Fulton Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Fulton Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880May 12, 2021

  Based on observation, interview, and record review, facility staff failed to follow standard precautions during the performance of routine testing of blood glucose for one resident (Resident #5). The facility failed to ensure hand hygiene was performed and clean gloves applied after potential exposure to blood during blood glucose testing and prior to taking glucose monitoring test strips out of a container used for multiple residents. This failure created an immediate jeopardy to resident health by potentially exposing residents who required blood glucose testing to the spread of blood borne infections in the facility. […]

• Actual harm, isolatedF600Oct 2, 2024

  Based on record review and interview, facility staff failed to ensure two residents (Resident #1 and Resident #2) remained free from sexual abuse when Resident #1 raised his/her shirt, and Resident #2 touched his/her chest inappropriately. The facility census was 34. The administrator was notified on 10/15/24 of past Non-Compliance which occurred on 9/30/24. On 9/29/24, Certified Medication Technician (CMT) B, notified Registered Nurse (RN) A he/she witnessed Resident #1 in Resident #2's room. He/She reported he/she observed Resident #1 with his/her shirt raised, and Resident #2 touched Resident #1's chest inappropriately. Staff immediately separated the residents, assessed the residents for injuries, moved Resident #1 to a secured unit, and notified the required parties and agencies. […]

• No harm, potential for more than minimal, widespreadF880Jun 27, 2025

  Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear Personal Protective Equipment (PPE) (gowns, gloves and/or eye protection) and/or failed to have EBP signs posted for 5 residents (Resident #18, #45, #52, #53, and #71), and failed to review Infection… […]

• No harm, potential for more than minimal, widespreadF881Jun 27, 2025

  Based on record review and interviews, facility staff failed to maintain an Antibiotic Stewardship Program (the monitoring for appropriate antibiotic use and effectiveness to improve outcomes and prevent development of antibiotic resistance). The facility census was 62.1. Review of the facility's policy titled, Antibiotic Stewardship Program, undated, showed:-The Infection Preventionist (IP) will be the hub of the program and have the knowledge and expertise to develop, implement and monitor the Antibiotic Stewardship Program;-The IP/Designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription;-The IP/Designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, start… […]

• No harm, potential for more than minimal, widespreadF882Jun 27, 2025

  Based on interview and record review, facility staff failed to delegate an Infection Preventionist (IP) with qualifications by education, training, experience or certification to perform the role. The facility census was 62.1. Review of the facility's policy titled Infection Prevention and Control Program, undated, showed the IP is qualified to conduct infection control and prevention activities as a result of education, training and experience. He/She will complete the Centers for Disease Control (CDC) Long Term Care Infection Preventionist training module.Review Registered Nurse (RN) W's, personnel records showed he/she completed two of 19 continuing education units of the CDC Long Term Care Infection Preventionist training module on 05/15/24.During an interview on 06/25/25 at 10:21… […]