Inspection Reports for
Fulton Nursing &Amp; Rehab

The facility failed to update care plans to address aggressive behaviors for three sampled residents and did not update care plans at least quarterly as required. Staff documented multiple incidents of resident altercations, but care plans lacked corresponding interventions. Interviews revealed staffing and workload issues impacting timely care plan updates.

Complaint #2697930 triggered the investigation. The complaint involved failure to separate COVID-19 positive residents from negative residents and inadequate infection control practices. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to separate residents who tested positive for COVID-19 from those who tested negative, placing negative residents at increased risk of exposure. Staff did not consistently follow infection control practices, including proper use of masks and PPE, and communication about COVID-19 positive residents was inadequate among staff.

Complaint #2644523 regarding failure to have an RN on duty for eight consecutive hours daily was substantiated by staffing records and interviews.

The facility failed to provide RN coverage for eight consecutive hours on multiple days in September and October 2025. Interviews with the Director of Nursing, Assistant Director of Nursing, and administrator confirmed awareness of the requirement and staffing challenges due to recent RN losses.

The facility was found deficient in multiple areas including inconsistent documentation of resident code status, failure to complete significant change assessments for hospice residents, incomplete and outdated care plans, inadequate fall documentation and neurological assessments, improper respiratory care including oxygen tubing and CPAP management, lack of dialysis communication and documentation, failure to post nurse staffing information, incomplete infection prevention and control program including lack of water management and antibiotic stewardship, failure to designate a qualified infection preventionist, and failure to provide and document resident immunizations.

The complaint investigation found that Resident #3's family was not notified of the resident's hospital transfer on 1/30/25 despite an active Durable Power of Attorney. For Resident #1, floor technician E was found to have roughly moved the resident's wheelchair causing a fall on 4/22/25; the technician was suspended and later terminated.

The facility failed to notify the responsible party of Resident #3's hospital transfer and failed to keep Resident #1 free from physical abuse when a floor technician aggressively moved the resident's wheelchair causing a fall. The facility took corrective actions including suspension and termination of the employee involved.

The complaint investigation found substantiated sexual abuse involving two residents with cognitive impairment. The facility staff witnessed the incident, intervened immediately, and notified appropriate parties. The Director of Nursing provided staff inservice on abuse prevention and monitoring.

The facility failed to ensure two residents remained free from sexual abuse when Resident #1 raised his/her shirt and Resident #2 touched Resident #1's chest inappropriately. Both residents had impaired cognition and neither recalled the incident. Staff intervened immediately, separated the residents, and implemented new monitoring and intervention protocols.

The facility was found deficient in multiple areas including failure to post survey results, protect resident privacy, maintain a safe and homelike environment, complete required resident assessments and care plans timely, ensure proper medication management and storage, provide adequate personal hygiene care, ensure safe resident transfers, maintain infection control practices, and ensure staff tuberculosis screening and dietary manager certification.

The facility failed to complete neurological checks and 72-hour fall follow-up documentation for three residents who experienced falls, and failed to complete weekly skin assessments for two residents. Interviews revealed staff awareness of required procedures but lack of completion and unclear responsibility for ensuring tasks were done.

The facility failed to complete and submit the required quarterly MDS assessments for seven residents, with assessments either incomplete, in progress, or missing signed/printed documentation. Validation reports confirmed the absence of these assessments in the facility's records.

The complaint investigation was substantiated with findings of misappropriation of Resident #1's funds. The Administrator conducted an investigation, reimbursed the resident, and implemented corrective actions.

The facility failed to have adequate systems in place to prevent misappropriation of Resident #1's money, resulting in missing funds. The investigation identified that four staff members had access to the safe, but the alleged perpetrator could not be determined. The facility reimbursed the resident and implemented corrective actions including setting up a Resident Trust Account and staff education.

The facility was found deficient in multiple areas including environmental maintenance, resident notification of transfers, medication administration and documentation, personal hygiene assistance, activities program qualifications, safety hazards, nurse staffing postings, psychotropic medication management, medication storage security, dialysis care communication, tuberculosis screening, and infection preventionist designation.