Fulton Center for Rehabilitation and Healthcare

Inspectors wroteBased on observation, interview, and record review during a survey, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to maintain sanitary bedside care equipment, ensure clean and orderly bedside food storage, safeguard and properly distribute resident-owned personal property, systematically track and investigate missing personal items, and maintain the structural integrity of physical plant walls.

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure that residents were free from abuse and or neglect for three (Resident #114, 156, and #181) of seven residents reviewed. Specifically, (a.) Resident #'s 114 and 181 were involved in a resident-to-resident altercation where Resident #181 pushed Resident #114's wheelchair from behind causing the resident to fall from their wheelchair; (b.) Resident #156 was admitted to the hospital with a Discharge summary dated 11/2025 documenting a compression fracture of the lumbar spine level 1. The hospital recommendation were to follow up with Orthopedics because they had recommended a kyphoplasty for the Lumbar 1 compression fracture and Resident #156 should be referred to neurosurgery for the procedure. There was no documentation of orthopedic, or neurosurgery follow up. [...]

Inspectors wroteBased on record reviews and interviews conducted during the survey, the facility failed to implement a system to consistently and accurately reconcile controlled medications in accordance with professional standards of practice. Specifically, the narcotic count record signature sheet for five of eight units were signed in advanced or incomplete.

Inspectors wroteBased on observations and interviews conducted during a survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) (Resident #'s 26, 79, and 116) of five (5) residents reviewed. Specifically, (a.) for Resident #'s 26 and 79, food was not served at an appetizing temperature during a lunch meal on 5/28/2026 and the fries were too crispy to eat; and (b.) Resident #116 was served burnt stuffed shells during a dinner meal that were not palatable. Additionally, 10 anonymous residents during a resident council meeting stated the food was not good, often cold, and was overcooked or undercooked.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #108) of one (1) resident reviewed for medication administration. Specifically, Resident #108 had an inhaler observed in their room that was not listed in the resident's orders, they reported using the medication, and they were not assessed for their ability to self-administer medication.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were able to exercise the right to self-determination, including making choices regarding daily routines and preferences, for two (Resident #4 and #79) of two residents reviewed for choices. Specifically, (a.) Resident #4 was not permitted to go outside as they preferred; (b.) Resident #79 had not been able to have a shower since they were admitted to the facility.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury, to the State Agency for three (Resident #'s 114, 181, and 191) of three residents reviewed. Specifically, the following incidents were not reported to the New York State Department of Health: (a.) Resident #191 had a fall with a significant injury of unknown origin; (b.) Resident #'s 114 and 181 were involved in a resident-to-resident altercation on 9/08/2025 where Resident #181 pushed Resident #114's wheelchair from behind causing the resident to fall. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were discharged according to professional standards for one (Resident #182) of one resident reviewed. Specifically, the facility refused to accept Resident #182 back to the facility following a brief hospital evaluation.

Inspectors wroteBased on interviews and record review conducted during a survey, the facility failed to ensure that Preadmission Screening and Level II Preadmission Screening and Resident Review's (PASARRs) were completed according to professional standards of practice prior to admission and as needed for two (Resident #'s 19 and 180) of three residents reviewed. Specifically, (a.) Resident #19's Preadmission Screening and Resident Review instrument indicated the resident had serious mental illness, was admitted to the facility for convalescent care, and a new screen was not completed at the end the residents convalescent care stay when the resident remained in the facility, and (b.) Resident #180 was admitted to the facility prior to receiving Level II PASARR recommendations. [...]

Inspectors wroteBased on record review and interviews during the survey, the facility failed to ensure the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for four (Residents #26, 79, 161, and 175) of 43 residents reviewed for comprehensive care plans. Specifically, for (a) Resident #26, the comprehensive care plan did not include care areas that addressed the need for multiple medications including Ropinirole HCl two milligrams for restless leg syndrome, Tizanidine HCl four milligrams for muscle spasms, Kenalog-49 injection suspension 40 milligrams per milliliter for pain, and Lidocaine HCl injection solution one percent 10 milliliters to mix with Kenalog; [...]

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 105 and 110) of three (3) residents reviewed. Specifically, (a.) Resident #105 was bed bound and was not offered to attend activities or provided with activities; [...]

Inspectors wroteBased on observation, record review and interviews conducted during a survey, the facility did not ensure that residents were provided with Quality of Care according to professional standards of practice for two (Residents #65, and #29) of forty-three residents reviewed. Specifically, Resident #65 was prescribed injectable medication for Diabetes Mellitus (body cannot process sugars, leading to high blood sugars) without the diagnosis of Diabetes Mellitus causing the resident to have a significant drop in blood sugar. Resident #29 had bilateral upper extremity dressings that were observed not to be intact for several hours a day after nursing was made aware.

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for two (2) (Resident #10 and #105) of four (4) residents reviewed. Specifically, Resident #105's left heel pressure ulcer showed significant decline. There was no daily documentation of the wound assessment and staff did not notify the provider of the decline. Resident #10 was noted with a Stage Four pressure ulcer with a care planned intervention and physicians order for wound vacuum. The wound vacuum dressing ordered was not in place. No dressing was observed on the wound bed, and no removed dressing was observed in the resident's bed linens or surrounding area.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for four (Cart A 300-hall, Cart B 400-hall, Cart D 700 hall and Cart D 800 hall) out of four medication carts reviewed. Specifically, one stock medication had expired; one bottle of Flonase was uncapped; one loose pill was found in cart; one inhaler had an open date but was never opened; one stock medication had conflicting expiration dates; one Lantus kwik pen had no open date; one Lantus vial had no open date; five inhalers had no open and or expiration dates; one inhaler had no label at all; three narcotic count shifts were signed out prior to actual count reconciliation and change of shift; another narcotic book had multiple missing signatures for shift change. [...]

Inspectors wroteBased on observation, record review and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the central kitchen. Specifically, skim milk cartons were found past expiration dates.

Inspectors wroteBased on observation, record review, and interview conducted during the survey, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #10) of 43 residents reviewed for infection control practices. Specifically, 1.) Certified Nurse Aide # 5 failed to utilize Enhanced Barrier Precautions during resident care, increasing the risk of cross- contamination for a resident with a stage four pressure ulcer. These deficient practices placed the residents at risk for potential infection and compromised care delivery.

Inspectors wroteBased on record review and interview during an abbreviated survey (Case #455653), the facility did not ensure a final accounting of resident funds to the probate jurisdiction (a court that hears matters surrounding a person's death) administering the resident's Estate, within 30 days of the resident's death in accordance with State law for 1 resident (Resident #1) of 3 resident reviewed for transfer of personal funds upon death to the probate jurisdiction administering the resident's Estate. Specifically, Resident #1's date of death was [DATE]. A check dated [DATE] issued by the facility from the Resident Fund Trust Account was paid to the order of New York State Department of Health. This was evidenced by: The Policy and Procedure titled, Resident Funds Accounts (RFA) created 8/2014 and last updated 8/2020 documented upon the death of a resident: a. [...]

Inspectors wroteBased on observation and interview during abbreviated survey (case #NY00329501), the facility did not provide effective maintenance services one (1) of 4 resident units and 3 dining areas. Specifically, furniture in the facility was not in good repair. This is evidenced by: During observations on 01/10/2024 from 10:26 AM through 1:31 PM, resident chairs had worn upholstery in the following areas: Golden Hours Room dining and recreation room: 3 chairs. Mountain View Dining Room: 2 chairs. Evergreen Dining Room: 6 chairs. D Unit nurse station: 2 chairs. During an interview on 05/08/2024 at 2:52 PM, Administrator #1 stated that Director of Maintenance #1 would be directed to remove that worn chairs, and new chairs would be ordered. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure residents who needed respiratory care for 4 (Resident #'s 4, 41, 46, and 73) of 7 residents reviewed for respiratory care were provided such care, consistent with professional standards of practice. Specifically, for Resident #4, the facility did not ensure supplemental oxygen was provided as ordered by the physician on 11/10/2023, 11/13/2023, 11/14/2023, and 11/15/2023 and did not ensure supplemental oxygen tubing was dated and labeled to reflect the tubing was changed as ordered; for Resident #41, the facility did not ensure supplemental oxygen was provided as ordered by the physician on 11/10/2023, 11/13/2023, and 11/14/2023 and the resident's nasal cannula (NC) and humidifier bottle were changed as ordered by the physician on 11/08/2023; [...]

Inspectors wroteBased on record review, observations and interviews during the recertification survey dated 11/9/2023-11/16/2023, the facility did not ensure that each resident received, and the facility provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature for 5 of 5 units. Specifically, on 11/15/2023, the facility did not ensure food served was pleasant tasting and that cold food was served at temperatures less than 41 degrees Fahrenheit (F), and warm food was served at temperatures greater than 135 F. This was evidenced by: Food Council Meeting Minutes dated August 2023 through October 2023 documented the following: - 9/26/2023 - Residents complained that the food was served cold, and trays delivered late. - 10/24/2023 - Residents complained that trays were delivered. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey from 11/9/2023 through 11/16/2023, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences, for one (Resident #4) of one resident reviewed for dialysis. Specifically, for Resident #4, the facility did not ensure nursing consistently completed and reviewed the resident's dialysis communication log between 10/12/2023 through 11/9/2023. This was evidenced by: Resident #4: Resident #4 was admitted to the facility on [DATE] with the diagnoses of end-stage renal disease (ESRD), chronic respiratory failure, and essential hypertension. [...]

Inspectors wroteBased on observation, record review, and interview during a recertification and abbreviated survey (Case #NY00283608) the facility did not ensure that medications for a resident, ordered by the physician were administered by a Licensed Professional Nurse in accordance with regulation for one (Resident #523) of 17 residents reviewed. Specifically, the facility did not ensure medications were provided by a Licensed Professional Nurse, when on 9/19/2021, on the evening shift, a Certified Nursing Aide (CNA) gave medications to Resident #523 after a Registered Nurse (RN) prepared them. This was evidenced by: The facility's policy and procedure for Medication Administration dated 12/2019, documented that only persons licensed or permitted by this State (New York) to prepare, administer, and document the administration of medications may do so. Resident #523: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00291136), the facility did not ensure the resident representative(s) was informed when accidents occurred for 1 (Resident #1) out of 9 residents reviewed. Specifically, the facility did not inform Resident #1's representative after the resident had an unwitnessed fall on 12/25/21 and was sent out to the hospital. This was evidenced by: The Policy and Procedure (P&P) titled, Change in Condition Notification, dated August 2019, read in pertinent part, It was the policy of this facility to monitor residents' for changes in their condition, to respond appropriately to those changes and to notify the physician and responsible party/family member of changes. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, food temperature thermometers are to be calibrated, and food and non-food contact surfaces, floors, and walls are to be kept clean and in good repair. Specifically, automatic dish washing machines were not rinsing at the specified water pressure, food temperature thermometers were not in calibration, and in the main kitchen and unit kitchenettes the floors, walls, and equipment were not clean and/or in good repair. Additionally, the Emergency Food Supply Storage Room floor and walls were not clean, does not have a door, was very dusty and had a heavy musty odor. This is evidenced as follows. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not provide a Facility Assessment that documented a facility wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies during the recertification survey. Specifically, the facility did not ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This is evidenced by: On 07/21/2021, the Facility assessment dated [DATE], documented under the heading Staffing Plan that staffing was modeled to meet the needs of all resident based on their clinical acuity. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not ensure corridors were equipped with firmly secured handrails on each side. Specifically, handrails were not firmly secured and affixed to corridor walls. This is evidenced as follows. During facility observations on 07/20/2021 at 1:50 PM, the handrail on the corridor wall between resident room #'s 169 and #171 was loose when checked. The Director of Maintenance stated in an interview on 07/20/2021 at 4:18 PM, that the loose handrail will be repaired and checked and the other handrails will also be checked. 483.90(i)(3)

Inspectors wroteBased on interviews, and record review during a recertification survey, the facility did not ensure it immediately consulted the resident's physician when there was a significant change in condition for 1 (Resident #52) of 2 residents reviewed for hospitalization. Specifically, for Resident #52, the facility did not ensure that the Medical Doctor (MD) was notified on 7/17/2021 that the resident, who was receiving a blood thinner medication, had been vomiting since the evening of 7/16/2021, and given a medication to prevent vomiting twice with no effect, vomited a large amount of black liquid and continued to vomit until the resident was found in his room, grey in color and gasping for breath. Subsequently, the resident was admitted to the hospital with the diagnosis of gastrointestinal bleed and shock. This is evidenced by: Resident #52: [...]

Inspectors wroteBased on interview and record review during a recertification survey, the facility did not ensure that all alleged violations are thoroughly investigated in response to allegations of abuse, neglect, exploitation, or mistreatment. Specifically, for Resident #83, the facility did not ensure a thorough investigation was completed when the resident reported their watch was missing. This is evidenced by: A facility policy titled Grievances, last revised 9/2020, documented the facility will investigate and resolve resident grievances timely to ensure residents' rights are protected. The Director of Social Work (DSW) is the facility's Grievance Officer (GO) and is responsible for facilitating the complaint/grievance process. All complaint/grievances should be given to the GO/DSW when they are received. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. The resident environment is to remain as free from accident hazards as is possible. Specifically, sharp objects were protruding from door frames in resident areas. This is evidenced as follows. A general inspection of the nursing units on 07/20/2021 01:50 PM revealed two protruding and partially attached screws in each of the door frames in resident room #'s 812, 813, and #903 and the Evergreen Dining Room resident area storeroom door. The Director of Maintenance stated in an interview on 07/20/2021 at 04:40 PM that the facility will be checked for protruding screws. 10 NYCRR 415.12(h)(1)

Inspectors wroteBased on observation, record review and interview during a recertification and abbreviated (Case # NY00278860) survey, the facility did not ensure sufficient nursing staff to provide nursing and related services for 1 (Unit D) of 4 units surveyed. Specifically, the facility did not ensure there was sufficient staffing to ensure residents were fed and cared for in a timely manner on the D unit, Wing 800 on 7/15/2021 and 7/20/2021. This was evidenced by: The Policy & Procedure titled Dining and dated 1/2020 documented, residents who are unable to come to the dining room or who desire to dine in their own room shall be provided with room service. Nursing Services was responsible for the delivery of individual trays including obtaining tray from cart and assisting the resident with tray set-up as necessary. Trays shall be delivered within 15 minutes of cart delivery. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure foods brought to residents is in accordance with adopted regulations. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that they bring to residents. This is evidenced is as follows. The facility policy for foods brought in by visitors was reviewed on 07/16/2021. This policy states that the Dietitian/Nursing will provide family and visitors with education of safe food handling practices. Observations inside the A Unit kitchenette refrigerator on 07/16/2021 at 9:42 AM, revealed food in residential/domestic style containers labeled with the name of Resident #62. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services and that bed and bath linens provided to the residents' were clean and in good condition. Specifically; the facility did not ensure that on 4 of 4 resident units and the service areas, furniture, walls, and floors were clean and/or in good repair. This was evidenced by: This is evidenced as follows. Finding #1 The facility did not ensure that on 4 of 4 resident units and the service areas, furniture, walls, and floors were clean and/or in good repair. Resident Units A, B, C and D and the service areas were spot checked on 07/20/2021 at 11:30 AM and again at 01:50 PM. The vanities in resident room #'s 163, 606, 608, 813, and #909 had chipped paint or missing drawer fronts. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, dumpsters were not maintained in a sanitary condition. This is evidenced as follows. The garbage dumpsters were inspected on 07/15/2021 at 9:59 AM. One of 3 dumpsters was placed on the earthen ground and was soiled with oily black drip marks around the side door. The instructions on the dumpster state Notice, Container Must Be Placed on a Hard Level Surface, Load Uniformly. The Director of Maintenance stated in an interview on 07/15/2021 at 1:31 PM, that the waste disposal vendor will be instructed to place all dumpsters on the blacktop, and the dumpster that needs cleaning will be switched out. 10 NYCRR 415.14(h)