Resident 9 tested positive for COVID on December 20 and again on December 29, yet remained roommates with Resident 10, who tested negative. Inspectors observed both residents in their shared room on December 30 without masks.
The same day, inspectors watched Resident 9 leave the room multiple times despite the positive diagnosis.
Resident 11, who tested positive on December 22, told inspectors he would prefer to move rooms if his roommate was sick with COVID. His roommate had indeed tested positive eight days earlier, but no one offered to relocate either resident.
"I don't want to be in a room with a sick resident, however no one asked if I wanted to move rooms," Resident 8 told inspectors on December 30.
A certified nursing assistant acknowledged the scope of the problem during the inspection. Of 13 total residents in the 300 dining hall, seven had tested positive for COVID-19, CNA C said.
Yet basic infection control collapsed throughout the outbreak.
CMT D, a certified medication technician, told inspectors he didn't know which residents had tested positive for COVID-19, though he was aware some were infected. He said supervisors hadn't told him during shift changes who had the virus.
The medication technician acknowledged he was new to the facility and had only been instructed to wear a mask. When inspectors observed him, the mask was positioned below his nose. CMT D admitted this wouldn't provide protection from the virus and that he should be wearing an N95 mask instead.
The Assistant Director of Nursing revealed even deeper gaps in the facility's response. During a December 30 interview, the ADON said she didn't know who on Hall 300 was COVID-positive or why there was no signage on infected residents' doors.
"Staff are probably going in and out of rooms without the proper PPE," the ADON told inspectors.
She also couldn't explain why there were no red bags in rooms for proper disposal of personal protective equipment. The ADON said she and the Director of Nursing were responsible for ensuring staff compliance with PPE requirements.
LPN B pointed to a list of COVID-positive residents posted at the nurse's station that was updated every three days. The licensed practical nurse said everyone should know about the list and that nurses knew what protective equipment to wear.
But LPN B couldn't explain why there was no signage on infected residents' doors, saying that was the Infection Preventionist's responsibility.
The Director of Nursing confirmed a list of positive residents was posted at the nurse's station and said all nurses should be aware of it. Yet multiple staff members demonstrated they either didn't know about the list or weren't using it.
The Infection Preventionist described interventions implemented to contain the outbreak: room trays for positive residents, some room changes, masks, handwashing reminders, family notifications, and cancellation of the Christmas party.
The IP said all residents had been asked to wear masks outside their rooms, but many refused.
During the inspection's final day, Administrator blamed the nursing supervisors for the breakdown. The Administrator said the ADON and DON were responsible for educating nurses on proper PPE use and that nurses were responsible for compliance.
The Administrator said a list of COVID-positive residents was posted at the nurse's station and expressed confusion about why staff claimed they didn't have the information.
The Director of Nursing attempted to justify the room assignments, saying the facility follows policy regarding resident placement during COVID outbreaks. But she acknowledged some residents refuse to be moved and rooms aren't always available.
She said they had relocated some residents and that families were notified about positive cases in the facility.
The breakdown in basic infection control protocols left COVID-positive and negative residents sharing dining spaces, bedrooms, and common areas without proper precautions. Staff responsible for medication administration and direct patient care couldn't identify which residents were infected, while supervisors pointed fingers at each other for the failures.
Resident 8's simple request to avoid rooming with a sick patient went unheard, while Resident 11 remained paired with a COVID-positive roommate for over a week without anyone offering alternatives.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fulton Nursing & Rehab from 2025-12-31 including all violations, facility responses, and corrective action plans.