Inspection Reports for
Fulton Center for Rehabilitation and Healthcare
847 Cohwy 122, Gloversville, NY, 12078
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 29, 2024
Visit Reason
Safe/clean/comfortable/homelike environment deficiency with Level 2 severity, corrected as of July 2, 2024.
Findings
Safe/clean/comfortable/homelike environment deficiency with Level 2 severity, corrected as of July 2, 2024.
Deficiencies (1)
Safe/clean/comfortable/homelike environment
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator #1 stated that the Director of Maintenance would be directed to remove worn chairs and order new ones. | |
| Director of Maintenance | Director of Maintenance #1 referenced regarding removal and replacement of worn chairs. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Prepared medications that were administered by CNA #12 |
| CNA #12 | Certified Nursing Aide | Administered medications prepared by RN #4 |
| Director of Nursing | DON | Reported and confirmed the medication administration incident |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Nov 16, 2023
Visit Reason
Multiple Level 2 standard health citations including dialysis, nutritive value, qualified persons, respiratory care, standards of construction, and one Level 2 life safety code citation for electrical equipment testing and maintenance.
Findings
Multiple Level 2 standard health citations including dialysis, nutritive value, qualified persons, respiratory care, standards of construction, and one Level 2 life safety code citation for electrical equipment testing and maintenance.
Deficiencies (6)
Dialysis
Nutritive value/appear, palatable/prefer temp
Qualified persons
Respiratory/tracheostomy care and suctioning
Standards of construction for new existing nh
Electrical equipment - testing and maintenanc
Inspection Report
Annual Inspection
Deficiencies: 3
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Interviewed regarding oxygen flow rate discrepancies for Resident #4 |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding oxygen flow rate and documentation for Resident #4 |
| RN #3 | Registered Nurse Unit Manager | Interviewed regarding oxygen monitoring and documentation for Resident #4 |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding oxygen equipment maintenance for Resident #41 |
| LPN #5 | Licensed Practical Nurse | Documented changing of oxygen equipment for Resident #41 |
| LPNUM #10 | Licensed Practical Nurse Unit Manager | Interviewed regarding oxygen tubing maintenance and documentation for Resident #46 |
| CNA #10 | Certified Nursing Assistant | Interviewed regarding oxygen tubing observations for Resident #46 |
| DON | Director of Nursing | Interviewed regarding oxygen care policies and staff education |
| CNA #8 | Certified Nursing Aide | Interviewed regarding dialysis training and notification to nurses |
| CNA #9 | Certified Nursing Aide | Interviewed regarding dialysis training and notification to nurses |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding dialysis communication documentation |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding dialysis communication documentation |
| RN #3 | Registered Nurse Unit Manager | Interviewed regarding dialysis communication review and documentation |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident complaints about cold food and reheating practices |
| CNA #10 | Certified Nurse Aide | Interviewed regarding resident complaints about cold food and dietary communication |
| FSD | Food Service Director | Interviewed regarding food temperature monitoring and equipment issues |
| Administrator | Facility Administrator | Interviewed regarding awareness of food quality complaints and trends |
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding notification procedures after resident falls |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policies and procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 6, 2023
Visit Reason
Level 2 deficiency for notifying of changes (injury/decline/room, etc.), corrected as of November 6, 2023.
Findings
Level 2 deficiency for notifying of changes (injury/decline/room, etc.), corrected as of November 6, 2023.
Deficiencies (1)
Notify of changes (injury/decline/room, etc. )
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 11, 2022
Visit Reason
Level 2 deficiencies for food procurement, sanitary preparation and infection prevention & control, both corrected as of October 26, 2022.
Findings
Level 2 deficiencies for food procurement, sanitary preparation and infection prevention & control, both corrected as of October 26, 2022.
Deficiencies (2)
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jan 28, 2022
Visit Reason
Level 4 immediate jeopardy deficiency for free from abuse and neglect (corrected Feb 24, 2022), plus Level 2 deficiencies for reporting alleged violations and other minor issues.
Findings
Level 4 immediate jeopardy deficiency for free from abuse and neglect (corrected Feb 24, 2022), plus Level 2 deficiencies for reporting alleged violations and other minor issues.
Deficiencies (3)
Free from abuse and neglect
General requirements
Reporting of alleged violations
Inspection Report
Certification
Capacity: 60
Deficiencies: 1
Date: Dec 30, 2021
Visit Reason
Level 2 deficiency for physical environment, corrected as of January 7, 2022.
Findings
Level 2 deficiency for physical environment, corrected as of January 7, 2022.
Deficiencies (1)
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 10
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.
Deficiencies (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
Facility census: 171
Unit census: 20
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
| Name | Title | Context |
|---|---|---|
| RNM #3 | Registered Nurse Manager | Named in failure to notify physician and grievance investigation |
| LPN #4 | Licensed Practical Nurse | Named in failure to notify physician and resident care observations |
| CNA #5 | Certified Nursing Assistant | Named in resident care observations and reporting |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing and care issues |
| Administrator | Facility Administrator | Interviewed regarding staffing and facility operations |
| Director of Maintenance | Director of Maintenance | Interviewed regarding environmental hazards and dumpster maintenance |
| Food Service Director | Food Service Director | Interviewed regarding food service deficiencies |
| Registered Dietician | Registered Dietician | Interviewed regarding food brought in by visitors |
| Human Resource Director | Human Resource Director | Interviewed regarding staffing and facility assessment |
Inspection Report
Annual Inspection
Deficiencies: 7
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | CNA | Interviewed regarding resident dignity and covering Resident #48 |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding expectations for covering Resident #48 |
| Director of Nursing | DON | Interviewed regarding resident dignity and supervision during meals |
| Certified Nursing Assistant #6 | CNA | Interviewed regarding supervision of Resident #59 during meals |
| Unit Assistant #12 | UA | Interviewed regarding meal delivery and supervision of Resident #59 |
| Unit Assistant #13 | UA | Interviewed regarding meal delivery and supervision of Resident #59 |
| Registered Nurse Manager #3 | RNM | Interviewed regarding supervision and care plan for Resident #59 |
| Speech Therapist #4 | ST | Interviewed regarding swallowing evaluation and diet recommendations for Resident #59 |
| Food Service Director | FSD | Interviewed regarding dietitian consultations and food safety issues |
| Registered Dietitian | RD | Interviewed regarding consultation frequency with Food Service Director |
| Director of Maintenance | Interviewed regarding dumpster cleaning and maintenance issues | |
| Infection Control Nurse | Interviewed regarding infection prevention and control program review | |
| Registered Nurse Consultant #6 | RN Consultant | Interviewed regarding infection prevention and control program review |
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