff brought
to the nurses attention he/she did not place the needle in the pen and the insulin did not
have a way to be administered. Additional observation showed the RN put a needle on the
pen without cleansing the rubber [MEDICATION NAME] that had been in contact with the
resident’s skin. He/She dialed the dose selector to one and pointed it toward the trash
can, and depressed the plunger. The RN dialed the dose selector to five units. Observation
showed the RN put the pen onto the resident’s abdomen and pushed but not far enough for
the clear cover to retract and expose the needle. The RN pushed the plunger and the
insulin shot onto the resident’s abdomen. The RN counted to five and wiped the insulin
dripping down the resident’s abdomen and said, now you are done. The resident did not
receive his/her insulin.
During an interview on 8/03/18, at 11:27 A.M., RN K said staff are expected to put on the
needle, prime it with 1 unit by shooting it in the trash can, and dial the dose prior to
the administration of the insulin. Additionally, they are to push into area to give the
injection, press the plunger down and count to five. He/She said he/she did not know to
cleanse the rubber [MEDICATION NAME], make sure the insulin came out when primed, or push
the pen into the site until the white part that contains the needle is against the skin.
During an interview on 8/3/18, at 6:11 P.M., the director of nursing (DON) said staff are
expected to give insulin with a insulin pen according to the manufacturers instructions.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, facility staff failed to prevent
trauma, and use proper techniques to prevent infection during the use of an indwelling
catheter for one resident (Resident #14). The facility staff also failed to obtain a
physicians order with an indication for use of a urinary catheter, use proper techniques

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
to prevent infection during the use of an urinary catheter, and provide dignity during the
use of a urinary catheter for two residents (Resident #27 and #54). The facility failed to
obtain an indication for use of a urinary catheter after a resident returned from the
hospital, attempt to remove the catheter, or secure the catheter in a way to prevent
trauma for one resident (Resident #58). The facility’s census was 60.
1. Review of the facility’s policy Catheter Care, dated (MONTH) 2012, directs staff to:
-To prevent infection and reduce irritation;
-Procedure to cleanse the insertion site;
-Secure catheter utilizing a leg band.
Further review of the facility policy showed the policies did not contain indications for
use, or general catheter precautions, and maintenance.
2. Review of Resident #14’s significant change in status assessment (SCSA) Minimum Data
Set (MDS), a federally mandated assessment, dated 2/6/18, showed staff documented:
-Cognition moderately impaired;
-Extensive assistance of one staff member for dressing, and eating;
-Extensive assistance of two staff member for bed mobility;
-Dependent on two staff members for transfers, and toilet use;
-Use of an indwelling urinary catheter.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented:
-Cognition moderately impaired;
-Limited assistance of one staff member for eating;
-Dependent on one staff member for dressing, and toilet use;
-Dependent on two staff members for transfers, and bed mobility;
-Opioid administration every day;
-Use of an indwelling urinary catheter.
Review of the resident’s Care Plan, last updated 5/4/18, directs staff to:
-Flush catheter with 60 milliliter (ml) of normal saline as needed for blood clots in the
catheter;
-Resident has abnormal formation related to the urethra, the catheter needs to be inserted
by the physician or urologist if the nurse is unsuccessful with the first try;
-The resident has episodes of bright red to dark urine periodically with clots. He/She has
been taken to the ER and the urologist, but bleeding continues unexpected and unrelated
episodes.
-Avoid lying on top of tubing;
-Do not allow tubing or any part of system to touch the floor;
-Change catheter bag every week on Sunday;
-Encourage fluids at meals and offer between meals;
-Position bag below level of bladder and put in a privacy bag;
-Do not allow the tubing or bag to the touch floor;
-Provide catheter care every shift and as needed.
Observation on 8/1/18, at 2:03 P.M., showed the staff raised the resident in a mechanical
lift, transferring from the wheelchair to the bed. Observation showed the catheter hung on
the bar of the mechanical lift above the resident’s head. Additional observation showed
the resident did not have the tubing secured to his/her leg.
Observation showed on 8/3/18, at 3:26 P.M., showed certified nurse assistant (CNA) B and
CNA F provide perineal care to the resident. Observation showed the catheter is not
secured to the resident’s leg to prevent trauma.
During an interview on 8/3/18, at 3:30 P.M., CNA B said he/she has not seen the facility
use leg straps for catheters.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
During an interview on 8/03/18, at 3:45 P.M., CNA F said during mechanical lift transfers
he/she usually hangs the catheter bag up on the hoyer bar or with the hoyer straps above
the resident’s head. He/She said the catheter bag is supposed to be below the bladder but
he/she just does it during transfers.
3. Review of Resident #27’s significant change MDS, dated [DATE], showed staff assessed
the resident as
-admission date of [DATE];
– Understood and understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– Required total dependence with transfers, toilet use, and bathing;
– Uses a catheter;
– [DIAGNOSES REDACTED].
– On hospice.
Review of the resident’s hospital discharge report, dated 6/20/18, showed the resident
discharged to the facility with a Foley catheter in place due to [MEDICAL CONDITION].
Review of the resident’s care plan, last reviewed on 7/26/18, showed the following:
– Resident has an indwelling urinary catheter;
– Resident will have catheter care managed appropriately;
– Position bag below level of bladder, place bag in privacy cover.
Observation on 8/2/18, at 11:31 A.M., showed the resident in bed with his/her catheter
unsecured to prevent trauma.
Observation on 8/3/18 at 10:00 A.M. showed the resident in bed with his/her catheter
unsecured to prevent trauma.
4. Review of Resident #54’s readmission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with physical and verbal behaviors;
-Requires total physical assistance of one person for bathing;
-Requires extensive physical assistance of two persons for bed mobility, transfers,
dressing, toileting, and personal hygiene;
-Requires extensive physical assistance of one person for locomotion;
-Requires limited physical assistance of one person for eating;
-Impaired range of motion of the lower extremity on one side;
-Catheter;
-Always incontinent of bowel;
-[DIAGNOSES REDACTED].
-Almost constant pain rated 8 on a scale of 0 – 10 and uses pain medication as needed;
-Skin intact;
-During the seven day look back, took antidepressant medication for seven days, antibiotic
medication for seven days, and an Opioid for seven days.
Review of the current Physician Order Sheet (POS), showed no written order for the
catheter.
Review of the resident’s Plan of Care, dated 06/28/18, showed the following:
-Staff are directed to see the POS for orders regarding changing the catheter,
-Keep the catheter system a closed system as much as possible. Don’t let any part of
tubing or bag touch the floor. Keep the bag below the bladder level and put in a privacy
bag.
Observation on 07/31/18 at 10:50 A.M., showed the resident lay in a low bed on his/her
left side with the catheter bag touching the floor with no dignity bag covering it.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
Observation on 08/01/18 at 9:39 A.M., showed the resident lay in bed and the uncovered
catheter bag touch the floor.
During an interview on 08/01/18 at 9:45 A.M., CNA N said the catheter bag should not be
touching the floor and should be in a dignity bag. The CNA said it is hard to keep it off
the floor when the resident is in a low bed but a dignity bag would provide a barrier.
During an interview on 08/03/18 at 6:15 P.M., the administrator and Director of Nursing
(DON) said the catheter bag should always be covered with a privacy bag and the catheter
bag and tubing should never be allowed to touch the floor.
5. Review of Resident #58’s admission MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Extensive assistance of two staff members for bed mobility, transfers, locomotion,
dressing, toilet use, and hygiene;
-Did not have urinary appliances;
-Always incontinent of urine.
Review of the resident’s Bowel and Bladder Assessment, dated 6/27/18, showed the staff
documented that upon return from the hospital the resident is always incontinent and did
not have an indwelling catheter.
Review of the resident’s Hospital Discharge Summary, dated 7/2/18, showed the hospital
[DIAGNOSES REDACTED].
-[MEDICAL CONDITION] ulcer;
-[MEDICAL CONDITION];
-Espophagitis;
-[MEDICAL CONDITION];
-Acute Kidney injury;
-[MEDICAL CONDITION];
-[MEDICAL CONDITION] of the left lower extremity;
-Dementia.
The hospital discharge paperwork did not contain a physician’s order for continued use of
a catheter or a [DIAGNOSES REDACTED].
Review of the resident’s Physician’s Order Sheet, dated 7/2/18-8/2/18, directed staff:
-Catheter care every shift and as needed;
-Change the catheter monthly;
-Catheter type is a size 16 french (FR) with a 10 milliliter (ml) bulb.
The physician’s orders did not contain an indication for the use of a urinary catheter.
Review of the resident’s Nurses Notes, dated 7/2/18, showed the staff documented the
resident has a foley catheter.
Review of the resident’s Care Plan, last updated 7/5/18, directed the staff as follows:
-Resident has an indwelling urinary catheter;
-Assess drainage: Record the amount, type, color, and odor;
-Observe for leakage;
-Avoid lying on top of tubing when you put me to bed;
-Change catheter bag every week;
-Change catheter per MD order;
-Encourage fluids at meals and offer between meals;
-Keep catheter system a closed system as much as possible, do not allow any part of
catheter system to touch floor, keep drainage bag below bladder level at all times;
-Provide catheter care every shift and as needed;
-Keep the resident clean and dry as possible.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-Report urinary tract infection [MEDICAL CONDITION] (acute confusion, urgency, frequency,
bladder spasms, nocturia-urinating more at night, burning, pain, difficulty urinating, low
back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine,
blood in urine).
Further review showed the Care Plan did not contain an indication for the use of a urinary
catheter, or to secure the catheter to avoid trauma.
Review of the resident’s Quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognition moderately impaired;
-Extensive assistance of one staff member for locomotion, and bathing;
-Extensive assistance of two staff members for eating, bed mobility, transfers, dressing,
toilet use, and hygiene;
-Walking, turning around while walking, and moving on and off the toilet did not occur;
-Indwelling urinary catheter;
-[MEDICAL CONDITION], and a Urinary tract infection;
-Frequent pain rated at a 5 on a 1-10 scale;
-Vomiting.
Observation on 7/31/18, at 11:12 A.M., showed the resident’s catheter tubing pulled down
to the resident’s left side. Observation showed the tubing did not have a device to secure
the tubing to the resident’s leg to prevent trauma and contamination of the tubing.
Review of the resident’s Bowel and Bladder Assessment, dated 7/31/18, showed the staff
documented that the resident had a indwelling urinary catheter. The resident is not a good
candidate for retraining because of his/her cognition.
Review of the resident’s medical record showed the record did not contain documentation of
an attempt to remove the catheter or a post void residual.
6. During an interview on 8/3/18, at 5:40 P.M., licensed practical nurse (LPN) L said
staff are expected to have a physician’s order for catheter use including: size of the
catheter, bulb size, an indication/[DIAGNOSES REDACTED]. He/She said for a new admission
staff are expected to see why a catheter was inserted in the hospital and see if there is
a reason for continued use or if the facility staff should attempt to remove the catheter.
He/She said appropriate indications to support the use of a catheter include [MEDICAL
CONDITION] bladder, Stage 3 or Stage 4 wounds on the resident’s buttocks, and [MEDICAL
CONDITION] if it is retention that will not resolve with time. He/She said staff should
have slack in the catheter tubing, and secure the tubing in place with a leg strap. He/She
said staff are expected to keep the catheter bag lower than the level of the resident’s
bladder, and should not hang the catheter bag on the hoyer lift above the resident’s head.

During an interview on 8/3/18, at 6:11 P.M., the DON said that staff are expected to have
a physicians order with an appropriate [DIAGNOSES REDACTED]. He/She said the order should
be transcribed on the treatment administration record that would include how often change
the catheter, dignity bag and to gravity, and catheter care. He/She said the resident’s
should have a leg straps, or device to secure the catheter to their leg to prevent trauma
and the catheter from sliding in and out. He/She said the catheter should be between their
legs, and should not touch the floor. He/She said the catheter drainage bag should always
be below the resident’s bladder, and staff should not hang the bag on the hoyer bar above
their head. He/She said the catheter orders should be reviewed and transcribed every month
to the new physicians orders, the Medication Administration Record, [REDACTED]

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident interview and record review, facility staff failed to
address one resident’s pain (Resident #54). The facility census was 60.
Review of Resident #27’s significant change Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/14/18, showed the following:
– admission date of [DATE];
– Understood and understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– Required total dependence with transfers, toilet use, and bathing;
– Uses a catheter;
– [DIAGNOSES REDACTED].
– At risk for pressure ulcers;
– No unhealed pressure ulcers;
– Received hospice.
Review of the resident’s care plan, last reviewed on 7/26/18, showed the following:
– Problem start date: 6/29/18;
– Problem: Resident has open areas on heels and left hip;
– Goal: Skin will heal without problems;
– Problem: Resident is at risk for pressure ulcers;
– Goal: Resident’s skin will remain intact;
– Approach: Use pillows to relieve pressure on the heels.
Review of the resident’s Braden Scale assessment, dated 5/21/18, showed a score of 17, at
risk for pressure sores.
Review of the resident’s physician order [REDACTED].
– [DIAGNOSES REDACTED].
Review of the resident’s nurse’s notes showed the following:
– On 6//13/17 at 7:54 P.M., resident admitted to hospital related to hip incision;
– On 6/20/18 at 2:55 P.M., resident returned to facility;
– On 6/30/18 at 12:00 P.M., bilateral heels stage 1 with dark areas in skin, skin prep
applied, blue booties on to reduce pressure;
– On 7/3/18 at 2:31 P.M., resident complains of back hurting when up in wheelchair;
– On 7/5/18 at 3:22 P.M., skin is pink, warm, and dry with treatment in place to coccyx as
ordered;
– On 7/10/18 at 11:20 P.M., resident sent to hospital per family request;
– On 7/13/18 at 11:00 P.M., resident returned to facility. Open area to left buttock,
right heel with three darkened areas that were firm and dry and were present when resident
was sent to hospital, left heel had two scabbed areas. Heels are firm, Pressure relieving
boots on. Hospice notified of resident’s return;
– On 7/14/18 at 11:00 A.M., hospice to see resident. Dark areas remain on right heel,
three scabs remain on left heel, Baza applied to buttocks for redness, pain medication
given;
Review of the resident’s new admit nutritional assessment with wound report, dated
6/21/18, showed the following:
– Multiple ulcers at various stages;
– Right heel soft, has scabbed area which measures 0.5 cm by 1.5 cm;
– Left heel soft, has bruised area which measures 0.8 cm by 1.2 cm;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
– Both heels skin prepped and heel protectors applied, heels elevated on pillows;
– Small area to left hip measures 0.5 cm by 0.5 cm.
Review of the resident’s wound report for the left heel, dated 6/29/18, showed the
following:
– Resident expresses pain related to wound;
– Nurse unable to stage;
– Surrounding tissue is [DIAGNOSES REDACTED], dry/flaky;
– Interventions: Pressure reducing device for chair, turning/repositioning;
– Measures taken: physical therapy, catheter, heel protectors;
– Physician not notified, no explanation given.
Review of the resident’s wound report for the right heel, dated 6/29/18, showed the
following:
– Resident expresses pain related to the wound;
– Nurse unable to stage;
– Surrounding tissue is [DIAGNOSES REDACTED];
– Interventions: pressure reducing device for chair, turning/repositioning;
– Measures taken: physical therapy, catheter, and heel protectors;
– Physician not notified, no explanation.
Review of the resident’s wound report for left heel, dated 7/4/18, showed the following:
– Resident expresses pain related to wound;
– Nurse unable to stage;
– Surrounding tissue is [DIAGNOSES REDACTED];
– Interventions: Pressure reducing device for chair, turning/repositioning;
– Measures taken: physical therapy, catheter, heel protectors;
– Physician not notified, no explanation given.
Review of the resident’s wound report for right heel, dated 7/4/18, showed the following:
– Resident expresses pain related to the wound;
– Nurse unable to stage;
– Surrounding tissue is [DIAGNOSES REDACTED];
– Interventions: pressure reducing device for chair, turning/repositioning;
– Measures taken: physical therapy, catheter, and heel protectors;
– Physician not notified, no explanation.
Review of the resident’s wound report for left heel, dated 7/20/18, showed the following:
– Resident expresses pain related to wound;
– Surrounding tissue is dry/flaky;
– Interventions: Pressure reducing device for chair, turning/repositioning;
– Measures taken: heel protectors;
– Physician not notified, no explanation given.
Review of the resident’s wound report for left buttock, dated 7/27/18, showed the
following:
– Resident expresses or shows signs of pain related to the wound area;
– Pressure sore;
– Onset of 7/27/18;
– Acquired in house;
– Current measurement 5 cm by 5 cm by 0.1 cm, volume 2.5;
– Stage 2;
– Bed tissue is slough;
– Scant amount and serosanguineous exudate;
– Surrounding tissue is [DIAGNOSES REDACTED];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
– Interventions: Pressure reducing device for chair, turning/repositioning, applications
of ointments/medications;
– Measures taken: catheter, heel protectors;
– Treatment: Clean with wound cleanser, apply [MEDICATION NAME] to wound bed, cover with
foam dressing daily and as needed;
– Physician notified.
Review of the resident’s hospice service record showed the following:
– On 7/23/18, informed resident had sore on bottom, blisters/sores on both heels;
– On 7/26/18, resident had open pressure on bottom, bandage present, now a hoyer lift;
– On 7/30/18, resident had open wound on bottom with no bandage, nurse informed.
Observation on 8/1/18 at 1:00 P.M., showed the resident sitting on a hoyer pad in his/her
wheelchair in the dining room. The resident slid down in the wheel chair and the hoyer pad
covered the left side of his/her face. The resident repeatedly yelled oh and ow. At 1:04
P.M., two staff moved the resident up in the wheelchair, using the hoyer pad. The resident
stopped yelling.
Observation on 8/02/18, at 12:45 P.M., showed the resident at the dining room table in
his/her Broda chair (reclining chair on wheels). Observation showed the resident call out,
my bottom hurts really bad. Additional observation showed certified nurse assistant (CNA)
E sat beside the resident and did not reposition the resident or alert the nurse of the
resident’s pain. At 1:08 P.M., the resident sat in the dining room table in his/her Broda
chair. The resident yelled out, I’m so hungry and thirsty and my bottom hurts so bad.
Observation showed CNA E sat beside the resident and did not reposition the resident or
alert the nurse of the resident’s pain. At 1:11 P.M., the resident sat in the dining room
table in his/her Broda chair. The resident yelled out, I’m so hungry and thirsty and my
bottom hurts so bad, but I will be ok I guess. Observation showed CNA E sat beside the
resident and did not reposition the resident or alert the nurse of the resident’s pain. At
1:16 P.M., the resident continued to sit in the dining room table in his/her Broda chair.
The resident put his/her head back and moaned loudly. The resident yelled out, my back
hurts so bad, my bottom is so sore. Observation showed CNA E sat beside the resident and
did not reposition the resident or alert the nurse of the resident’s pain. At 1:22 P.M.,
the resident yelled out, I just want to cry and cry I am hurting so bad. Additional
observation showed the resident did not have a pressure reducing cushion in his/her Broda
chair. At this time, CNA J sat beside the resident. The CNA did not reposition the
resident or alert the nurse of the resident’s pain. The resident sat in his/her Broda
chair for at least thirty-seven minutes, voicing pain, and staff did not address the
resident’s complaints or notify the nurse of the resident’s complaints of pain.
During an interview, on 8/2/18, at 1:22 P.M., CNA J said the resident is not on a pressure
reduction cushion.
Observation on 8/02/18, at 1:30 P.M., showed the resident at the dining room table in
his/her Broda chair. The resident yelled out, my bottom hurts so bad. Observation showed
the resident did not have a pressure reducing cushion in his/her Broda chair. Observation
showed CNA J sat beside the resident. The CNA did not reposition the resident or alert the
nurse of the resident’s pain.
During an interview on 8/03/18, at 6:11 P.M., the director of nursing said staff are
expected to do interventions to prevent development or worsening of pressure wounds like
repositioning, float heels, low air loss, all mattresses pressure reducing, and wheelchair
pressure reducing cushions. He/She said he/she did not know if the resident had a pressure
reduction cushion in his/her chair.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to obtain stop dates of 14
days or less on PRN (as needed) [MEDICAL CONDITION] medications (a chemical substance that
changes brain function and results in alterations in perception, mood, consciousness or
behavior) for three residents (Resident #23, #33, & #40)out of 15 sampled residents.
The facility census was 60.
1. Review of the facility’s policy Antipsychotic Medication Use, dated (MONTH) 2012, shows
antipsychotic medication therapy shall be used only when it is necessary to treat specific
conditions for which they are indicated and effective. If antipsychotic medications are
administered as needed (PRN) dosages repeatedly over several days, the physician should
discuss the situation with staff and evaluate the resident as needed to determine whether
the use is appropriate and the symptoms are responding to the medication.
2. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 05/19/18, showed staff assessed the
resident as follows:
-Cognitively intact with no behaviors;
-[DIAGNOSES REDACTED].
-One fall with no injury;
-Weight loss;
-Medication use during the seven day look back period include four days of anxiolytic
(anti-anxiety), seven days of antidepressant, and seven days of anticoagulant medications.
Review of the resident’s current physician’s orders [REDACTED].
-04/17/18 [MEDICATION NAME] ([MEDICATION NAME]) 0.5 milligrams (mg) twice daily PRN for
anxiety. Further review showed the order did not contain a stop date;
-04/06/18 [MEDICATION NAME] ([MEDICATION NAME]) 50 mg three times daily PRN for anxiety.
Further review showed the order did not contain a stop date.
Review of the resident’s Pharmacist Medication Regimen Review, showed the pharmacist
documented:
-Recommendation date 03/22/18 – Resident has a PRN order for an anxiolytic, which has been
in place for greater than 14 days without a stop date: [MEDICATION NAME] PRN. Please
discontinue PRN [MEDICATION NAME]. If the medication cannot be discontinued at this time,
current regulations require that the prescriber document the indication for use, the
intended duration of therapy, and the rationale for the extended time period. The
physician accepted the recommendation and the medication was discontinued 03/27/18. The
medication was reordered on [DATE] with no stop date.
-Recommendation date 05/17/18 – Resident has a PRN order for an anxiolytic, which has been
in place for greater than 14 days without a stop date: [MEDICATION NAME] PRN and
[MEDICATION NAME] PRN. If the medication cannot be discontinued at this time, current
regulations require that the prescriber document the indication for use, the intended
duration of therapy, and the rationale for the extended time period.
– On 05/29/18 the physician did not discontinue the [MEDICATION NAME] PRN because staff
were giving it regularly for anxiety. The [MEDICATION NAME] order was not addressed by the
physician. Orders for both medications are on the current Physician order [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
3. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment with hallucinations, delusions, and behaviors;
-[DIAGNOSES REDACTED].
-Weight loss;
–Medication use during the seven day look back period include seven days of insulin,
seven days of antipsychotic medications, and seven days of an Opioid.
-A Gradual Dose Reduction (GDR) was contraindicated on 06/01/18.
Review of the resident’s current POS, shows staff are directed to administer:
-05/19/18 [MEDICATION NAME] ([MEDICATION NAME]) 5 mg/milliliter (ml): 1 ml (5 mg)
intramuscularly (IM) two times daily PRN for [MEDICAL CONDITION] disorder. Further review
showed the order did not contain an end date;
-05/19/17 [MEDICATION NAME] ([MEDICATION NAME]) 10 mg: 0.5 ml (2.5 mg) IM three times
daily PRN for anxiety disorder. Further review showed the order did not contain an end
date;
-05/19/17 [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg tablet three times a day PRN for
anxiety disorder. Further review showed the order did not contain an end date;
-05/19/17 [MEDICATION NAME] ([MEDICATION NAME]) 25 mg tablet two times daily PRN for
anxiety disorder. Further review showed the order did not contain an end date.
Review of the resident’s Pharmacist Medication Regimen Review, showed the pharmacist
documented:
– Recommendation date 10/27/17: The resident has four PRN orders for antipsychotic
medications: [REDACTED].
The pharmacist recommended discontinuing the PRN antipsychotic orders. Upcoming regulation
in (MONTH) (YEAR) will require an evaluation every 14 days for PRN antipsychotic orders.
Documentation showed the consultation report was sent to the psychiatrist on 11/03/17. The
record did not contain a response. Further review showed the medications remain on the
POS.
4. Review of Resident #40’s significant change MDS dated [DATE], showed staff assessed the
resident as follows:
-Severely cognitively impaired with behaviors;
-[DIAGNOSES REDACTED].
-Use of oxygen and on hospice.
Review of the current POS shows staff are directed to administer [MEDICATION NAME] one
tablet (0.5 mg) every four hours PRN for anxiety, ordered 03/21/18. Further review showed
the record did not contain a stop date.
5. During an interview on 08/03/18 at 10:11 A.M., Registered Nurse (RN) M said the
pharmacist comes to the facility monthly to review resident medications. The pharmacist
gives any written recommendations to the Director of Nursing (DON). After reviewing the
recommendations, the DON gives them to the charge nurse to fax to the responsible
physician. If the physician does not respond in three days, the charge nurse is to refax
the recommendation and follow up with a phone call to the physician’s office. RN M said
he/she is not aware of PRN psychoactive medications requiring a 14 day stop date.
6. During an interview on 08/03/18 at 10:30 A.M., the Administrator and DON said they were
not aware of the change in regulation requiring a 14 day stop date for PRN psychotic
medication.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, facility staff failed to properly
sanitize manually washed kitchenware to prevent the potential for cross-contamination.
Facility staff failed to allow manually washed kitchenware to air dry prior to use or
storage to prevent cross-contamination and bacterial growth. Facility staff also failed to
change gloves and wash their hands as often as necessary, using approved techniques, to
prevent cross contamination. The facility census was 60.
1. Review of the (YEAR) Food and Drug Administration Food Code, Chapter 2, Section 301.12
(Cleaning Procedure) showed:
(A) Except as specified in paragraph (D) of this section, FOOD EMPLOYEES shall clean their
hands and exposed portions of their arms, including surrogate prosthetic devices for hands
or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is
equipped as specified under § 5-202.12 and Subpart 6-301.
(B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean
their hands and exposed portions of their arms, including surrogate prosthetic devices for
hands and arms:
(1) Rinse under clean, running warm water;
(2) Apply an amount of cleaning compound recommended by the cleaning compound
manufacturer;
(3) Rub together vigorously for at least 10 to 15 seconds while:
(a) Paying particular attention to removing soil from underneath the fingernails during
the cleaning procedure, and
(b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic
devices for hands and arms, finger tips, and areas between the fingers;
(4) Thoroughly rinse under clean, running warm water; and
(5) Immediately follow the cleaning procedure with thorough drying using a method as
specified under § 6-301.12.
(C) To avoid recontaminating their hands or surrogate prosthetic devices, FOOD EMPLOYEES
may use disposable paper towels or similar clean barriers when touching surfaces such as
manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door.
(D) If APPROVED and capable of removing the types of soils encountered in the FOOD
operations involved, an automatic handwashing facility may be used by FOOD EMPLOYEES to
clean their hands or surrogate prosthetic devices.
Review of the (YEAR) Food and Drug Administration Food Code, Chapter 2, Section 301.14
(When to Wash) showed:
FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified
under § 2-301.12 immediately before engaging in FOOD preparation including working with
exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE SERVICE and SINGLE-USE
ARTICLES and:
(A) After touching bare human body parts other than clean hands and clean, exposed
portions of arms;
(B) After using the toilet room;
(C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in
paragraph 2-403.11(B);
(D) Except as specified in paragraph 2-401.11(B), after coughing, sneezing, using a
handkerchief or disposable tissue, using tobacco, eating, or drinking;
(E) After handling soiled EQUIPMENT or UTENSILS;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 35)
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to
prevent cross contamination when changing tasks;
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD;
(H) Before donning gloves to initiate a task that involves working with FOOD; and
(I) After engaging in other activities that contaminate the hands.
2. Observation on 07/31/18 at 12:45 P.M., showed Cook S picked up the lid to a five pound
container of cottage cheese from the floor with gloved hands. Observation showed the cook
removed his/her gloves and washed the lid in the three compartment sink. Observation
showed, after the cook washed and rinsed the lid, he/she dipped the lid in sanitizing
solution, immediately removed and then placed the wet lid on the countertop in the cook’s
station. Observation showed the cook then washed his/her hands in the handwashing sink and
turned the faucet off with his/her bare wet hands. Further observation showed the cook
prepared a bowl of cottage cheese for service to a resident at the noon meal, placed the
wet lid on the container of cottage cheese and returned the container to the walk-in
cooler.
3. Observation on 07/31/18 at 12:55 P.M., showed Cook S washed rubber spatulas in the
three compartment sink. Observation showed, after the cook washed and rinsed the spatulas,
he/she dipped the spatulas in sanitizing solution, immediately removed and then placed the
wet spatulas on the countertop in the cook’s station. Observation showed the cook then
washed his/her hands in the handwashing sink and turned the faucet off with his/her bare
wet hands. Further observation showed the cook used the wet spatulas to stir pureed food
items on the stove.
Review of the quaternary ammonium sanitizer’s product labeling showed instruction to
immerse kitchenware in a solution with a concentration of 200-400 parts per million for at
least 60 seconds and allow the the kitchenware to air dry.
4. Observation on 07/31/18 at 1:05 P.M., showed Cook S washed his/her hands at the
handwashing sink. Further observation showed the cook turned the faucet off with his/her
wet bare hands.
5. Observation on 07/31/18 at 1:16 P.M., showed Cook S touched the trash can lid with
his/her gloved hands to dispose of food waste. Observation showed, with the same gloved
hands, the cook prepared a grilled cheese sandwich and portioned cheese curls from the bag
onto a plate for service to a resident. Further observation showed the cook used the same
soiled gloves to prepare peanut butter and jelly sandwiches for service to residents at
the noon meal.
6. Observation on 08/02/18 at 7:53 A.M., showed Cook U washed portion scoops in the three
compartment sink. Observation showed, after the cook washed and rinsed the scoops, the
cook placed the scoops under running sanitizer from the hose for three seconds and then
rinsed the scoops with running water from the faucet. Observation showed the cook placed
the wet scoops into food items on the steamtable. Further observation showed the cook
washed his/her hands at the handwashing sink. Observation showed the cook turned the
faucet off with his/her bare wet hands and then served food items from the steamtable to
residents for breakfast.
7. Observation on 08/02/18 at 11:04 A.M., showed Cook V washed his/her hands at the
handwashing sink. Further observation showed the cook turned the faucet off with a paper
towel and then used the same paper towel to dry his/her hands.
During an interview on 08/02/18 at 11:06 A.M., the cook said the purpose of turning the
faucet off with a paper towel is so he/she did not touch the dirty faucet. The cook said
he/she did not think about drying his/her hands with the same paper towel being a problem.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 36)
8. Observation on 08/02/18 at 11:18 A.M., showed Cook W washed his/her hands at the
handwashing sink. Further observation showed the cook turned the faucet off with a paper
towel and then used the same paper towel to dry his/her hands. Observation showed the cook
returned to cook’s station and prepared gravy for service at the noon meal.
During an interview on 08/02/18 at 11:20 A.M., The cook said the purpose of turning the
faucet off with a paper towel is so you do not dirty your hands again. The cook said
he/she should have dried his/her hands and then used a separate towel to turn off the
faucet, but he/she forgot.
9. Observation on 08/02/18 at 11:34 A.M., showed Cook U washed soiled dishes at the
mechanical dishwashing station. Observation showed, without washing his/her hands, the
cook removed clean dishes from the dishwasher and placed them on the clean side of the
dishwashing station. Further observation showed the cook repeated the same procedure two
additional times.
During an interview on 08/02/18 at 1:00 P.M., the cook said staff should wash their hands
after touching anything dirty. The cook said he/she rinsed his/her hands off with the
spray nozzle from the dirty side of the dishwashing station before he/she handled the
clean dishes and he/she thought that was okay.
10. Observation on 08/02/18 at 11:36 A.M., showed Cook W washed the food processor in the
three compartment sink. Observation showed, after washing, the cook rinsed the food
processor with sanitizer from the hose and then used the food processor while wet to
prepare pureed buttered noodles for service at the noon meal.
11. Observation on at 08/02/18 at 12:04 P.M. Observation showed Cook W washed the food
processor in the three compartment sink. Observation showed, after washing, the cook
rinsed the food processor with water from the faucet and then dried the food processor
with a cloth towel. Further observation showed the food processor remained wet to touch
when the cook placed it on the base and used it to prepare pureed blackeyed peas.
12. During an interview on 08/02/18 at 1:28 P.M., the Dietary Manager (DM) said staff
should wash hands before handling food, anytime they change gloves, when they enter or
exit kitchen, touch the trash can, and between handling dirty and clean dishes. The DM
said all are staff trained on handwashing procedures upon hire. The DM said staff are
trained to turn the faucet off with a separate papertowel. The DM said dishes that are
washed in the three compartment sink should be washed, rinsed and put in the sanitizer for
one minute. The DM said all dishes should be air dried before use and staff trained not to
move the dishes until they are dry.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to appropriately
sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after
use for five residents (Residents #26, #32, #33, #37, #43), and failed to store resident’s
oxygen tubing to prevent contamination and the spread of bacteria for one resident’s
(Resident #42) to prevent the spread of infection causing contaminants. The facility
census was 60.
1. Review of the manufacturer’s user guide for Evencare G3 blood glucose monitoring
system, shows:
-All parts of the glucose monitoring system should be considered potentially infectious

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
and are capable of transmitting blood-borne pathogens between patients and healthcare
professionals;
-The glucose monitored should be cleaned and disinfected between each patient using
approved disinfecting wipes;
-Prior to disinfecting the glucose meter, staff should wash hands with soap and water and
put on single use medical protective gloves;
-Inspect the meter for blood, debris, dust, or lint and thoroughly clean blood and body
fluids from the surface of the meter. Wipe all surfaces of the meter, including the front
and back surfaces until visibly clean, avoiding wetting the meter test strip port;
-To disinfect the meter, clean the meter surface with one of the approved disinfecting
wipes. Allow the surface of the meter to remain wet at room temperature for the contact
time listed on the wipe’s directions for use.
2. Review of the facility’s policy and procedure for Blood Glucose Monitoring, dated
(MONTH) 2012, shows the purpose is to obtain a blood sample to determine the resident’s
blood glucose level. Staff are directed to do the following:
-Place equipment on a clean surface (such as a clean towel);
-Put gloves on;
-Disinfect the glucose monitor and return it to the cart;
-Remove gloves and wash hands.
3. Review of the directions located on the box of the bleach wipes, show staff are
directed to clean, disinfect, and deodorize the glucometer by using a clean wipe to remove
any heavy soil. A clean wipe is to be used to thoroughly wet the surface and the treated
surface must remain visibly wet for a full two minutes to disinfect against all pathogens.
Staff are directed to use additional wipes if needed to make sure the surface remains wet
for the allotted time.
4. Observation on 08/01/18 at 11:15 A.M., showed Registered Nurse (RN) D prepare to do a
blood sugar check for Resident #32. The RN took the glucometer from the medication cart
and sat it on a table (with no barrier) in the office across from the nurse’s station. The
RN placed the glucometer on top of the medication cart, and did not use a barrier. The RN
sat the glucometer on the resident’s bed while prepping the resident’s finger and
administering the fingerstick. The RN placed the glucometer back on the resident’s bed
after he/she obtained the sample. The RN picked the glucometer up, returned to the
medication cart, and placed the glucometer with the soiled test strip, on top of the
medication cart. Without changing gloves, the RN obtained the resident’s insulin pen from
the top drawer of the medication cart and gave the insulin. The RN dropped the insulin pen
on the floor, picked it up, placed it in a baggie and returned it to the medication cart.
The RN then removed the soiled test strip from the glucometer, discarded it, and wiped the
glucometer off with a disinfectant wipe. The RN did not ensure the glucometer’s surface
remained wet for the allotted time.
5. Observation on 08/01/18 at 11:30 A.M., showed RN D assist Resident #33 to room to
obtain a blood sugar. Without washing or sanitizing hands, the RN put a glove on his/her
right hand, picked up the glucometer, carried it into the resident’s room and placed it on
a table without a barrier. The RN obtained the blood sample and sat the glucometer with
the soiled test strip in place back onto the table. The RN placed the glucometer back on
top of the medication cart without a barrier.
6. Observation on 08/02/18 at 11:15 A.M., showed Certified Medication Aide (CMT) Q obtain
a blood sample from Resident #43. The CMT did not use a barrier between the supplies and
the medication cart. The CMT applied gloves and did not place a barrier between the
supplies and the top of the table. After he/she obtained the blood sample, the CMT sat the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
glucometer containing the soiled test strip, back onto the table. The CMT wiped off the
glucometer with a bleach wipe but did not ensure the surface of the glucometer remained
wet for the allotted time required for disinfection.
7. During an observation on 08/02/18 at 11:30 A.M., CMT Q obtained a blood sample from
Resident #26. The CMT did not use a barrier between the supplies and the medication cart.
The CMT applied gloves and did not place a barrier between the supplies and the top of the
table. After he/she obtained the blood sample, the CMT sat the glucometer containing the
soiled test strip, back onto the table. The CMT wiped off the glucometer with a bleach
wipe but did not ensure the surface of the glucometer remained wet for the allotted time
required for disinfection.
8. During an observation on 08/02/18 at 11:38 A.M., CMT Q obtained a blood sample from
Resident #37 Without washing or sanitizing hands, the RN put a glove on his/her right
hand, picked up the glucometer, carried it into the resident’s room and placed it on a
table without a barrier. The RN obtained the blood sample and sat the glucometer with the
soiled test strip in place back onto the table. The RN placed the glucometer back on top
of the medication cart without a barrier.
9. During an interview on 08/02/18 at 12:12 P.M., CMT Q said he/she didn’t think about
putting a barrier down for infection control, but it makes sense to do so, and he/she
should have. The CMT said he/she did not read the directions on the container of
disinfectant wipes, and did not know the surface should remain wet for a certain amount
time in order to disinfect.
10. During an interview 08/03/18 11:27 AM., registered nurse (RN) K said staff should wipe
down the glucometer with a antibacterial wipe between residents. He/She did not know how
long the surface should remain wet.
11. During an interview on 08/02/18 at 02:00 P.M., the Director of Nursing (DON) and the
administrator said they expect the glucometer to be cleansed and disinfected according to
the directions on the wipes and per the glucometer manufacturer. The DON said she did not
know the staff did not allow the surface to remain wet the allotted time.
12. Review of the facility’s Oxygen Administration policy, dated (MONTH) 2012, shows
staff are directed as follows:
-Nasal cannula, face mask, or nasal catheter as ordered;
-Set the flow meter to the rate ordered by the physician;
-Place mask or cannula on resident as indicated;
-Label humidifier with date and time opened.
The policy did not contain how often to change the oxygen tubing or how to store the
tubing when not in use.
13. Observation on 7/31/18, at 11:17 A.M., showed Resident #42 in his/her recliner with
the resident’s oxygen nasal cannula tubing undated and hung uncovered over the oxygen
concentrator.
14 Observation on 7/31/18, at 12:00 P.M., showed a medication nebulizer mask undated and
uncovered on the bedside table in resident room [ROOM NUMBER].
15. During an interview on 8/3/18 at 5:40 P.M., licensed practical nurse (LPN) L said
staff are expected to change oxygen tubing weekly. He/She said the oxygen tubing should be
coiled in a bag when not in use.
During an interview on 8/3/18, at 6:11 P.M., the director of nursing (DON) said the tubing
is to be changed weekly and placed in a bag when not in use.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265663

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

08/03/2018

NAME OF PROVIDER OF SUPPLIER

FULTON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1510 BLUFF STREET
FULTON, MO 65251

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some