Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fulton Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with schizoaffective disorder had a bedside commode left visibly soiled with urine and stool, and staff confirmed commodes should be cleaned after every use. Another resident with CHF, CKD, and bipolar disorder had unlabeled food and decomposing orange juice left on the bedside table for days, and a labeled bottle of body wash was found in another resident’s room. A third resident with COPD and HF reported missing clothing and said the items were never reimbursed; records showed no missing-item forms were completed, and the D Hskp acknowledged there was no follow-up.
The facility failed to protect residents from abuse and neglect when one cognitively intact resident pushed another resident’s wheelchair from behind, causing a fall and injury, and when staff later described the event as a resident-to-resident altercation despite the injured resident reporting threats and assault. The facility also failed to recognize and follow up on a resident’s L1 compression fracture documented in a hospital discharge summary; the DON and Administrator stated they were unaware of the fracture and could not provide evidence of the recommended ortho/neurosurgery follow-up.
Incomplete and premature narcotic count signatures were found on multiple unit narcotic count records. Surveyors identified missing oncoming and outgoing nurse signatures and instances where LPNs signed the narcotic count book in advance for future shifts. Interviews confirmed that some nurses signed early, some had not signed yet, and the DON acknowledged ongoing audits due to missing signatures and advance signing.
Food was not consistently palatable or served at an appetizing temperature. Residents and a resident council reported cold, overcooked, undercooked, and stale items, and meal observations found late tray delivery with food such as fries, cottage cheese, and other items served at improper temperatures. One resident was served burnt stuffed shells that were tough to cut, while two other residents received meals with fries that were too crispy or hard to eat.
A resident with COPD and asthma had a home inhaler at bedside even though the PRN albuterol order had been discontinued. The resident said they still used it on occasion, but the chart lacked documentation of a self-administration assessment, physician approval, or care plan notation. The inhaler was later found hidden in a tissue box, and the DON stated they did not believe the resident could self-administer meds.
Two residents were not able to exercise basic daily choices. One resident with quadriplegia, AFib, and depression wanted to go outside for fresh air and visits, but staff said the patio stayed locked unless activities staff were present, despite the resident’s preference and the Administrator’s statement that residents could go out anytime. Another cognitively intact resident with COPD, a chronic ulcer, and morbid obesity reported not having a shower for over a year because the facility’s stretcher shower was broken, and staff said bed baths were provided until it was repaired.
Failure to Report Abuse, Neglect, and Injury of Unknown Origin: The facility did not report a resident with a significant unwitnessed injury of unknown origin or a resident-to-resident altercation in which one resident pushed another resident’s wheelchair and caused a fall with injury. Records showed the injured resident had severe cognitive impairment and was found on the floor with a forehead bruise and altered presentation, while the other incident involved statements from the residents and an LPN, police involvement, and a later neck fracture. The DON and Administrator said they ruled out abuse and therefore did not report the events to DOH.
Facility staff refused to accept a resident back after a hospital psych eval, despite hospital records showing the resident was alert, oriented, cooperative, and did not require psych hospitalization. The resident had a hx of DM2, Afib, and CVA with L-sided hemiparesis, and had exhibited behavioral issues during discharge planning. When the ambulance returned the resident to the facility, staff denied entry and the resident was sent back to the hospital.
PASARR screening was not completed as required for two residents. One resident with serious mental illness remained in the facility beyond the convalescent stay covered by the initial PASARR, but no new Level I screen or Level II referral was documented. Another resident with Down syndrome, anxiety, and dementia was admitted before Level II PASARR recommendations were received. Staff stated they sometimes admitted residents while Level II was still pending, even though PASARR was intended to be completed before admission.
A facility failed to develop complete person-centered care plans with measurable goals and timeframes for several residents. One resident’s plan did not address multiple meds for pain, spasms, and restless legs; another resident’s plan did not include PT needs or self-management of an ostomy pouch; and a third resident’s plan did not address repeated aggression and refusal of care. Records and staff interviews showed the missing care plan areas despite documented diagnoses, orders, and ongoing symptoms.
Failure to provide and document resident activities for two residents. One resident who was bed bound and had MS, FTT, and PVD had care plan interests in exercise, word search, painting, coloring, crafting, dogs, and comedy movies, but was repeatedly observed in bed and the Rec Director said there was no activity documentation and staff did not bring the resident to activities. Another resident with AD, depression, PVD, and severe visual impairment was observed in bed with no stimulation present, and the Rec Director could not provide proof that activities were offered, provided, or attended despite the resident’s care plan interests in music and the coffee cart.
A resident with no documented DM diagnosis was ordered Mounjaro and later developed symptomatic hypoglycemia requiring glucagon and ED transfer. Another resident with bilateral forearm graft sites had loose, non-intact dressings left in place for hours after staff were notified, with exposed reddened areas and bleeding noted. Staff interviews confirmed the dressings should have been changed much sooner.
Two residents had pressure ulcer care failures. One resident with a Stage 4 wound and a wound vac order was observed with a large open wound but no wound vac or dressing in place. Another resident with a worsening Stage 4 heel wound had contractures with the heel pressed under the opposite leg, and staff documented the dressing change but did not measure the wound or document changes beyond marking the treatment complete. The DON said the treatment nurse was responsible for documenting wound changes and notifying the provider, but the NP was not made aware of the decline.
Medication carts contained multiple labeling and storage problems, including an expired stock med, an uncapped Flonase bottle, a loose pill, inhalers with missing open and/or expiration dates, insulin products without open dates, and one inhaler with no label. Narcotic count records were also inaccurate, with shift changes signed before counts were completed and multiple missing signatures; an LPN reported routinely signing the narcotic sheet in advance, while the DON acknowledged issues with missing signatures and advance signing.
Expired skim milk cartons were found in a small plastic cooler in the walk-in cooler and later observed being placed on residents’ lunch trays at the tray line. The DFS stated the milk was precooled and separated to maintain temperature during tray prep, but the cartons were past their expiration date.
Failure to use EBP during resident care for a resident with a stage 4 pressure ulcer. The resident had severe cognitive impairment, sepsis, and acute respiratory failure, and was dependent for toileting hygiene. During incontinent care, a CNA wore gloves but did not wear a gown while turning and providing care with a large open wound present, despite the facility policy requiring gloves and an isolation gown for high-contact activities.
A resident’s personal funds were not conveyed to the appropriate probate jurisdiction within the required 30‑day timeframe after death, contrary to State law and facility policy. Instead, the facility waited several months before issuing a check from the Resident Fund Trust Account to the county Department of Social Services, which returned the check because it no longer accepted Personal Needs Account funds and directed that such funds be sent to the State DOH. The facility then issued a new check to the State DOH to close the account. An email from the State DOH confirmed that deceased residents’ funds must be returned within 30 days of death, and the facility’s Finance Director acknowledged confusion about where and when the funds should have been sent, as well as complicating family issues.
Unsanitary bedside equipment, disordered food storage, and mishandled resident property
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by allowing resident bedside care equipment and personal areas to remain unsanitary and disordered. Resident #17, who was admitted with schizoaffective disorder, peripheral vascular disease, and dementia and was documented as communicative and cognitively intact, was observed with a bedside commode that was visibly soiled with urine and stool smears. On a later observation, the commode bucket was improperly placed and crooked on its frame, with urine in the bottom and stool smeared on the interior side. The resident stated they could not walk to the bathroom and had to slide to the commode, and said staff sometimes took up to an hour to respond and that it got smelly. Staff interviews confirmed commodes were supposed to be emptied, wiped down, and sanitized after every use, and the DON acknowledged dirty commodes were an infection control and homelike environment concern. Resident #25, who had diastolic heart failure, stage 4 chronic kidney disease, and bipolar disorder with psychotic features and was documented as communicative and cognitively intact, had multiple covered, unlabeled containers and an open bottle of unlabeled orange juice with separated, decomposing fluid left on the bedside table over several consecutive days alongside old food remnants. The resident stated family brought outside food and they relied on housekeeping to clear dirty dishes. The Director of Housekeeping stated staff were expected to dispose of old food daily and confirmed they were only notified of the decaying items after several days, at which point a deep cleaning was needed. The same resident also had a clearly labeled bottle of Dove Men’s Body Wash missing from the room and later found on another resident’s over-the-bed table elsewhere in the facility. Resident #26, who had COPD, heart failure, and restless leg syndrome and was documented as cognitively intact and communicative, reported that laundry went missing frequently and that four items, including an oversized sweater, were missing, requiring the resident to buy a replacement out of pocket. Facility records showed a property drop-off form for a red rose button-down sweater cardigan, but no misappropriation or missing items forms were completed for the missing clothing. The resident reported the missing items to housekeeping, but the Director of Housekeeping acknowledged the missing sweater had been reported and that no follow-up was done, and also stated items were only replaced if there was a paper trail. Staff interviews showed some were unaware of the missing-items form process, while the Administrator stated anyone could accept a grievance or misappropriation form and that a seven-day investigation turnaround was expected.
Failure to Protect Residents from Abuse and Unrecognized Fracture Follow-Up
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect for three residents reviewed. One event involved two cognitively intact residents, one with cervical spinal cord injury, quadriplegia, and multiple sclerosis, and the other with COPD, bipolar disorder, and type 2 diabetes. A complaint documented that one resident pushed the other resident’s wheelchair from behind while the resident was seated at the nurse’s station, causing the resident to fall from the wheelchair and land with the wheelchair on top of them. The injured resident reported being attacked by the other resident, stated the other resident had threatened to kill them, and said staff knew the other resident was dangerous. The other resident stated they lost their cool after overhearing an accusation about a stolen cell phone and admitted pushing the wheelchair enough to jar the resident and cause the fall. Facility documentation described the event as a resident-to-resident altercation, and staff interviews confirmed the residents were separated after the incident. A second resident, who was cognitively intact and had end stage renal disease, bipolar disorder, and major depressive disorder, was hospitalized with a discharge summary documenting an acute on chronic L1 compression fracture. The hospital record stated orthopedics recommended kyphoplasty and that the resident should be referred to neurosurgery for the procedure. Facility records also listed a wedge compression fracture of the first lumbar vertebra, and later notes referenced low back pain and a recent history of L1 fracture managed non-surgically. However, the Director of Nursing and Administrator stated they had no knowledge that the resident had a lumbar fracture, and the Director of Nursing could not provide documentation of orthopedic or neurosurgery follow-up recommended by the hospital. The report also documented that the facility’s investigation and interviews did not show awareness of the lumbar fracture when the resident returned from the hospital. The Administrator stated that a documented fracture on the discharge summary should have prompted an investigation once notified, but this was not done. The record further showed that the resident reported severe back pain and said they had a seizure in the facility and their back broke, while facility staff stated they had no knowledge of any fall or seizure activity related to the fracture.
Incomplete and Premature Narcotic Count Signatures
Penalty
Summary
The facility failed to implement a system to consistently and accurately reconcile controlled medications in accordance with professional standards of practice. During record review, surveyors found that the narcotic count record signature sheets for five of eight units were incomplete or signed in advance. On Unit A cart 300, the 7 AM-3 PM LPN signed as the off-going nurse at 3 PM before the shift ended. On Unit C cart 500, the 7 AM-3 PM LPN had not signed as the oncoming nurse at 7 AM when reviewed later that morning. On Unit D cart 800, multiple entries were missing oncoming and outgoing nurse signatures on several dates, and the 3 PM-11 PM LPN signed in advance as the off-going nurse at 11 PM. On Unit C cart 900, several oncoming and outgoing nurse signatures were missing across multiple shifts. On Unit E cart 100, entries were missing for oncoming or outgoing nurse signatures on several shifts, and the 7 AM-3 PM LPN signed in advance as the off-going nurse at 3 PM. During interviews, an LPN stated they had signed the narcotic count book in advance for the outgoing shift, explaining they did so so they would not forget. Another LPN stated they had not yet signed because it had been a busy morning and acknowledged they should have signed when they first came on shift. A different LPN stated the narcotic count book should never be signed in advance because that would be signing for something that was not done. The DON stated they had been auditing the narcotic count books and would increase audits due to missing signatures and nurses signing in advance.
Food Served at Improper Temperature and Not Palatable
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for three residents. Survey observations and interviews showed that meals were delivered late and that some items were cold, overcooked, undercooked, or burnt. The facility policy on food temperatures stated that hot and cold food items were to be recorded on all menu items and substitutions during meal service to maintain quality assurance and monitor potentially hazardous temperatures. During a resident council interview, 10 anonymous residents stated the food was horrible, often cold, and frequently overcooked or undercooked. They reported chicken tenders were rock hard, bread was stale or dried out, and an egg salad sandwich was poorly prepared. During a meal observation, trays were delivered to the unit over an extended period, with the last tray served after the meal cart arrived, and a resident stated the food was lukewarm but usually cold. Resident #26, who had COPD, heart failure, and restless leg syndrome and was cognitively intact, stated the food was not the greatest and was often cold. On observation, the resident’s tray included soup at 124 degrees Fahrenheit, a hot dog at 106 degrees Fahrenheit, waffle fries at 84 degrees Fahrenheit, mixed fruit at 57 degrees Fahrenheit, and apple juice at 57 degrees Fahrenheit; some waffle fries were too crispy to eat. Resident #79, who had COPD, a chronic ulcer, and morbid obesity and was cognitively intact, reported food was not good and had been served burnt food before; on observation, cottage cheese was 58.3 degrees Fahrenheit and some waffle fries were too hard to eat. Resident #116, who had chronic respiratory failure, heart failure, and depression and was cognitively intact, was served stuffed shells that were burnt and tough on top, and the resident stated dinner trays were always late and that the burned shells were difficult to cut because the resident did not have teeth.
Failure to Assess Self-Administration of a Resident’s Inhaler
Penalty
Summary
The facility failed to ensure a resident could safely self-administer medication when clinically appropriate. Resident #108, who had diagnoses of COPD, asthma with acute exacerbation, and obesity, was cognitively intact per the MDS and was observed with a blue inhaler on the bedside tray table. The resident stated the inhaler had been brought from home after the facility discontinued the order for it, and that they used it on occasion. The resident’s physician orders did not include an order for the albuterol inhaler, and the medical record did not contain documentation that the resident had been assessed for the ability to self-administer medications or that the physician had documented the resident could self-administer them. The resident’s care plan also did not document that the resident could self-administer medications. During interview, the resident stated the facility tried to take away the inhaler and that the DON told them to hide it, and the inhaler was later found hidden inside a tissue box on the tray table. The DON stated they did not believe the resident was able to self-administer medication and said they were not aware of any residents who could self-administer medication, while the LPN stated the resident had a previously discontinued PRN albuterol inhaler and that there were potential risks if it was not used appropriately.
Failure to Support Resident Choice for Outdoor Access and Showers
Penalty
Summary
The facility failed to ensure resident self-determination and choice for two residents reviewed for preferences. The report states that the facility’s Resident Rights policy required residents to be supported in exercising their rights, including access to people and services inside and outside the facility, and that the Out on Pass/Therapeutic Leave policy was not to be used when a resident simply wanted to sit outside on facility property. Surveyors found that residents were not consistently able to make choices about daily routines and preferences. Resident #4 was admitted with quadriplegia, atrial fibrillation, and major depressive disorder. The resident’s MDS indicated they could understand and be understood, and their preferences included going outside and getting fresh air when the weather was nice. The care plan stated the resident could make recreation and leisure preferences known and included interests such as football and use of a cell phone. During interview, the resident stated the only activity they wanted was to go outside, especially when friends and family visited, but they were frequently denied because of a facility rule requiring activities staff to be present. Staff interviews confirmed the patio door remained locked and residents could not go outside unless activities staff were available to unlock it, although the Administrator stated residents could go outside at any time and nursing supervisors had keys. Resident #79 was admitted with COPD, a chronic skin ulcer, and morbid obesity. The resident’s MDS documented that they were cognitively intact and could understand and be understood. Record review showed a work order for the stretcher shower being broken, and staff stated the shower bed had been out for repair and residents would be offered bed baths until it was fixed. The resident stated they had not been able to have a shower since admission and had repeatedly asked for one, but were told the shower bed was still broken. The resident also stated they had not had a shower in over one year, while the DON and Administrator stated they were unaware the resident had not been receiving showers instead of bed baths.
Failure to Report Abuse, Neglect, and Injury of Unknown Origin
Penalty
Summary
The facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source to the State Agency within the required time frames for three residents. The report states that incidents involving a resident with a significant injury of unknown origin and two residents involved in a resident-to-resident altercation were not reported to the New York State Department of Health as required. The facility policy required unwitnessed incidents or injuries of known or unknown origin to be investigated for potential abuse and for the DON and Administrator to determine whether outside reporting was required. Resident #191 had diagnoses including unspecified dementia, chronic kidney disease stage 3A, and gait and mobility abnormalities, and the MDS documented severe cognitive impairment. On 3/31/2026, the resident was found on the floor by staff, could not verbalize what happened, and had a bruise on the mid-forehead, widened eyes with a staring glare, and inability to follow simple directions. The resident was assisted to bed and sent to the emergency room. The incident record documented no witnesses, one staff statement, and no statement from one of the staff involved. There was also no documentation of when or where the resident was last seen before being found on the floor. Resident #114 and Resident #181 were involved in a resident-to-resident altercation in which Resident #181 pushed Resident #114's wheelchair from behind, causing Resident #114 to fall. A complaint later documented that Resident #114 suffered a neck fracture as a result. Facility records included statements from both residents and an LPN describing the event, and police were called. During interviews, the DON and Administrator stated they ruled out abuse and therefore did not report the incident to the State Agency. The DON later stated that an unwitnessed fall with significant injury would be considered an injury of unknown origin and that resident-to-resident allegations and incidents would be abuse, and both the DON and Administrator acknowledged that such events would need to be reported within the required time frame.
Facility Refused Readmission After Hospital Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure a resident was discharged according to professional standards when it refused to accept the resident back after a brief hospital psychiatric evaluation. The resident was admitted with diagnoses including type 2 diabetes mellitus, paroxysmal atrial fibrillation, and cerebrovascular accident with left-sided hemiparesis. The resident’s care plan identified a discharge goal of returning to the community/shelter, and the resident was documented as cognitively intact on the MDS. Records showed the resident had a history of behavioral concerns, including yelling, profanity, crying, pounding fists on the table during discharge planning, and later threatening and accusatory behavior. The resident was sent to the hospital for evaluation after an aggressive incident involving facility staff. The hospital psychiatric evaluation documented that the resident was alert and oriented, cooperative, denied suicidal and homicidal ideation, denied hallucinations, was not psychotic or delusional, and did not require psychiatric hospitalization. Hospital documentation indicated the resident was to be discharged back to the facility via ambulance. Despite the hospital’s discharge back to the facility, the resident was denied entry when the ambulance returned. A complaint from a police officer stated the facility supervisor said the resident would not be accepted back because of the assault allegation and that the resident was sent back to the hospital, where the resident was left crying in the parking lot and housed overnight. During later interviews, facility leadership stated they believed the resident had been discharged to the community and was no longer a resident, while the DON stated that any resident sent for psychiatric evaluation would have been allowed back once discharged from the hospital.
PASARR Screening Not Completed Before or During Required Timeframes
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed according to professional standards of practice prior to admission and as needed for two residents. The facility’s policy stated that every admission must have a PASARR completed prior to admission, that Level II PASARR recommendations must be completed before admission when required, and that if a resident no longer met exemption criteria, a new Level I and Level II evaluation would be completed within the required timeframe. One resident had diagnoses including bipolar disorder, schizoaffective disorder, and depression, and a PASARR completed before admission documented serious mental illness and a brief, finite convalescent stay. The resident remained in the facility beyond 120 days for convalescent care, but there was no documented evidence that a new Level I screen was completed and a Level II referral was made after that point. The Director of Social Work stated that because the resident had been in the facility longer than 120 days and had serious mental illness, a new screen would be needed. A second resident with Down syndrome, anxiety, and dementia was admitted before receiving Level II PASARR recommendations for intellectual disabilities. The record showed the PASARR process was initiated and completed after the resident had already been admitted. The complaint record also documented that the Office for People with Developmental Disabilities became aware the resident had been admitted without the PASARR for developmental disabilities being completed prior to admission. The Director of Social Work stated the facility sometimes admitted residents while a Level II referral was pending, and the Administrator stated the purpose of PASARR was to ensure the facility could meet residents’ needs prior to admission.
Missing Comprehensive Care Plan Areas for Medications, Therapy, and Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented with measurable objectives and timeframes to address residents’ medical, nursing, mental, and psychosocial needs for four residents reviewed. The deficiency was identified during record review and interviews and involved missing care plan areas for medication management, ostomy self-management, physical therapy needs, and aggressive behaviors/refusal of care. For one resident with COPD, heart failure, and restless leg syndrome, the record showed orders for Ropinirole for restless leg syndrome, Tizanidine for muscle spasms, Kenalog-40 injection for pain, and Lidocaine injection to mix with Kenalog. The resident’s comprehensive care plan addressed alteration in comfort and a skin tear and noted the resident could request pain medications, but it did not include a care area for muscle spasms or the need for muscle relaxers. The DON stated there should have been a care plan for the spasmodic medications and that care plan areas should exist for all medications residents were taking. For another resident with COPD, type 2 diabetes, and obesity, the record showed the resident had a fall from a wheelchair and later received PT and OT services, with therapy notes stating the resident was at baseline and later could participate in an open gym program. The comprehensive care plan included fall risk and limited physical mobility related to a right below-the-knee amputation, but there was no documented PT care area and no documented evidence that PT was being utilized in the care plan. The resident stated they had asked for therapy to strengthen the left lower extremity and keep the right stump strong for a future prosthesis, but were told insurance would not cover therapy. For a third resident with type 2 diabetes, major depressive disorder, and adjustment disorder, the record documented repeated yelling, verbal and physical aggression, spitting, disrobing, refusal of care, refusal of medications, and disturbing other residents and staff. The resident had orders for lorazepam, Depakote, and clonazepam for anxiety and conduct. Although the care plan addressed activities, communication difficulty, grief, and mood symptoms, it did not include a care area for the resident’s aggressive behaviors and refusal of care. Staff interviews indicated care plans were created by management and that behavior changes should have been reflected in the care plans.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to ensure an ongoing program of activities that supported each resident’s choices and interests for two residents reviewed. The report states that the facility did not provide or document activities for a bed bound resident with multiple sclerosis, adult failure to thrive, and peripheral vascular disease, despite a care plan that identified interests in exercise, word search, painting, adult coloring, crafting, dogs, and comedy movies. The resident’s care plan also directed staff to assist with finding programs of interest, provide independent leisure supplies, and provide a monthly calendar and daily schedule of events. For the bed bound resident, observations on multiple days showed the resident remained in bed and was not observed out of bed during the observation period. During interview, the Recreation Director stated residents who did not come out of their rooms received one-to-one visits, but the last one-to-one visit for this resident was the day before the interview and consisted of talking about the weather and asking if the resident wanted to come to activities. The Recreation Director also stated there was no documentation for activities and that the resident did not come to activities because staff did not bring them down. A second resident with Alzheimer’s disease, depression, peripheral vascular disease, and severely impaired vision or no vision was also found without documented activity support. The resident’s care plan identified interests in the coffee cart and music appreciation and included interventions to assist with finding programs of interest and to introduce distracting stimuli such as music, conversation, and touch. Observations showed the resident in bed with no television on and no other stimulation or activities present, including one observation in the dark with the resident using fingers to lick leftover food from a breakfast tray. The Recreation Director stated the resident enjoyed music, drumming on the table, the refreshment cart, activities room visits, and veteran visits, and that the resident was offered activities such as patio time, music, and karaoke, but also stated the department had not been documenting resident participation and could not provide proof that the resident was offered, provided with, or attended activities.
Medication Without Documented Diagnosis and Delayed Wound Dressing Care
Penalty
Summary
The facility did not ensure appropriate treatment and care according to orders, resident preferences, and goals for two residents. One resident, admitted with chronic obstructive pulmonary disease, morbid obesity, and cellulitis of the right lower limb, was cognitively intact and had no documented diagnosis of Diabetes Mellitus in the record, yet had an order dated 04/06/2026 for Mounjaro 10 mg subcutaneously every Wednesday for Diabetes Mellitus. On 05/26/2026, the resident reported not feeling right and was found pale, cool, and diaphoretic with a blood sugar of 56. Glucagon 1 mg IM was ordered, the blood sugar later rose to 71 and then 81, and the provider ordered transfer to the emergency department. A second resident, admitted with necrotizing fasciitis, need for assistance with personal care, and an unspecified open wound of the upper arm, had orders starting 05/14/2026 to cleanse the right and left forearm surgical/graft sites with normal saline, pat dry, and apply xeroform every three days and as needed. The MAR for 05/2026 had no documented evidence of any as-needed dressing changes. During observation on 05/22/2026, bilateral gauze dressings dated 05/21/2026 were loose and not intact, with exposed reddened areas on the right hand and left forearm. The dressings remained unchanged at 1:30 PM and were not changed until 3:30 PM. During another observation on 05/26/2026, the resident again had loose, not intact bilateral dressings dated 05/25/2026, with exposed red areas and a small amount of bright red blood on the right hand. The resident stated the dressings had come loose overnight and that nursing staff had been told earlier that morning, but the dressings were still not changed later that day. RN #2 stated the dressings should not be left loose all day, and LPN #6 stated that if dressings were falling off and a nurse was alerted, the dressing should be changed within 30 minutes. The DON stated that if a dressing became loose, the assigned nurse would be expected to change it within one hour of notification.
Pressure ulcer care and wound monitoring failures
Penalty
Summary
The facility did not ensure appropriate pressure ulcer care and prevention for two residents. Resident #10 had diagnoses including pressure ulcer, sepsis, and acute respiratory failure, and was assessed as having severe cognitive impairment with a pressure injury. The care plan documented a Stage 4 pressure ulcer to the left upper back and sacrum, and the physician’s orders included a wound vac. During observation, the resident was turned for incontinent care and a large open wound was seen without a wound vac in place, without evidence that one had recently been in place, and without any dressing or wound foam in the bedding or surrounding area. Resident #105 had diagnoses including multiple sclerosis, adult failure to thrive, and a chronic ulcer of the left foot, and was cognitively intact. The resident had contractures of both lower extremities with the left heel pressed underneath the right leg. During dressing change observation, the left heel wound was open with depth, irregular borders, foul odor, moderate bloody/serosanguinous drainage, and white material in the wound bed. The wound was cleansed, Medihoney was applied, and it was covered with a thin dry dressing. Staff stated the wound had worsened since admission and that no additional documentation was done after wound treatments beyond checking the treatment off in the electronic record. Record review showed the wound care consultant documented the left heel as a Stage 4 full-thickness pressure wound with a marked increase in size compared with a prior note. The consultant note also stated the wound progress was not at goal due to generalized decline of the patient. Staff interviews showed the treatment nurse was responsible for documenting wound changes and notifying the physician or nurse practitioner, but the DON stated the nurse practitioner was not routinely following wounds and the nurse practitioner stated they were not made aware of the changes in the resident’s wound until later.
Medication Labeling, Storage, and Narcotic Count Documentation Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on four medication carts reviewed: Cart A on the 300-hall, Cart B on the 400-hall, Cart D on the 700 hall, and Cart D on the 800 hall. Surveyors observed one expired stock medication, one uncapped bottle of Flonase, one loose pill in a cart, one inhaler with an open date but no evidence it had been opened, one stock medication with conflicting expiration dates, one Lantus KwikPen with no open date, one Lantus vial with no open date, five inhalers with no open and/or expiration dates, and one inhaler with no label at all. The facility policy stated medications must be stored safely and securely, maintained in an orderly and clean manner, and labeled with appropriate open and expiration dates, including insulin pens, cartridges, and multi-dose vials. Narcotic count documentation was also incomplete and inaccurate. Surveyors found three narcotic count shift changes signed as reconciled before the actual count and end-of-shift change occurred, and another narcotic book had multiple missing shift-change signatures. During interviews, one LPN stated they routinely signed the narcotic count sheet in advance so they would not forget at the end of shift, while another LPN stated they had not yet signed because it had been a busy morning and should have signed when they first came on shift. The DON stated nurses are checked on competencies for medication administration, shortened expiration dates after opening, multi-dose vial medications, and narcotic counts, and acknowledged auditing the narcotic count books due to missing signatures and nurses signing in advance.
Expired Milk Served on Tray Line
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional food service safety standards in the central kitchen. During inspection, approximately 15 cartons of skim milk were found in a small plastic cooler in the walk-in cooler after their expiration date of 5/17/2026. Later the same day, the cooler was observed at the tray line and the expired milk was being placed on residents’ lunch trays. During interview, the Director of Food Services stated the milk in the coolers on the tray line was precooled and separated to maintain temperature during tray preparation, and staff were observed using milk cartons that were past expiration.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an infection control program for one resident with a stage four pressure ulcer. Resident #10 was admitted with diagnoses including pressure ulcer, sepsis, and acute respiratory failure. The Minimum Data Set dated 3/17/2026 documented severe cognitive impairment and the presence of a pressure injury. The active physician orders lacked an order for Enhanced Barrier Precautions, and the CNA Kardex dated 5/28/2026 also lacked Enhanced Barrier Precautions, even though the resident was dependent for toileting hygiene. During an observation on 5/21/2026 at 11:35 AM, CNA #5 entered the resident’s room, put on gloves, turned the resident on her side, and stated they were going to do incontinent care while a large open wound was present. The CNA did not wear a gown and then returned the resident to her back and exited the room. The facility’s policy stated Enhanced Barrier Precautions apply to residents with wounds and require disposable gloves and an isolation gown before high-contact activities such as transferring and providing hygiene. The Infection Preventionist later stated the resident was on Enhanced Barrier Precautions for a wound and that the CNA would wear a gown and gloves with high care.
Failure to Timely Convey Deceased Resident’s Personal Funds to Proper Estate Authority
Penalty
Summary
The deficiency involves the facility’s failure to convey a deceased resident’s personal funds and provide a final accounting to the appropriate probate jurisdiction within 30 days of death, as required by State law and the facility’s own Resident Funds Accounts policy. The policy, last updated in 8/2020, states that upon a resident’s death, unutilized resident funds and a final accounting must be sent within 30 days to the appointed executor or administrator of the estate, or, if none exists, to the County Public Administrator, and where applicable, in accordance with Surrogate Court Procedure Act Section 1310. For one resident, the date of death was documented, but instead of following this 30‑day requirement, the facility delayed disposition of the funds and did not send them to the probate jurisdiction administering the estate. Record review showed that when the resident died, the facility’s practice was to wait 6 months before acting on the funds. After this waiting period, the facility mailed a check from the Resident Fund Trust Account to the County Department of Social Services overseeing the resident’s Medicaid, but the county returned the check, stating it no longer accepted Personal Needs Account funds and provided an address for where the funds should be sent. A subsequent letter from the County Attorney confirmed that Personal Needs Account checks for Medicaid reimbursement should instead be sent to the New York State Department of Health. A check for $10,785.41 was then issued from the Resident Fund Trust Account to the New York State Department of Health to close the resident’s account. An email from the New York State Department of Health’s Division of Legal Affairs documented that funds of a deceased resident must be returned within 30 days of death. During interview, the facility’s Director of Finance reported being new to the position at the time, and described confusion about where and when the money should have been sent, as well as family dynamic issues that complicated disbursement of the funds.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gloversville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nathan Littauer Hospital Nursing Home | 2 mi | ★★★★★ | 0 | 0 |
| Wells Rehabilitation And Nursing Center | 4.9 mi | ★★★★★ | 1 | 0 |
| Wilkinson Residential Health Care Facility | 11 mi | ★★★★★ | 0 | 0 |
| River Ridge Living Center | 12.4 mi | ★★★★★ | 2 | 0 |
| Palatine Nursing Home | 14.5 mi | ★★★★★ | 15 | 0 |
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