Inspection Reports for
Fulton Center for Rehabilitation and Healthcare

847 Cohwy 122, Gloversville, NY, 12078

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7 Reports

1 state, 6 CMS 2019–2026

Inspection Report — Feb 5, 2026

Complaint Investigation State
Date: Feb 5, 2026

Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2026 with deficiency and enforcement history.

Complaint Details
The facility received 221 complaints with 8 on-site inspections conducted. Complaint citation categories include Administration (0), Dietary Services (2), Other Services (1), Physical Environment (1), Quality of Care (1), and Resident Rights (3).
Findings
Across 8 inspections, 5 resulted in citations totaling 12 deficiencies primarily related to standard health and one life safety code citation. The facility had 6 enforcement actions with fines totaling $66,000 and a high complaint volume with 221 complaints recorded.

Citations (11)
Standard Health Citation — Notice And Conveyance Of Personal Funds: Minor potential harm noted in isolated instance.
Standard Health Citation — Safe/clean/comfortable/homelike Environment: Minor potential harm found in a pattern of deficiencies.
Standard Health Citation — Dialysis: Minor potential harm noted in isolated deficiency.
Standard Health Citation — Nutritive Value/appear, Palatable/prefer Temp: Minor potential harm found in a pattern of deficiencies.
Standard Health Citation — Qualified Persons: Minor potential harm noted in isolated deficiency not yet corrected.
Standard Health Citation — Respiratory/tracheostomy Care And Suctioning: Minor potential harm found in a pattern of deficiencies.
Standard Health Citation — Standards Of Construction For New Existing Nh: Minor potential harm noted in isolated deficiency.
Life Safety Code Citation — Electrical Equipment - Testing And Maintenanc: Minor potential harm found in a pattern of deficiencies.
Standard Health Citation — Notify Of Changes (injury/decline/room, Etc.): Minor potential harm noted in isolated deficiency.
Standard Health Citation — Food Procurement,store/prepare/serve-sanitary: Minor potential harm found in a pattern of deficiencies.
Standard Health Citation — Infection Prevention & Control: Minor potential harm found in a pattern of deficiencies.
Report Facts
Inspections on page: 8 Total violations/deficiencies cited: 12 Inspections with violations: 5 Inspections without violations: 3 Total complaints: 221 On-site complaint inspections: 8 Total enforcement actions: 6 Total fines: 66000 Citations issued from complaints: 7

Inspection Report — Jan 10, 2024

Abbreviated Survey CMS
Date: Jan 10, 2024

Visit Reason
The visit was an abbreviated survey to assess the facility's maintenance services and compliance with safety and comfort standards.

Findings
The facility failed to provide effective maintenance services in one of four resident units and three dining areas, specifically due to worn upholstery on resident chairs.

Citations (1)
F 0584: The facility did not provide effective maintenance services in one resident unit and three dining areas. Resident chairs had worn upholstery in multiple locations including dining and recreation rooms and the nurse station.
Report Facts
Worn chairs: 13

Employees mentioned
NameTitleContext
AdministratorAdministrator #1 stated that the Director of Maintenance would be directed to remove worn chairs and order new ones.
Director of MaintenanceDirector of Maintenance #1 referenced regarding removal and replacement of worn chairs.

Inspection Report — Nov 16, 2023

Abbreviated Survey CMS
Date: Nov 16, 2023

Visit Reason
The visit was a recertification and abbreviated survey to assess compliance with medication administration regulations at the facility.

Findings
The facility did not ensure that medications ordered by a physician were administered by a Licensed Professional Nurse for one resident. A Certified Nursing Aide administered medications prepared by a Registered Nurse, which was against facility policy and state regulations.

Citations (1)
F 0659: The facility failed to ensure medications were administered by a Licensed Professional Nurse as required. A Certified Nursing Aide gave medications to Resident #523 that were prepared by a Registered Nurse on 9/19/2021.
Report Facts
Residents reviewed: 17 Staff reeducated: 99

Employees mentioned
NameTitleContext
RN #4Registered NursePrepared medications that were administered by CNA #12
CNA #12Certified Nursing AideAdministered medications prepared by RN #4
Director of NursingDONReported and confirmed the medication administration incident

Inspection Report — Nov 16, 2023

Annual Inspection CMS
Date: Nov 16, 2023

Visit Reason
The inspection was a recertification survey conducted to assess compliance with professional standards of practice, care plans, and regulatory requirements for residents receiving respiratory care, dialysis, and food service.

Findings
The facility failed to provide respiratory care consistent with physician orders for multiple residents, did not ensure proper documentation and communication for dialysis care, and did not maintain food at safe and palatable temperatures. Several residents' oxygen equipment was not maintained or changed as ordered, dialysis communication logs were incomplete, and food served was often cold, unpalatable, or improperly seasoned.

Citations (3)
F 0695: The facility did not ensure residents received respiratory care per physician orders, including proper oxygen flow rates and timely changing and labeling of oxygen tubing and equipment.
F 0698: The facility did not ensure residents requiring dialysis received consistent nursing review and completion of dialysis communication logs between 10/12/2023 and 11/9/2023.
F 0804: The facility did not ensure food served was palatable, attractive, and maintained at safe temperatures; multiple observations showed cold or poorly prepared food and resident complaints about food temperature and quality.
Report Facts
Residents reviewed for respiratory care: 7 Dialysis frequency: 3 Food temperature measurements: 41 Food temperature measurements: 135

Employees mentioned
NameTitleContext
LPN #7Licensed Practical NurseInterviewed regarding oxygen flow rate discrepancies for Resident #4
LPN #9Licensed Practical NurseInterviewed regarding oxygen flow rate and documentation for Resident #4
RN #3Registered Nurse Unit ManagerInterviewed regarding oxygen monitoring and documentation for Resident #4
LPN #4Licensed Practical NurseInterviewed regarding oxygen equipment maintenance for Resident #41
LPN #5Licensed Practical NurseDocumented changing of oxygen equipment for Resident #41
LPNUM #10Licensed Practical Nurse Unit ManagerInterviewed regarding oxygen tubing maintenance and documentation for Resident #46
CNA #10Certified Nursing AssistantInterviewed regarding oxygen tubing observations for Resident #46
DONDirector of NursingInterviewed regarding oxygen care policies and staff education
CNA #8Certified Nursing AideInterviewed regarding dialysis training and notification to nurses
CNA #9Certified Nursing AideInterviewed regarding dialysis training and notification to nurses
LPN #7Licensed Practical NurseInterviewed regarding dialysis communication documentation
LPN #9Licensed Practical NurseInterviewed regarding dialysis communication documentation
RN #3Registered Nurse Unit ManagerInterviewed regarding dialysis communication review and documentation
CNA #4Certified Nurse AideInterviewed regarding resident complaints about cold food and reheating practices
CNA #10Certified Nurse AideInterviewed regarding resident complaints about cold food and dietary communication
FSDFood Service DirectorInterviewed regarding food temperature monitoring and equipment issues
AdministratorFacility AdministratorInterviewed regarding awareness of food quality complaints and trends

Inspection Report — Oct 6, 2023

Abbreviated Survey CMS
Date: Oct 6, 2023

Visit Reason
The visit was an abbreviated survey to assess compliance with notification requirements following resident accidents.

Findings
The facility failed to notify the resident's representative after an unwitnessed fall of Resident #1 on 12/25/2021, despite policy requiring notification of family or responsible parties after such incidents.

Citations (1)
F 0580: The facility did not ensure the resident representative was informed when Resident #1 had an unwitnessed fall on 12/25/21 and was sent to the hospital. The resident's family member was documented as emergency contact but was not notified as required by policy.
Report Facts
Residents reviewed: 9 Resident falls: 1

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1Licensed Practical NurseInterviewed regarding notification procedures after resident falls
Director of NursingDirector of NursingInterviewed regarding notification policies and procedures

Inspection Report — Jul 21, 2021

Annual Inspection CMS
Date: Jul 21, 2021

Visit Reason
Recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home operations and resident care.

Findings
The facility was found deficient in multiple areas including failure to promptly notify physicians of significant resident condition changes, inadequate housekeeping and maintenance, insufficient investigation of resident grievances, environmental hazards, insufficient nursing staff to meet resident needs, food service safety violations, improper handling of food brought by visitors, improper garbage disposal, lack of a comprehensive facility-wide staffing assessment, and unsecured handrails in corridors.

Citations (10)
F 0580: The facility failed to immediately notify the resident's physician of a significant change in condition for Resident #52, who vomited black liquid and was later hospitalized with gastrointestinal bleeding and shock.
F 0584: The facility did not provide effective housekeeping and maintenance services; furniture, walls, floors, and utility areas were dirty or in disrepair on all resident units and service areas.
F 0610: The facility failed to thoroughly investigate a grievance regarding a missing watch reported by Resident #83, lacking documentation and follow-up.
F 0689: The facility environment was not free from accident hazards; protruding screws were found in door frames in multiple resident rooms and storerooms.
F 0725: The facility did not ensure sufficient nursing staff on Unit D, Wing 800, resulting in delayed meal delivery, inadequate feeding assistance, and incomplete resident care on 7/15/2021 and 7/20/2021.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; dishwashing machines were not operating properly, thermometers were uncalibrated, and kitchen and storage areas were dirty and in disrepair.
F 0813: The facility did not provide family and visitors with education on safe food handling practices for foods brought to residents, as evidenced by unlabeled food containers and lack of communication.
F 0814: The facility did not properly maintain garbage dumpsters; one dumpster was placed on earthen ground and was soiled with oily drip marks.
F 0838: The facility failed to conduct and document a facility-wide assessment to determine necessary resources and staffing to competently care for residents during day-to-day operations and emergencies.
F 0924: The facility did not ensure corridors were equipped with firmly secured handrails on each side; a handrail between resident rooms #169 and #171 was loose.
Report Facts
Residents requiring assistance with eating: 13 Residents requiring assistance with transferring: 12 Residents requiring assistance with toileting: 15 Residents dependent for eating: 1 Residents dependent for transferring: 4 Residents dependent for toileting: 3 Dishwasher rinse water pressure: 28 Food thermometer calibration temperature: 35

Employees mentioned
NameTitleContext
RNM #3Registered Nurse ManagerNamed in failure to notify physician and grievance investigation
LPN #4Licensed Practical NurseNamed in failure to notify physician and resident care observations
CNA #5Certified Nursing AssistantNamed in resident care observations and reporting
Director of NursingDirector of NursingInterviewed regarding staffing and care issues
AdministratorFacility AdministratorInterviewed regarding staffing and facility operations
Director of MaintenanceDirector of MaintenanceInterviewed regarding environmental hazards and dumpster maintenance
Food Service DirectorFood Service DirectorInterviewed regarding food service deficiencies
Registered DieticianRegistered DieticianInterviewed regarding food brought in by visitors
Human Resource DirectorHuman Resource DirectorInterviewed regarding staffing and facility assessment

Inspection Report — Jul 24, 2019

Annual Inspection CMS
Date: Jul 24, 2019

Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.

Findings
The facility was found deficient in multiple areas including resident dignity and privacy, supervision to prevent accidents, food and nutrition services qualifications, food safety and sanitation, garbage disposal, infection prevention and control program, and maintenance of essential equipment.

Citations (7)
10NYCRR415.3(c)(1)(i) The facility did not ensure Resident #48 was treated with dignity and respect as he was uncovered in bed and visible from the hallway on multiple occasions.
10NYCRR415.12(h)(1) The facility did not ensure Resident #59 was supervised during meals despite his severe dysphagia and risk of choking and aspiration.
10NYCRR415.14(a)(1)(2) The Food Service Director did not receive frequent scheduled consultations from the qualified dietitian as required.
10 NYCRR 415.14(h) The facility did not store, prepare, distribute, and serve food in accordance with professional standards; tuna salad was not cooled properly and food contact surfaces were unclean.
10 NYCRR 415.14(h) One of two trash dumpsters was heavily soiled, not clean, and not pest resistant.
10NYCRR415.19(a)(1-3) The facility did not conduct an annual review of its infection prevention and control program and update it as necessary.
10 NYCRR 415.5(e)(1)(2) Essential equipment and plumbing fixtures in the kitchen were not maintained in safe operating condition, including leaking refrigerators and malfunctioning drawers.
Report Facts
Residents affected: 1 Residents affected: 1 Residents affected: 2 Dates of observations: 3

Employees mentioned
NameTitleContext
Certified Nursing Assistant #2CNAInterviewed regarding resident dignity and covering Resident #48
Licensed Practical Nurse #2LPNInterviewed regarding expectations for covering Resident #48
Director of NursingDONInterviewed regarding resident dignity and supervision during meals
Certified Nursing Assistant #6CNAInterviewed regarding supervision of Resident #59 during meals
Unit Assistant #12UAInterviewed regarding meal delivery and supervision of Resident #59
Unit Assistant #13UAInterviewed regarding meal delivery and supervision of Resident #59
Registered Nurse Manager #3RNMInterviewed regarding supervision and care plan for Resident #59
Speech Therapist #4STInterviewed regarding swallowing evaluation and diet recommendations for Resident #59
Food Service DirectorFSDInterviewed regarding dietitian consultations and food safety issues
Registered DietitianRDInterviewed regarding consultation frequency with Food Service Director
Director of MaintenanceInterviewed regarding dumpster cleaning and maintenance issues
Infection Control NurseInterviewed regarding infection prevention and control program review
Registered Nurse Consultant #6RN ConsultantInterviewed regarding infection prevention and control program review

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