Inspection Report Summary
The most recent inspection on July 3, 2025, found no deficiencies and substantiated that prior issues had been corrected; complaint investigations conducted at that time were unsubstantiated. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, infection control, care planning, environmental sanitation, and staff background checks, with a significant enforcement action in late 2023 involving immediate jeopardy for failure to prevent and address sexual abuse, which was resolved after corrective measures. Complaint investigations over time included several substantiated cases involving abuse, delayed notifications to families, and safety concerns, but many complaints were also unsubstantiated or resolved without deficiencies. The facility had recurring issues with maintaining a safe, clean, and homelike environment, as well as lapses in resident care and safety practices, though these were addressed in follow-up surveys. The trend indicates improvement in recent inspections with correction of cited deficiencies and no new enforcement actions listed in the available reports.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
173% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
94 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Fulton Center for Rehabilitation LLC following a survey completed on July 3, 2025.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
A revisit survey was conducted from July 2, 2025, through July 3, 2025, in conjunction with an investigation of Complaint Intake Number GA00255489.
Complaint Details
Complaint Intake Number GA00255489 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the prior Revisit/Complaint Survey concluded on May 1, 2025, were found to be corrected. The complaint investigation found Complaint number GA00255489 to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Fulton Center Rehab LLC to investigate complaint #GA00255597.
Complaint Details
Complaint #GA00255597 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 96
Deficiencies: 9
Date: May 1, 2025
Visit Reason
Routine inspection of Fulton Center for Rehabilitation LLC to assess compliance with regulatory requirements including environment, resident care, medication administration, and infection control.
Findings
The facility was found deficient in maintaining a clean and safe environment, providing accurate resident assessments and care plans, ensuring proper medication administration and pharmaceutical services, and implementing effective infection prevention and control measures. Multiple residents were affected by issues such as HVAC maintenance, lack of transfer notices, incomplete assessments, inadequate grooming assistance, smoking policy violations, medication errors, and poor infection control practices.
Deficiencies (9)
Facility failed to maintain resident rooms in a clean, comfortable, homelike environment with issues such as dirty HVAC units, cracked drywall, loose door handles, and worn furniture.
Failed to issue written transfer notice and bed hold policy to one resident related to hospital transfer.
Failed to ensure accurate and complete quarterly assessments related to smoking status and safety for two residents.
Failed to develop and implement a comprehensive person-centered care plan for one resident, including psychosocial needs and care plan meetings.
Failed to provide necessary assistance with grooming and personal hygiene for one resident with cognitive and physical limitations.
Failed to ensure smoking materials were maintained by staff and smoking occurred only in designated areas for one resident.
Failed to provide two medications as ordered to one resident during medication administration, with missing medications and lack of monitoring.
Medication error rate exceeded 5 percent with three errors in 26 opportunities for two residents during medication administration.
Failed to ensure proper infection prevention and control practices including hand hygiene, wound care technique, clean environment in laundry, and proper handling of oxygen tubing.
Report Facts
Residents affected: 10
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 11.54
Facility census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered medications to resident R44, failed to perform hand hygiene, and reported missing medications |
| LPN BB | Licensed Practical Nurse | Administered medications to resident R42, failed to monitor medication ingestion |
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Performed wound care without changing gloves between steps |
| Maintenance Director | Maintenance Director | Confirmed HVAC maintenance deficiencies and recent hire |
| Administrator | Administrator | Discussed HVAC cleaning responsibilities and smoking policy enforcement |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in smoking assessments, medication administration, and infection control |
| Social Services Director | Social Services Director | Responsible for care plan meetings and smoking evaluations |
| Licensed Practical Nurse GG | Licensed Practical Nurse | Confirmed smoking assessment frequency and grooming needs |
| Certified Nursing Assistant HH | Certified Nursing Assistant | New staff who had not offered grooming to resident R76 |
| Certified Nursing Assistant DD | Certified Nursing Assistant | New staff who had not offered grooming to resident R76 |
| Infection Preventionist | Infection Preventionist / Staff Development Coordinator | Reported on infection control training and hand hygiene compliance |
| Laundry Aide EE | Laundry Aide | Did not wear PPE when processing soiled laundry |
Inspection Report
Routine
Census: 96
Deficiencies: 9
Date: May 1, 2025
Visit Reason
Routine inspection of Fulton Center for Rehabilitation LLC to assess compliance with regulatory requirements including environment, resident care, medication administration, and infection control.
Findings
The facility was found deficient in maintaining a clean and safe environment, providing accurate resident assessments and care plans, ensuring proper medication administration and pharmaceutical services, maintaining infection control practices, and providing adequate resident care including grooming and smoking safety.
Deficiencies (9)
Failed to maintain resident rooms in a clean, comfortable, homelike environment with issues such as dirty HVAC units, cracked drywall, loose door handles, and worn furniture.
Failed to issue written transfer notice and bed hold policy to one resident transferred to hospital.
Failed to ensure accurate and complete quarterly assessments related to smoking status and safety for two residents.
Failed to develop and implement a comprehensive person-centered care plan for one resident, including lack of documented care plan meetings.
Failed to provide necessary assistance with grooming and personal hygiene for one resident with cognitive impairment and physical limitations.
Failed to ensure smoking materials were maintained by staff and smoking occurred only in designated areas for one resident who smokes.
Failed to provide two ordered medications to one resident during medication administration and failed to document communication and monitoring related to missing medications.
Medication error rate exceeded 5 percent with three errors in 26 opportunities for two residents during medication administration.
Failed to ensure staff followed proper infection control techniques during medication administration, wound care, and resident care; failed to maintain clean laundry environment; and failed to ensure oxygen tubing was kept covered and sanitary.
Report Facts
Residents affected: 10
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 11.54
Facility census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered medications to resident R44, failed to perform hand hygiene, and reported missing medications |
| Maintenance Director | Maintenance Director | Confirmed observations of environmental deficiencies and recent hire |
| Administrator | Facility Administrator | Discussed housekeeping and maintenance roles and recent staffing changes |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in smoking assessments, medication administration, and infection control |
| MDS Coordinator | MDS Coordinator | Interviewed regarding smoking assessment frequency |
| LPN GG | Licensed Practical Nurse | Confirmed smoking assessment frequency and grooming requirements |
| Social Work Director | Social Work Director | Interviewed about smoking evaluations and care plan meetings |
| CNA HH | Certified Nursing Assistant | Interviewed about grooming assistance for resident R76 |
| CNA DD | Certified Nursing Assistant | Interviewed about grooming assistance and concerns about lesion on resident R76 |
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Observed performing wound care without proper hand hygiene |
| Infection Preventionist | Infection Preventionist / Staff Development Coordinator | Discussed infection control expectations and staff training |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 6
Date: May 1, 2025
Visit Reason
A State Licensure survey was conducted at Fulton Center for Rehabilitation LLC from April 29, 2025 through May 1, 2025 to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey revealed multiple deficiencies including failure to provide prescribed medications timely, inadequate infection control practices, incomplete person-centered care planning, unsafe smoking practices, poor environmental sanitation in resident rooms, and lack of required criminal background checks for certain employees.
Deficiencies (6)
Failure to provide two prescribed medications to resident R44 during medication administration.
Failure to follow proper infection control techniques during medication administration, wound care, and resident care; unsanitary laundry room conditions; and improper handling of oxygen tubing.
Failure to develop and implement a comprehensive person-centered care plan and properly assess resident R35's psychosocial needs and preferences.
Failure to ensure smoking materials were maintained by recreation staff and smoking occurred only in designated areas for resident R39.
Failure to maintain resident rooms in a clean, comfortable, homelike environment with issues such as dirty HVAC units, cracked drywall, loose door handles, and worn furniture in 10 of 32 occupied rooms.
Failure to conduct fingerprint criminal background checks for two employees (Director of Nursing and Licensed Practical Nurse) prior to hiring.
Report Facts
Facility census: 96
Residents involved in medication deficiency: 1
Residents involved in care plan deficiency: 1
Residents involved in smoking safety deficiency: 1
Rooms with environmental sanitation deficiencies: 10
Employees without criminal background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered medications to resident R44 and reported missing medications |
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Observed performing wound care without proper hand hygiene |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration policies and infection control expectations; identified lack of criminal background check |
| Infection Preventionist | Infection Preventionist / Staff Development Coordinator | Discussed infection control training and hand hygiene compliance |
| Laundry Aide EE | Laundry Aide | Reported not wearing PPE when processing soiled laundry due to heat and medical condition |
| Social Services Director | Social Services Director (SSD) | Discussed care plan meetings and smoking assessments |
| Maintenance Director | Maintenance Director | Confirmed maintenance deficiencies and recent hiring |
| Administrator | Facility Administrator | Provided information on smoking policy enforcement, maintenance staffing, and employee background checks |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 9
Date: May 1, 2025
Visit Reason
A recertification survey was conducted from April 29, 2025 to May 1, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00253582, GA00253447, GA00253145, GA00253434, and GA00249672 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a clean and safe environment, failure to issue proper transfer notices, incomplete resident assessments, inadequate care planning, failure to provide necessary assistance with grooming, medication administration errors, and lapses in infection control practices.
Deficiencies (9)
Facility failed to maintain resident rooms in a clean, comfortable, homelike environment with issues such as dirty HVAC units, cracked drywall, loose door handles, and worn furniture.
Facility failed to issue a written transfer notice and bed hold policy to a resident transferred to hospital.
Facility failed to ensure accurate and complete quarterly assessments related to smoking status and safety for two residents.
Facility failed to develop and implement a comprehensive person-centered care plan and properly assess one resident.
Facility failed to provide necessary assistance with grooming and personal hygiene for one resident requiring staff support.
Facility failed to ensure smoking materials were maintained with recreation staff and smoking occurred only in designated areas for one resident.
Facility failed to provide two prescribed medications to one resident during medication review and administration.
Facility failed to ensure medication error rate was less than five percent for two residents during medication administration, with an error rate of 11.54 percent.
Facility failed to ensure staff followed proper infection control techniques during medication administration, wound care, and resident care; failed to maintain a clean laundry environment; and failed to ensure oxygen tubing was kept covered and sanitary.
Report Facts
Residents present: 96
Rooms with deficiencies: 10
Medication error rate: 11.54
Smoking assessments completed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered medications to resident R44, failed to perform hand hygiene, and reported missing medications |
| LPN BB | Licensed Practical Nurse | Administered medications to resident R42 and failed to monitor medication ingestion |
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Performed wound care without changing gloves between steps |
| Maintenance Director | Maintenance Director | Confirmed HVAC and maintenance deficiencies and recent hire |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in transfer notices, smoking assessments, medication administration, and infection control |
| Social Services Director | Social Services Director | Confirmed lack of care plan meetings and incomplete smoking assessments |
| Infection Preventionist | Infection Preventionist / Staff Development Coordinator | Confirmed lapses in hand hygiene and infection control practices |
Inspection Report
Life Safety
Census: 95
Capacity: 109
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found to be in substantial compliance.
Report Facts
Certified beds: 109
Census: 95
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate four complaint numbers: GA00247286, GA00246884, GA00245390, and GA00245146.
Complaint Details
Complaints GA00247286, GA00246884, and GA00245146 were unsubstantiated. Complaint GA00245390 was substantiated.
Findings
Three complaints were unsubstantiated, and one complaint (GA00245390) was substantiated. No deficiencies were cited during the survey.
Report Facts
Complaints investigated: 4
Facility census: 99
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Fulton Center for Rehabilitation LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers from March 5, 2024 through March 12, 2024.
Complaint Details
Complaints GA00244323 and GA00244495 were substantiated with no regulatory violations cited. Complaints GA00243722 and GA00244271 were unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and implemented CDC recommended practices for COVID-19. Two complaints were substantiated with no regulatory violations cited, and two complaints were unsubstantiated with no violations cited.
Report Facts
Complaint investigations: 4
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00241362 and GA00242812.
Complaint Details
Investigation of complaints GA00241362 and GA00242812 with no deficiencies cited.
Findings
No deficiencies were cited related to the complaints GA00241362 and GA00242812.
Inspection Report
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Fulton Center for Rehabilitation LLC following a survey completed on December 15, 2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/19/2023 Recertification survey, State Licensure survey, and 11/2/2023 Complaint Investigation survey.
Findings
All deficiencies cited in the prior surveys were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/19/2023 Recertification survey, State Licensure survey, and 11/2/2023 Complaint Investigation survey.
Findings
All deficiencies cited in the prior surveys were found to be corrected during this revisit survey.
Report Facts
Census: 93
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/19/2023 Recertification survey and 11/2/2023 Complaint Investigation survey.
Findings
All deficiencies cited in the previous Recertification and Complaint Investigation surveys were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 6
Date: Nov 2, 2023
Visit Reason
The inspection was conducted due to allegations of sexual abuse and physical abuse involving residents R15, R16, R13, and R20, as well as concerns about timely reporting and investigation of abuse incidents.
Complaint Details
The complaint investigation was triggered by allegations of sexual abuse involving resident R15 by resident R16, and physical abuse involving resident R13 by resident R20. The investigation found failures in timely notification, reporting, investigation, and prevention of abuse.
Findings
The facility failed to timely notify the family of a sexual abuse allegation involving resident R15, failed to ensure residents were free from abuse, failed to timely report an incident of sexual abuse, and failed to thoroughly investigate the sexual abuse allegation. The facility also failed to provide ordered wound care for resident R9 and failed to effectively oversee an abuse prevention program.
Deficiencies (6)
Failed to notify the resident's representative timely of an allegation of sexual abuse for resident R15.
Failed to ensure residents were free from abuse, including sexual abuse of R15 by R16 and physical abuse of R13 by R20.
Failed to timely report an incident of sexual abuse for resident R15.
Failed to thoroughly investigate an incident of sexual abuse for resident R15.
Failed to provide daily wound care treatments as ordered for resident R9, resulting in actual harm.
Failed to effectively oversee an abuse prevention program to promote and maintain an abuse free environment.
Report Facts
Facility census: 95
Wound measurements: 7
Wound measurements: 7.5
Wound measurements: 0.2
Wound measurements: 11
Wound measurements: 11
Wound measurements: 5
BIMS score: 0
BIMS score: 13
BIMS score: 10
BIMS score: 6
Medication dosage: 300
Medication dosage: 50
Staff education completion rate: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant AA | CNA | Observed and reported sexual abuse incident involving R16 and R15 |
| Certified Nursing Assistant BB | CNA | Observed and reported sexual abuse incident involving R16 and R15 |
| Director of Nursing | DON | Interviewed regarding notification and investigation of abuse allegations |
| Administrator | Administrator | Unaware of abuse allegations initially; later reported and involved in investigation and corrective actions |
| Nurse Practitioner | NP | Documented progress notes on R16's inappropriate sexual behavior |
| Psychiatric Nurse Practitioner | PNP | Documented progress notes on R16's inappropriate sexual behavior |
| Physician | Physician | Documented progress notes on R16's inappropriate sexual behavior |
| Staff Development Coordinator | SDC | Responsible for staff training on abuse; interviewed about awareness of abuse allegations |
| Social Services Director | SSD | Interviewed and involved in resident assessments and abuse investigations |
| Wound Care Nurse | Wound Care Nurse | Provided wound care progress notes and interviews regarding R9's wound care |
Inspection Report
Original Licensing
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
A Licensure Survey was initiated on 10/17/2023 and concluded on 11/2/2023 to assess compliance with licensure requirements for the facility.
Complaint Details
The visit was complaint-related due to an allegation of sexual abuse involving resident R15. The facility was found to have delayed notification to the resident's family, with notification occurring on 10/31/2023 for an incident reported on 8/31/2023.
Findings
The facility failed to notify the resident's representative timely of an allegation of sexual abuse involving resident R15. Interviews and record reviews confirmed the delay in notification despite multiple reports of the incident.
Deficiencies (1)
Failure to notify the resident's representative timely of an allegation of sexual abuse for one of 27 sampled residents (R15).
Report Facts
Sample residents: 27
Dates of incident and notification: Incident reported on 8/31/2023; family notified on 10/31/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant AA | Certified Nursing Assistant | Reported observation of alleged sexual abuse incident involving residents R15 and R16 |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Reported observation of alleged sexual abuse incident involving residents R15 and R16 |
| Director of Nursing | Director of Nursing | Interviewed regarding notification of resident's family about the allegation of sexual abuse |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 6
Date: Nov 2, 2023
Visit Reason
An abbreviated/partial extended survey was conducted from 10/17/2023 to 11/2/2023 investigating multiple complaints, some of which were substantiated, including allegations of sexual abuse and neglect.
Complaint Details
The investigation was initiated due to multiple complaints alleging sexual abuse and neglect. Several complaints were substantiated. Immediate Jeopardy was identified on 10/26/2023 related to failure to prevent sexual abuse and failure to report and investigate allegations. The Immediate Jeopardy was removed on 10/31/2023 after corrective actions were implemented.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with actual harm identified related to failure to prevent and address sexual abuse, failure to notify family timely, failure to investigate abuse allegations, and failure to provide ordered wound care. Immediate Jeopardy was identified and removed after corrective actions.
Deficiencies (6)
Failure to maintain an environment free from sexual abuse for one resident (R15) by another resident (R16).
Failure to timely notify resident representative of an allegation of sexual abuse for one resident (R15).
Failure to report an incident of alleged sexual abuse for one resident (R15).
Failure to thoroughly investigate an incident of sexual abuse for one resident (R15).
Failure to provide daily wound care treatments as ordered for one resident (R9) with a Stage 3 facility-acquired pressure ulcer.
Failure of facility administration to effectively oversee an abuse prevention program to maintain an abuse-free environment.
Report Facts
Resident census: 95
Pressure ulcer size: 7
Pressure ulcer size: 7.5
Pressure ulcer size: 0.2
Medication dosage: 300
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed and reported sexual abuse incident involving R16 and R15. |
| CNA BB | Certified Nursing Assistant | Observed sexual abuse incident involving R16 and R15 and reported to nurse. |
| Administrator | Facility Administrator and Abuse Coordinator, was unaware of sexual abuse allegations until surveyor notification. | |
| Director of Nursing | DON | Involved in investigation and oversight of abuse allegations and wound care issues. |
| Nurse Practitioner | NP | Documented and treated resident R16 for inappropriate sexual behavior. |
| Physician | Saw resident R16 for inappropriate sexual behavior. | |
| Psychiatric Nurse Practitioner | PNP | Saw resident R16 for inappropriate sexual behavior and prescribed medication. |
| Wound Care Nurse | Provided wound care treatments and documentation for resident R9. | |
| Regional Director of Operations | RDO | Involved in re-education and oversight of abuse prevention and investigation. |
Inspection Report
Life Safety
Census: 95
Capacity: 109
Deficiencies: 2
Date: Oct 23, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including missing electrical panel circuit covers in two locations and failure to maintain critical identification signage in the oxygen storage area.
Deficiencies (2)
Electrical panel circuit covers were missing in the boiler room and laundry, exposing staff to electrical shock hazards.
Oxygen storage area lacked posted 'Full' and 'Empty' signage to designate bottle status.
Report Facts
Smoke Compartments affected: 1
Certified beds: 109
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of missing electrical panel covers and lack of oxygen storage signage during facility tour |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
A State Licensure survey was conducted at Fulton Center for Rehabilitation from October 17, 2023 through October 19, 2023 to assess compliance with state health and safety regulations.
Findings
The survey revealed deficiencies including failure to follow proper hand hygiene practices during tracheostomy care for one resident, and failure to maintain a working call light system for three residents, potentially impacting timely staff response.
Deficiencies (2)
Failure to provide hand hygiene practices during tracheostomy care for one resident, increasing risk of infection.
Failure to provide a working call light system that relays calls directly to staff for three residents, risking delayed response to resident needs.
Report Facts
Residents with non-functioning call lights: 3
Resident reviewed for trach care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse | Performed tracheostomy care on Resident R243 with deficient hand hygiene practices. |
| FF | Communications Company Employee | Was at the facility to replace the call light system in room 201. |
| Director of Nursing | Interviewed regarding call light system issues. | |
| Regional Supervisor | Interviewed and confirmed call light system issues. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 17, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations related to maintaining a safe, clean, and homelike environment, infection prevention and control, and ensuring working call systems for residents.
Findings
The facility was found to have multiple deficiencies including disrepair in nine resident rooms and the therapy room, failure to provide proper hand hygiene during tracheostomy care for one resident, and non-functioning call light systems for three residents. The facility acknowledged ongoing repairs and lack of maintenance personnel.
Deficiencies (3)
Facility failed to maintain a safe, clean, homelike environment in nine resident rooms and the therapy room due to disrepair including broken furniture, damaged walls, ceilings needing repair, and plumbing issues.
Failure to provide proper hand hygiene practices during tracheostomy care for one resident, increasing risk of infection.
Failure to provide a working call system in residents' bathrooms and bathing areas for three residents, potentially delaying response to resident needs.
Report Facts
Resident rooms in disrepair: 9
Residents affected by call light deficiency: 3
Residents affected by tracheostomy care deficiency: 1
Resident rooms total: 43
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Performed tracheostomy care on resident R243 with deficient hand hygiene practices |
| AA | Regional Property Manager | Interviewed regarding facility maintenance issues and bed disrepair |
| FF | Communications Company Employee | Observed replacing call light system in resident room |
| EE | Regional Supervisor | Confirmed call light system deficiencies with Director of Nursing |
| DON | Director of Nursing | Confirmed call light system deficiencies and discussed temporary measures |
Inspection Report
Routine
Census: 95
Deficiencies: 3
Date: Oct 17, 2023
Visit Reason
A standard survey was conducted at Fulton Center for Rehabilitation from October 17, 2023, through October 19, 2023, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean environment conditions in multiple resident rooms and therapy room, failure to follow proper infection prevention practices during tracheostomy care, and a non-functioning resident call light system affecting multiple residents.
Deficiencies (3)
Facility failed to maintain a safe, clean, home-like environment in nine resident rooms and the therapy room due to disrepair including broken beds, patched ceilings, leaking sinks, damaged walls, missing cabinet doors, and hanging exit signs.
Failed to provide proper hand hygiene during tracheostomy care for one resident, increasing risk of infection.
Resident call light system was not functioning properly for three residents, potentially delaying staff response to resident needs.
Report Facts
Resident census: 95
Resident rooms inspected: 43
Resident rooms with disrepair: 9
Residents affected by call light deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Performed tracheostomy care with deficient hand hygiene practices |
| Administrator | Interviewed regarding facility maintenance and repair issues | |
| Regional Property Manager (AA) | Interviewed regarding facility maintenance and repair issues | |
| Director of Nursing (DON) | Interviewed regarding call light system deficiencies | |
| Regional Supervisor (EE) | Interviewed regarding call light system deficiencies | |
| Employee from communications company (FF) | Observed replacing call light system in room 201 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
A revisit survey was conducted at Fulton Center for Rehabilitation from November 2, 2022 through November 4, 2022 to verify correction of deficiencies cited in the August 26, 2022 survey.
Findings
All deficiencies cited as a result of the August 26, 2022 survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
A revisit survey was conducted at Fulton Center for Rehabilitation from November 2, 2022 through November 4, 2022 to verify correction of deficiencies cited in the August 26, 2022 survey.
Findings
All deficiencies cited as a result of the August 26, 2022 survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from November 2 to November 4, 2022, to investigate Complaint Numbers GA00227592 and GA00228899 and to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00227592 was unsubstantiated; disposition of Complaint GA00228899 is pending.
Findings
Complaint GA00227592 was found to be unsubstantiated, while the disposition of Complaint GA00228899 is pending due to a request for additional information.
Report Facts
Resident Census: 92
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 26, 2022
Visit Reason
The inspection was conducted based on complaints and observations related to failure to notify family of changes in resident condition, unsafe and unclean environment, incomplete care plans, inappropriate medication administration, and inadequate catheter care.
Complaint Details
The complaint investigation revealed failures in notification of family about resident condition changes, environmental safety and cleanliness, care planning, medication administration, and catheter care.
Findings
The facility was found deficient in promptly notifying family members of resident condition changes, maintaining a safe and clean environment, developing complete care plans for catheter and oxygen therapy, providing appropriate nursing care related to diarrhea and medication administration, and ensuring proper catheter care and timely medical notification.
Deficiencies (5)
Failed to promptly notify family/representative of a change in condition for two residents.
Failed to maintain a safe, clean, homelike environment on two halls with multiple maintenance issues.
Failed to develop a complete care plan related to catheter maintenance and oxygen therapy for one resident.
Failed to provide appropriate nursing care ensuring medical needs were met for one resident with diarrhea receiving IV fluids while still receiving constipation medications.
Failed to provide appropriate catheter care including securing catheter tubing, timely medical notification, and appropriate indication for ongoing catheter use for one resident.
Report Facts
Residents sampled: 40
Dates of observations/interviews: Aug 23, 2022
Dates of observations/interviews: Aug 25, 2022
Medication administration dates: 4
IV fluid start date: Aug 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Administered medications and flushed catheter for resident R#70 and R#38; involved in care and observations related to diarrhea and catheter care |
| CNA CC | Certified Nursing Assistant | Provided incontinent care and reported on resident R#70's diarrhea status |
| Director of Nursing | Director of Nursing | Interviewed regarding notification expectations, care plan deficiencies, and catheter care policies |
| MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Interviewed regarding care plan deficiencies for resident R#84 |
| Maintenance Director | Maintenance Director | Interviewed regarding facility maintenance and environmental deficiencies |
| Administrator | Administrator | Interviewed regarding awareness and plans for repairing facility damages |
Inspection Report
Renewal
Deficiencies: 4
Date: Aug 26, 2022
Visit Reason
A Licensure Survey was conducted from 8/23/22 through 8/26/22 to assess compliance with licensure requirements for Fulton Center for Rehabilitation LLC.
Findings
The facility was found deficient in promptly notifying residents' responsible parties of significant changes in condition for two residents, providing appropriate nursing care related to medication administration and catheter care for two residents, and maintaining a safe, clean, and homelike environment due to multiple maintenance issues including damaged walls, ceiling tiles, and blinds.
Deficiencies (4)
Failure to promptly notify family/representative of change in condition for two residents (#337 and #386).
Failure to provide appropriate nursing care for resident #70, including continued administration of constipation medications despite diarrhea and dehydration.
Failure to ensure appropriate catheter care for resident #38, including securing catheter tubing and timely notification of medical provider regarding complications.
Failure to maintain a safe, clean, homelike environment on two halls with multiple issues such as missing drywall, sagging ceiling tiles, peeling walls, damaged door frames, missing floor tiles, torn blinds, and black discoloration due to air conditioning leaks.
Report Facts
Sample size: 40
Medication administration dates: 4
IV fluid start date: Aug 19, 2022
Catheter order start date: Aug 4, 2022
Observation dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Administered medication and flushed catheter for residents #70 and #38; interviewed during survey |
| CNA CC | Certified Nursing Assistant | Provided incontinent care and interviewed regarding resident #70's diarrhea |
| Director of Nursing | Director of Nursing | Interviewed regarding notification expectations and facility policies |
| Vice President of Property | Vice President of Property | Interviewed regarding facility maintenance and environmental conditions |
| Administrator | Administrator | Interviewed regarding awareness and plans for facility repairs |
Inspection Report
Routine
Census: 96
Deficiencies: 5
Date: Aug 26, 2022
Visit Reason
A standard survey was conducted from August 23 through August 26, 2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, revealing noncompliance with regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to promptly notify family of changes in condition, unsafe and unclean environment with maintenance issues, failure to develop comprehensive care plans for catheter and oxygen therapy, failure to provide appropriate nursing care related to diarrhea and medication administration, and failure to properly manage indwelling urinary catheter care and maintenance.
Deficiencies (5)
Failure to promptly notify family/representative of change in condition for two residents.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple maintenance issues observed on two halls.
Failure to develop and implement a comprehensive care plan related to catheter maintenance and oxygen therapy for one resident.
Failure to ensure nursing care met medical needs for one resident with diarrhea receiving contraindicated medications.
Failure to ensure appropriate indication, securement, and timely medical notification for indwelling urinary catheter care for one resident.
Report Facts
Resident census: 96
Sample size: 40
Medication administration dates: 4
IV fluid order duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding notification expectations and care plan deficiencies | |
| RN BB | Registered Nurse | Administered medication and flushed catheter without notifying provider |
| Certified Nursing Assistant CC | Interviewed regarding resident diarrhea status | |
| Vice President of Property | Interviewed regarding facility maintenance and repair expectations | |
| Administrator | Interviewed regarding awareness and plans for facility repairs | |
| MDS/Care Plan Coordinator | Interviewed regarding care plan deficiencies |
Inspection Report
Life Safety
Census: 93
Capacity: 109
Deficiencies: 5
Date: Aug 25, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to perform required smoke detector sensitivity testing, missing sprinkler escutcheon plate, corridor doors not properly latching to resist smoke spread, lack of electrical panel identification, and an out-of-date annual load test for the emergency generator.
Deficiencies (5)
Failed to have required smoke detection sensitivity testing done; last test was November 2019.
Missing sprinkler escutcheon plate in corridor near room #221.
Several resident room doors to corridor (rooms 201, 203, 204, 209) would close but did not latch to resist smoke spread.
Electrical panel in boiler room had no identification information for circuit shut off.
Generator was out of date for its annual load test.
Report Facts
Census: 93
Total Capacity: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
A revisit survey was conducted on 9/15/21 through 9/16/21 to verify correction of deficiencies cited during the 7/2/21 Standard Survey.
Findings
All deficiencies cited as a result of the 7/2/21 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
A revisit survey was conducted on 9/15/21 through 9/16/21 to verify correction of deficiencies cited in the 7/2/21 Standard Survey.
Findings
All deficiencies cited as a result of the 7/2/21 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Renewal
Census: 39
Capacity: 40
Deficiencies: 4
Date: Jul 2, 2021
Visit Reason
A Licensure Survey was conducted from 6/29/2021 through 7/2/2021 to assess compliance with licensure requirements.
Findings
The facility was found deficient in multiple areas including failure to use PPE during meal service for a resident on Transmission-Based Precautions, failure to develop and implement care plans for residents related to diabetes and catheter care, inadequate environmental sanitation with soiled privacy curtains and improperly stored supplies, and failure to provide a resident-centered activities program for one resident.
Deficiencies (4)
Staff failed to use Personal Protective Equipment (PPE) during meal service for one resident on Transmission-Based Precautions.
Failure to develop/implement care plans for two residents related to diabetes and catheter care.
Privacy curtain soiled and bed pans, catheter supplies, and personal hygiene supplies were unclean, unlabeled, and improperly stored in multiple rooms.
Failure to implement a resident-centered activities program for one resident.
Report Facts
Residents sampled: 39
Total rooms: 40
Days without documented activities: 182
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in PPE non-compliance during meal service and environmental sanitation interviews. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding infection control training, care plan expectations, and environmental sanitation responsibilities. |
| MDS Coordinator | MDS Coordinator | Discussed care plan updates and responsibilities. |
| Administrator | Administrator | Provided expectations for care plans and activity documentation. |
| LPN EE | Licensed Practical Nurse | Confirmed observations of soiled and unlabeled supplies. |
| LPN CC | Licensed Practical Nurse | Confirmed soiled privacy curtain and unlabeled catheter collection container. |
| Director of Housekeeping | Director of Housekeeping | Discussed housekeeping responsibilities and cleaning schedules. |
| Director of Activities | Director of Activities | Discussed activity program requirements and documentation. |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 5
Date: Jul 2, 2021
Visit Reason
A standard survey was conducted from June 29, 2021 through July 2, 2021, including investigation of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
The inspection included investigation of complaint intake numbers GA00212458, GA00212494, GA00212528, GA00213025, GA00213249, and GA00213571.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including accuracy of assessments, development and implementation of comprehensive care plans, provision of resident-centered activities, accident hazard supervision, and infection prevention and control. Specific deficiencies included inaccurate smoking assessments, incomplete care plans for diabetes and catheter care, failure to provide individualized activities, medication administration supervision lapses, and infection control breaches such as improper PPE use and unsanitary conditions in resident rooms.
Deficiencies (5)
Failed to ensure accurate comprehensive assessment for one resident related to smoking.
Failed to develop and implement comprehensive care plans for two residents related to diabetes and catheter care.
Failed to provide a resident-centered activities program for one resident.
Failed to ensure resident environment free of accident hazards and adequate supervision during medication administration for one resident.
Failed to maintain infection prevention and control program including PPE use, cleanliness of privacy curtains, and proper storage and labeling of bedpans and catheter supplies.
Report Facts
Resident census: 97
Sampled residents: 39
Days with no documented activities: 182
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Activities | Confirmed smoking assessments and activity program expectations | |
| Director of Nursing (DON) | Confirmed care plan expectations, medication supervision, and infection control policies | |
| MDS Coordinator | Discussed care plan updates and responsibilities | |
| RN EE | Registered Nurse | Observed leaving medications unattended at resident bedside |
| DNP HH | Doctor of Nursing Practice | Stated expectations for medication administration supervision |
| CNA AA | Certified Nursing Assistant | Observed not wearing PPE during meal service and discussed labeling and cleaning of bedpans and urinals |
| LPN EE | Licensed Practical Nurse | Confirmed unlabeled and soiled supplies in resident bathrooms |
| LPN CC | Licensed Practical Nurse | Confirmed soiled privacy curtain and unlabeled catheter collection container |
| Director of Housekeeping | Discussed curtain cleaning routines and responsibilities | |
| Administrator | Acknowledged issues with cleanliness and staff responsibilities |
Inspection Report
Life Safety
Census: 94
Capacity: 109
Deficiencies: 4
Date: Jun 30, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, with deficiencies noted in sprinkler system maintenance, corridor door smoke resistance, electrical safety, and gas cylinder storage. These deficiencies affected one of three smoke compartments.
Deficiencies (4)
Failure to maintain sprinkler system at highest readiness; loaded sprinkler heads found in Kitchen (3) and Laundry (2).
Resident room doors would not close to latch, compromising smoke resistance; affected rooms include 110, 111, 112, 114, 200, 203, 204, 210, and 218.
Multiple-outlet power supply located on the floor in the office hallway, posing risk of physical shock.
Oxygen cylinders stored less than 5 feet from combustibles in an office, failing to maintain required safety spacing.
Report Facts
Census: 94
Total Capacity: 109
Number of smoke compartments affected: 1
Number of loaded sprinkler heads in Kitchen: 3
Number of loaded sprinkler heads in Laundry: 2
Number of resident rooms with doors not latching: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 16, 2021
Visit Reason
This document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the visible content.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Feb 16, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the December 4, 2020 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on December 4, 2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the December 4, 2020 Complaint Survey were found to be corrected.
Report Facts
Total census: 97
Inspection Report
Abbreviated Survey
Census: 105
Deficiencies: 0
Date: Feb 12, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00211805 and GA00210847, along with a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints GA00211805 and GA00210847 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated, and the facility was found to be in compliance with infection control regulations related to COVID-19 and emergency preparedness.
Report Facts
Complaint numbers investigated: 2
Inspection Report
Routine
Census: 102
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Total census: 102
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 4, 2020
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and a Complaint survey.
Findings
No deficiencies were identified during the COVID-19 Focused Infection Control Survey or the Complaint survey.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: Dec 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with multiple complaint investigations related to alleged abuse and failure to notify family of a resident's hospitalization.
Complaint Details
Multiple complaint intake numbers were investigated, with some substantiated with deficiencies related to abuse and failure to notify family. Actual harm was identified when Resident #7 was physically abused by an LPN and the incident was not reported timely.
Findings
The facility was found to be in compliance with infection control regulations but had deficiencies related to failure to notify a resident's family of hospitalization and failure to prevent and report physical abuse of a resident by a staff member. Resident #7 was physically abused by an LPN who hit her with a coat hanger, resulting in multiple bruises. The abuse was not reported timely, and previous incidents were not reported or addressed. Resident #8's family was not notified timely of the resident's hospital transfer.
Deficiencies (3)
Failure to notify family of Resident #8's change in condition and hospital transfer in a timely manner.
Failure to ensure Resident #7 was free from physical abuse; LPN DD was observed hitting Resident #7 with a coat hanger causing multiple bruises.
Failure to report allegations of abuse promptly to the Administrator and State Survey Agency for Resident #7.
Report Facts
Total census: 92
Dates of incident: 2020-06-01 to 2020-06-03
Date of survey completion: 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Named as the staff member who physically abused Resident #7 by hitting her with a coat hanger. |
| CNA EE | Certified Nursing Assistant | Witnessed the abuse of Resident #7 and reported the incident after a delay due to fear of retribution. |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to notify family of Resident #8's hospitalization. |
| Nurse Practitioner NN | Nurse Practitioner | Provided clinical notes regarding Resident #7's bruising and condition. |
Inspection Report
Routine
Census: 97
Deficiencies: 0
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2020
Visit Reason
An unannounced complaint investigation was conducted for complaint GA 00202458.
Complaint Details
Complaint GA 00202458 was substantiated with no deficiencies cited.
Findings
The complaint was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00202044, GA00201418, GA00202082, and GA00202110 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00202110 was substantiated with no deficiency cited. Other complaints were investigated but no deficiencies were cited.
Findings
Complaint GA00202110 was substantiated with no deficiency cited. The survey concluded with no deficiencies noted in relation to the complaints investigated.
Report Facts
Resident Census: 101
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 0
Date: Jan 14, 2020
Visit Reason
A revisit survey was conducted from 1/13/20 to 1/14/20 to verify correction of deficiencies cited in the 11/26/19 Abbreviated/Partial Extended Survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 26, 2019
Visit Reason
The inspection was conducted following a complaint related to a resident being dropped from a Hoyer Lift during transfer, resulting in injury and concerns about the facility's adherence to care plan interventions and safe transfer policies.
Complaint Details
The complaint investigation was substantiated by findings that a resident was dropped from a Hoyer Lift sling during transfer by a CNA who did not follow policy. The resident reported pain and was evaluated with X-rays showing no fractures. The CNA was suspended. No fall assessment was conducted after the incident.
Findings
The facility failed to implement care plan interventions for the safe use of a Hoyer Lift during transfer for a resident with multiple impairments. The resident was dropped from the sling during transfer by a CNA who did not follow facility policy, resulting in injury and suspension of the CNA. The facility did not conduct a fall assessment after the incident.
Deficiencies (1)
Failure to implement care plan interventions for safe use of a Hoyer Lift during transfer for resident #1.
Report Facts
Date of Fall Incident: Jul 19, 2019
Date of X-rays: Jul 20, 2019
BIMS Score: 12
BIMS Score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA HH | Certified Nursing Assistant | Named in finding for improper transfer resulting in resident being dropped from Hoyer Lift sling |
| Director of Nursing | Interviewed regarding fall incident and facility response |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Nov 26, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00200059, which was substantiated with deficiencies related to resident care and safety.
Complaint Details
Complaint GA00200059 was substantiated with deficiencies related to failure in safe transfer practices and supervision, resulting in a resident fall during Hoyer Lift transfer.
Findings
The facility failed to implement the care plan interventions for the safe use of a Hoyer Lift during transfer for one resident, resulting in a fall incident. The facility also failed to ensure adequate supervision and safety measures during transfers, including improper use of wheelchairs during lift transfers. Staff education and corrective actions were implemented post-incident.
Deficiencies (2)
Failed to implement care plan interventions for safe use of Hoyer Lift during transfer for resident #1.
Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistance devices to prevent accidents during transfers.
Report Facts
Resident census: 105
Date of fall incident: Jul 19, 2019
BIMS score: 12
BIMS score: 10
Number of Hoyer Lifts: 2
Number of Sit to Stand lifts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA HH | Certified Nursing Assistant | Named in fall incident for improper transfer resulting in resident dropped from sling; suspended and educated |
| CNA AA | Certified Nursing Assistant | Observed performing Hoyer Lift transfer; did not attend in-service on proper Hoyer Lift use |
| CNA BB | Certified Nursing Assistant | Observed performing Hoyer Lift transfer; attended in-service on proper Hoyer Lift use |
| Director of Nursing | Director of Nursing | Provided interview confirming fall incident details and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing / Nurse Educator | Provided interview on staff education and facility equipment |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 1
Date: Nov 25, 2019
Visit Reason
The inspection was conducted due to complaints and observations of live roaches and pest infestations within the facility.
Complaint Details
The complaint investigation was substantiated by multiple resident interviews and observations confirming live roach sightings. The facility had a plan of correction but had not fully resolved the pest issue by the time of the survey.
Findings
The facility was found to have ongoing issues with live roaches in multiple resident rooms and common areas despite pest control efforts. Interviews with residents and staff confirmed sightings of live roaches. The facility had changed pest control companies recently and implemented a plan of correction involving environmental rounds and audits, but pest issues persisted.
Deficiencies (1)
Failure to maintain the premises free from debris and pests, with live roaches observed in resident rooms and common areas.
Report Facts
Resident rooms: 44
Rooms audited: 18
Rooms audited: 9
Rooms audited: 3
Rooms audited: 6
Rooms audited: 4
Rooms audited: 4
Rooms audited: 1
Rooms audited: 8
Rooms audited: 5
Rooms audited: 5
BIMS score: 10
BIMS score: 13
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding pest control efforts and environmental rounds. | |
| Administrator | Interviewed regarding pest control company changes, pest control plans, and post survey telephone interviews. | |
| Housekeeping Supervisor | Responsible for deep cleaning resident rooms as part of pest control efforts. | |
| New pest control service technician | Interviewed about pest control chemical rotation and treatment plans. |
Inspection Report
Routine
Capacity: 44
Deficiencies: 2
Date: Nov 25, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with environmental sanitation and housekeeping standards, specifically focusing on pest control related to roaches in resident rooms and common areas.
Findings
The facility failed to maintain an effective pest control program, with live roaches observed in multiple resident rooms and common areas. The facility did not fully follow its Plan of Correction for pest control, with audits showing persistent pest presence in 20 percent of rooms and missed environmental rounds.
Deficiencies (2)
Failed to maintain an effective pest control program related to roaches in resident rooms and common areas.
Failed to follow the Plan of Correction for pest control for 44 resident rooms.
Report Facts
Resident rooms: 44
Rooms with pest findings: 20
Number of roaches observed: 7
Number of roaches observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding pest control schedule and facility rounds. | |
| Housekeeping Supervisor | Interviewed about housekeeping duties and deep cleaning schedules. | |
| Administrator | Interviewed about pest control efforts and Plan of Correction. | |
| New pest control service technician | Interviewed about pest control chemical rotation and treatment plan. |
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 1
Date: Nov 25, 2019
Visit Reason
A revisit survey was conducted at Fulton Center for Rehabilitation on November 25, 2019 to the Complaint survey of 9/19/19 to determine if the facility was in substantial compliance with Medicare/Medicaid regulations.
Complaint Details
This revisit survey was conducted as a follow-up to a complaint survey dated 9/19/19. The revisit revealed the facility was not in substantial compliance related to the complaint survey.
Findings
The facility failed to maintain an effective pest control program as evidenced by live roaches observed in multiple resident rooms and common areas, resident interviews confirming ongoing pest sightings, and incomplete adherence to the facility's Plan of Correction for pest control in 44 resident rooms.
Deficiencies (1)
Failure to maintain an effective pest control program resulting in live pests observed in multiple resident rooms and common areas.
Report Facts
Resident census: 105
Resident rooms with pest control Plan of Correction issues: 44
Rooms audited for pest control: 18
Rooms audited for pest control: 9
Rooms audited for pest control: 3
Rooms audited for pest control: 6
Rooms audited for pest control: 4
Rooms audited for pest control: 4
Rooms audited for pest control: 1
Rooms audited for pest control: 8
Rooms audited for pest control: 5
Rooms audited for pest control: 5
BIMS score: 10
BIMS score: 13
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding pest control program and facility rounds | |
| Administrator | Interviewed regarding pest control efforts and Plan of Correction | |
| Housekeeping Supervisor | Responsible for deep cleaning resident rooms as part of pest control efforts | |
| New pest control service technician | Interviewed regarding pest control chemical rotation and treatment plan |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Date: Sep 19, 2019
Visit Reason
The inspection was conducted due to complaints from residents about roaches and other pests in the facility, as well as ongoing pest control issues documented in grievance logs and pest control service records.
Complaint Details
The visit was complaint-related due to resident complaints of roaches crawling in rooms, beds, and common areas. The complaints were substantiated by interviews, observations, and pest control records. Grievance logs showed multiple complaints over the past 6 months.
Findings
The facility failed to adequately follow pest control recommendations, resulting in roach infestations affecting at least 4 residents. Observations and interviews confirmed the presence of roaches in resident rooms, hallways, and the kitchen, with ongoing issues related to clutter, debris, and structural deficiencies that provide pest harborage.
Deficiencies (1)
Facility failed to follow pest control recommendations to reduce roaches and other pests, affecting 4 residents.
Report Facts
Census: 102
Residents affected: 4
Grievance complaints: 4
Pest control inspections: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding pest control technician fogging the kitchen | |
| Administrator | Interviewed about awareness of roach problem and pest control contract | |
| Resident Council President | Interviewed about resident complaints of roaches |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 11, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00194856 and GA00195231 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00194856 and GA00195231; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 16, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00193189, GA00193897, and GA00193989.
Complaint Details
Complaint number GA00193189 was substantiated with no deficiencies. Complaint number GA00193897 was partially substantiated with no deficiencies. Complaint number GA00193989 was unsubstantiated.
Findings
Complaint number GA00193189 was substantiated with no deficiencies, complaint number GA00193897 was partially substantiated with no deficiencies, and complaint number GA00193989 was unsubstantiated.
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 0
Date: Nov 28, 2018
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations.
Findings
The revisit survey revealed that the facility is in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 10, 2018
Visit Reason
A complaint survey was conducted to investigate complaint # GA 00191755 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint # GA 00191755 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 27, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare facility regulations, including review of resident care, nutrition, restorative nursing, injury management, and medication administration.
Findings
The facility was found deficient in multiple areas including failure to properly monitor and address significant weight loss in residents, lack of restorative nursing services and documentation, delayed orthopedic consultation and treatment for a resident with a fracture, inadequate skin integrity management with re-opened wounds not properly documented or treated, failure to administer ordered nebulizer treatments for respiratory symptoms, and failure to consistently apply prescribed hand splints (carrots) for contractures.
Deficiencies (6)
Failure to monitor and address significant weight loss in residents R#21, R#81, and R#70, including lack of timely dietician notification and physician involvement.
Lack of restorative nursing services and documentation for resident R#24 despite therapy discharge recommendations.
Delayed orthopedic consultation and treatment for resident R#14 with a displaced distal tibial fracture, including missed appointments and lack of follow-up.
Inadequate skin integrity management for resident R#74 with re-opened open areas on right lower extremity not properly documented or treated.
Failure to administer ordered prn nebulizer treatments for resident R#17 despite documented wheezing and shortness of breath.
Failure to consistently apply prescribed bilateral hand carrots (splints) for resident R#93, with splints often missing during observations.
Report Facts
Weight loss percentage: 30
Weight loss percentage: 29
Weight loss in pounds: 20
Weight: 176
Braden Scale score: 12
BIMS score: 0
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Dietician | Interviewed regarding unreported weight loss for residents R#21 and R#81. |
| AA | Unit Manager | Interviewed regarding weight monitoring and restorative nursing referrals. |
| DD | Certified Nursing Assistant | Reported decreased oral intake and feeding issues for resident R#21. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including weight loss reporting, restorative nursing, and fracture management. |
| UM/RN II | Unit Manager/Registered Nurse | Interviewed regarding weight loss reporting and nebulizer treatment administration. |
| LPN LL | Licensed Practical Nurse | Interviewed regarding failure to administer nebulizer treatment to resident R#17. |
| NP | Nurse Practitioner | Interviewed regarding management of resident R#14's fracture and resident R#17's respiratory treatments. |
| PTA FF | Physical Therapy Aide | Interviewed regarding restorative nursing and contracture management. |
Inspection Report
Routine
Census: 98
Deficiencies: 9
Date: Sep 27, 2018
Visit Reason
A standard survey was conducted from 9/24/18 through 9/27/18, including investigation of multiple complaint intake numbers which were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00190397, GA00190098, GA00189807, GA00189010 and GA00188019 were investigated in conjunction with this standard survey and all complaints were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure resident confidentiality, failure to notify hospice of a change in condition, failure to implement care plans, failure to provide restorative nursing services, failure to treat injuries and weight loss appropriately, failure to maintain range of motion devices, failure to provide adequate nutritional monitoring, and failure to provide ordered respiratory care.
Deficiencies (9)
Failure to ensure confidentiality of residents' care needs by posting care instructions above beds in view of roommates and visitors.
Failure to notify hospice provider of resident's change in condition after a fall.
Failure to implement care plans for respiratory and nutritional needs for three residents.
Failure to provide restorative nursing services to maintain resident's ability to walk after therapy discharge.
Failure to provide timely treatment and follow-up for resident's broken leg.
Failure to provide timely treatment for open skin areas and failure to document and report skin issues.
Failure to monitor and intervene for significant weight loss in two residents.
Failure to provide ordered nebulizer treatment and failure to notify physician after resident pulled out IV line.
Failure to maintain range of motion devices (hand carrots) in resident's hands as ordered.
Report Facts
Resident census: 98
Weight loss percentage: 11.39
Weight loss percentage: 30
Weight loss percentage: 29
Weight loss percentage: 5
Weight loss percentage: 6.84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Named in failure to assess resident after fall and failure to notify hospice |
| UM/RN II | Unit Manager/Registered Nurse | Named in failure to administer nebulizer treatment and failure to report weight loss |
| DON | Director of Nursing | Named in failure to be informed timely of weight loss and failure to locate change of condition policy |
| RD CC | Registered Dietitian | Named in failure to be notified of resident weight loss |
| NP MM | Nurse Practitioner | Named in failure to be notified of IV removal and failure to be informed of missed nebulizer treatments |
| LPN LL | Licensed Practical Nurse | Named in failure to administer nebulizer treatment |
| CNA DD | Certified Nursing Assistant | Named in failure to report skin issues and failure to apply hand carrots |
| CNA EE | Certified Nursing Assistant | Named in failure to report decreased oral intake and failure to report skin issues |
| UM AA | Unit Manager | Named in failure to report weight loss and failure to be informed of skin issues |
Inspection Report
Life Safety
Census: 102
Capacity: 109
Deficiencies: 4
Date: Sep 26, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with life safety requirements including failure to maintain fire extinguishers, resident room doors not latching properly to prevent smoke spread, electrical hazards exposing staff to shock risk, and failure to conduct the annual emergency generator test.
Deficiencies (4)
Fire extinguisher in the boiler room had not been serviced and tagged during the June 2018 annual inspection.
Resident room doors would not close to latch shut, potentially allowing smoke to enter rooms (Rooms 102, 215, 204).
Multiple outlet device located on the floor in the MDS office and electrical panel behind laundry washer had voided spaces exposing live electricity.
Annual 2-hour emergency generator test had not been conducted.
Report Facts
Staff at risk: 5
Residents at risk: 30
Staff at risk: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 6, 2018
Visit Reason
A complaint survey was conducted to investigate complaints GA00184834 and GA00184704 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaints GA00184834 and GA00184704 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
No deficiency was cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
A qualified Surveyor investigated Complaint #GA00182130 in conjunction with a revisit survey on 12/1/17.
Complaint Details
Complaint #GA00182130 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the revisit survey.
Report Facts
Complaint number: Complaint #GA00182130 investigated
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Fulton Center for Rehabilitation LLC, indicating a regulatory inspection was conducted and corrective actions are planned.
Findings
The document contains no specific deficiencies or findings detailed; it primarily serves as a form for reporting deficiencies and the provider's plan of correction.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 22, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 4, 2017
Visit Reason
An abbreviated survey was conducted from 11/4/17 through 12/6/17 at Fox Glove Center to investigate two complaints, GA00181443 and GA00181808.
Complaint Details
The complaints GA00181443 and GA00181808 were investigated and found to be not substantiated.
Findings
The complaints were not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements under 42 CFR, Part 483, Subpart B.
Inspection Report
Re-Inspection
Census: 101
Deficiencies: 0
Date: Oct 13, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 25, 2017 abbreviated survey.
Findings
All deficiencies cited in the previous abbreviated survey were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 103
Capacity: 109
Deficiencies: 3
Date: Oct 3, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with emergency lighting, sprinkler system maintenance and testing, utilities safety, and fire protection documentation requirements. Specific deficiencies included emergency lighting units failing to activate, missing sprinkler system data design plate, and multiple outlet power strips placed on the floor posing shock hazards.
Deficiencies (3)
Emergency lighting units did not activate in testing mode, failing to assure illuminated means of egress for evacuation.
Sprinkler system data design plate was missing from the sprinkler riser, and fire protection documentation was not assured.
Multiple outlet power strips were found on the floor in various offices, posing a risk of shock.
Report Facts
Residents and staff at risk: 50
Residents and/or staff at risk: 3
Census: 103
Total licensed beds: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting, sprinkler system, and power strip deficiencies during the tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 26, 2017
Visit Reason
The abbreviated survey was conducted to investigate a complaint #GA00180101 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00180101 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 7, 2017
Visit Reason
An Abbreviated Survey was conducted on 8/3/17 and 8/7/17 at Fox Glove Center to investigate complaints # GA00177892 and #GA00177750.
Complaint Details
Investigation of complaints # GA00177892 and #GA00177750; facility found in compliance.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 3, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint #GA00176423 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint investigation #GA00176423 was conducted and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted on 7/3/17 at Fox Glove Center.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 7, 2017
Visit Reason
An unannounced complaint investigation was conducted to investigate complaints related to the facility.
Complaint Details
The complaint investigation was for GA00171269. The Ombudsman and Complainant were notified and provided information related to the complaint.
Findings
No regulatory violations were cited during the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 20, 2017
Visit Reason
A complaint survey was conducted to investigate complaints GA00169004 and GA00170670.
Complaint Details
Complaints GA00169004 and GA00170670 were investigated and found not substantiated.
Findings
The facility was found to be in compliance; both complaints were not substantiated and no deficiencies were cited.
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