FULTON NURSING & REHAB

**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

**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:

**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].

**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

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.

**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

**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.

**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

**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

**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

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]

**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;

**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].

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;

**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