Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Fulton during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of exit-seeking behavior was identified as being at risk for elopement but did not have a required alarming device in place. Staff were unaware when the resident left the facility, and the resident was only returned after being found by a CNA outside the facility. The lack of the alarming device and staff awareness led to the resident's unauthorized exit.
A resident with multiple health issues, including hemiplegia and muscle weakness, fell during a transfer using an incorrect lift device, resulting in a fracture and hospitalization. The care plan inaccurately included ambulation interventions and lacked specific transfer instructions, contributing to the incident. Staff interviews revealed that transfer recommendations were not documented in the care plan, and the resident was diagnosed with metabolic encephalopathy and sepsis due to a UTI.
Two residents in an LTC facility experienced preventable pressure injuries due to the facility's failure to implement its pressure injury management policy. One resident, with multiple chronic conditions, did not receive timely wound assessments or treatment orders, and was observed without necessary offloading devices. Another resident, with schizoaffective disorder and cerebral palsy, had an open area on the coccyx, but the care plan did not address pressure offloading needs. Both cases lacked proper documentation and communication, leading to the development and worsening of pressure injuries.
Two residents in an LTC facility suffered serious injuries due to inadequate supervision and monitoring following significant medical and medication changes. One resident, with a history of multiple health issues, fell and sustained a fractured arm and brain bleed after medication adjustments without proper monitoring. Another resident, weakened by pneumonia, fell and fractured her arm due to a lack of updated safety interventions despite requiring increased assistance.
The facility failed to implement an effective infection prevention and control program, with missing documentation for staff illness surveillance from April to July 2024 and incomplete tracking of staff illnesses in November 2024. A resident with a UTI was not listed in the infection surveillance reports, and the facility's policy on infection prevention was not fully executed, leading to deficiencies.
A facility failed to document Medication Regimen Reviews and physician responses for a resident on psychotropic medications. Despite pharmacist recommendations for regular lab tests, these were not completed, and there was no documentation of the physician's rationale for discontinuing the tests. The DON confirmed the absence of necessary documentation and lab tests, contrary to the facility's policy on Psychoactive Medication Management.
The facility failed to implement an antibiotic stewardship program and ensure accurate monitoring of infections for three residents. A resident with dementia was prescribed antibiotics without documented symptoms or rationale. Another resident with multiple sclerosis received an ineffective antibiotic before culture results showed resistance. A third resident with lupus was also given an antibiotic without prior culture results, which later showed resistance. The facility's use of McGeer Criteria was not documented, leading to inappropriate antibiotic use.
A facility failed to provide a single occupancy room with the required 100 square feet, as a room was measured to be only 97 square feet. The Maintenance Director confirmed no changes to the room's size, and room sheets verified the measurements. No negative outcomes were noted for the resident.
A facility failed to timely report an abuse allegation involving two residents with dementia. An incident where one resident placed his hand inside another's shirt was reported late to the State Agency and not at all to local law enforcement. The Nursing Home Administrator misunderstood the reporting requirements, believing there was permissible contact between the residents.
Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Dementia with Mood Disturbance, and Major Depressive Disorder was admitted to the facility and assessed as being at risk for elopement. The resident was cognitively moderately impaired, independently ambulatory, and had recently returned from inpatient psychiatric treatment. An elopement risk assessment completed upon reentry indicated a high risk for wandering and exit-seeking behaviors, with documentation noting the resident verbalized a desire to leave the facility and scored above the threshold for elopement risk. Despite the identified risk, the resident did not have a personal alarming device in place, which was an intervention indicated for residents at risk of elopement. On the day of the incident, staff were unaware that the resident had left the facility until a CNA arriving for her shift observed the resident walking down a rural road. The CNA recognized the resident, engaged her, and transported her back to the facility, at which point other staff members assisted in escorting the resident inside. Multiple staff interviews confirmed that the resident was last seen at the nurse's station shortly before being found outside and that the required alarming device was not in use at the time of the incident. The failure to implement the necessary safety intervention for a resident known to be at risk for elopement resulted in the resident leaving the facility without staff knowledge. The absence of the alarming device, which would have triggered an alert and prevented the resident from exiting, directly contributed to the unauthorized leave of absence.
Removal Plan
- Re-assessed the elopement risk for R101 and implemented measures to prevent recurrence.
- Performed a resident count to ensure no other residents had eloped.
- Assessed all facility residents for risk of elopement for any previously unidentified residents at risk and ensured appropriate safety measures were in place.
- Reviewed and updated the facility Missing Guest/Elopement book.
- Re-education of the Elopement policy was initiated for all staff.
- Re-education of the Missing Guest Procedure for all staff was initiated.
- The Nursing Home Administrator was re-educated on the facility elopement policy and the expected information to be ascertained to ensure compliance with the facility policy across disciplines.
Failure to Revise Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised, resulting in a hospitalization due to a fracture sustained after a fall. The resident, who was admitted with diagnoses including generalized osteoarthritis, hemiplegia, and muscle weakness, was dependent on staff for transfers and did not ambulate. Despite this, the care plan in place at the time of the fall inaccurately included interventions for ambulation with a walker, conflicting with the resident's actual needs as indicated in the Minimum Data Set (MDS) assessments. The incident occurred when the resident, who was cognitively intact, fell during a transfer using a sit-to-stand lift. The resident reported feeling weak and tired from low blood pressures and suspected a urinary tract infection, which contributed to the fall. The fall incident report indicated that the resident should have been transferred using a Hoyer lift instead of a sit-to-stand lift, especially when tired. However, the care plan did not specify the number of staff or assistive devices required for transfers, and the recommendation for using a Hoyer lift was not documented in the care plan. Interviews with staff revealed that the resident was on the therapy caseload for deconditioning but was cut from services due to lack of progress. The Physical Therapy Assistant provided transfer status recommendations to nursing staff, but these were not reflected in the care plan. The Director of Nursing confirmed that the care plan lacked specific directions for transfers and acknowledged that the resident did not use a walker. The resident was hospitalized with a fracture and diagnosed with metabolic encephalopathy and sepsis due to a urinary tract infection.
Failure in Pressure Ulcer Management and Prevention
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management, resulting in preventable pressure injuries and worsening wounds for two residents. One resident, a female with chronic respiratory failure, heart failure, and diabetes, was dependent on staff for all activities of daily living. Upon readmission, her skin was noted to be reddened, but no comprehensive wound assessment or treatment orders were promptly initiated. Observations revealed that the resident was frequently left without offloading devices, and her urinary catheter was not properly secured, leading to skin breakdown and a new pressure injury. Another resident, with diagnoses including schizoaffective disorder and cerebral palsy, was found to have a sore and open area on the coccygeal region. Despite being at risk for pressure ulcers, the resident's care plan did not adequately address the need for pressure offloading while seated in a wheelchair. The resident was not repositioned frequently enough, and there was a lack of documentation and timely notification to the physician and guardian regarding the skin impairment. Both cases highlight the facility's failure to conduct comprehensive wound assessments, implement timely interventions, and ensure proper documentation and communication regarding skin integrity issues. These deficiencies contributed to the development and worsening of pressure injuries, indicating a lack of adherence to established care protocols and policies.
Inadequate Supervision and Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to provide enhanced supervision and assistance to residents experiencing acute medical changes and significant medication adjustments, leading to serious injuries for two residents. Resident #32, a female with a history of seizure disorder, stroke, congestive heart failure, and other conditions, was at risk for falls due to her medical conditions and medication side effects. Despite these risks, her fall risk assessment indicated no risk for falls. She experienced a fall resulting in a fractured left arm and a brain bleed after her medications, including Oxycodone and Lasix, were increased without adequate monitoring for side effects such as dizziness and sedation. Resident #16, a female with muscle weakness, anxiety disorder, developmental disorder, congestive heart failure, and dementia, also suffered from inadequate supervision. After being diagnosed with pneumonia and starting on Clindamycin, she became weak and required increased assistance for ambulation. Despite these changes, no new safety interventions were implemented in her care plan. She fell and fractured her right arm while being weak and unsteady on her feet. The facility's failure to adjust care plans and provide necessary supervision and monitoring for these residents with significant medical and medication changes resulted in severe injuries. The lack of appropriate interventions and monitoring for side effects contributed to the accidents, highlighting deficiencies in the facility's care and supervision protocols.
Deficiency in Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically in the area of staff illness surveillance. From April to July 2024, there was no completion of the Employee Infection Log, and no Infection Prevention Committee Meeting notes were available for review. This lack of documentation continued into August 2024, where the section on employee health and outbreaks was left blank. The November 2024 Staff Case List revealed incomplete tracking of staff illnesses, with missing details such as the unit worked, residents contacted, and dates of illness resolution and return to work. The facility's infection surveillance system also failed to adequately track resident infections. A resident with dementia and schizophrenia, who was diagnosed with a UTI in the emergency department and discharged with an antibiotic, was not listed in the August and September 2024 Infection Surveillance Monthly Report. The resident's laboratory results and antibiotic use were not documented for tracking and trending purposes. The Infection Control Preventionist (ICP) confirmed that residents prescribed antibiotics were included in the report, but those with symptoms not prescribed antibiotics were not. Interviews with the ICP and the Director of Nursing (DON) revealed that residents exhibiting symptoms of infection were tracked using a separate Resident at Risk list and discussed in weekly meetings, rather than being included in the Infection Surveillance Monthly Report. The facility's policy outlined the responsibilities of the Infection Preventionist, including collecting and analyzing infection data, but these responsibilities were not fully executed, leading to deficiencies in the infection prevention program.
Failure to Document Medication Regimen Reviews and Physician Responses
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were properly documented in the resident's clinical record, specifically lacking documentation of the physician's response to the pharmacist's recommendations for one resident. The resident, a male with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, was on multiple psychotropic medications, including Quetiapine Fumarate, Venlafaxine HCL ER, and Depakote. Despite the pharmacist's recommendations for regular laboratory tests to monitor the effects of these medications, the necessary tests were not completed, and there was no documentation of the physician's rationale for discontinuing these tests. The pharmacy Consultation Reports for the resident indicated missing lab values and recommended that the facility ensure these labs were obtained. However, the reports lacked signatures or initials from the provider to confirm that they were notified of these recommendations. The Director of Nursing (DON) confirmed that the MRRs were not in the resident's Electronic Medical Record (EMR) and were only obtained from the pharmacy upon request. The DON also acknowledged that the recommended laboratory tests were not completed and that there was no documentation or rationale for the discontinuation of the routine laboratory tests by the provider. The facility's policy on Psychoactive Medication Management emphasizes the importance of monitoring residents receiving psychoactive medications for efficacy, side effects, and adverse consequences. However, the facility did not adhere to this policy, as evidenced by the lack of follow-through on the pharmacist's recommendations and the absence of documentation in the resident's medical record. This oversight could potentially impact the resident's health, given the known side effects and necessary monitoring associated with the medications prescribed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as ensure accurate monitoring and documentation of infections for three residents. Resident #23, a female with dementia and schizophrenia, was admitted with a UTI diagnosis from the Emergency Department and prescribed an antibiotic. However, there was no documentation of UTI symptoms, onset of symptoms, or rationale for the antibiotic use in her medical record. The microbiology report later revealed no significant pathogens, yet the antibiotic course was completed without provider review until after completion. Resident #30, a female with overactive bladder and multiple sclerosis, was sent to the ER due to vaginal bleeding and abdominal pain. She was started on an antibiotic for a UTI without documented McGeer Criteria or rationale prior to culture results. The initial antibiotic was found to be resistant, and a new antibiotic was started after several doses of the ineffective one had been administered. Similarly, Resident #192, a female with lupus and a history of kidney stones, was sent to the ER for flank pain and started on an antibiotic for a UTI without prior culture results. The initial antibiotic was also found to be resistant, and a new one was started after several doses. Interviews with the Infection Control Preventionist and Director of Nursing revealed that the facility uses McGeer Criteria for antibiotic stewardship, but it was not documented in the Electronic Medical Record. The facility's policy requires antibiotics to be prescribed only when appropriate, with follow-up on culture results to ensure the correct antibiotic is used. However, the documentation and adherence to these protocols were lacking, as evidenced by the cases of the three residents. The facility's failure to document symptoms and follow McGeer Criteria contributed to the inappropriate use of antibiotics.
Room Size Deficiency Identified
Penalty
Summary
The facility failed to ensure that a resident's room met the required square footage for single occupancy, which is 100 square feet. During an observation on November 18, 2024, at 10:00 AM, the room was measured to be 9 feet 6 inches by 10 feet 3 inches, totaling only 97 square feet. An interview with the Maintenance Director confirmed that there had been no changes to the room's size or configuration. A review of the room sheets corroborated the measurements and bed occupancy. No negative outcomes were identified for the resident residing in the room.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime and ensuring timely reporting of abuse allegations to the State Agency. An incident occurred where a resident was reported to have placed his hand inside the shirt of another resident. This incident was discovered on the evening of 8/7/24 but was not reported to the State Agency until the following afternoon, exceeding the two-hour reporting requirement. Additionally, the incident was not reported to local law enforcement, as the Nursing Home Administrator believed there was some type of contact allowed between the two residents involved. The residents involved in the incident had been diagnosed with unspecified dementia, with one having additional behavioral disturbances. Both residents had guardians or activated Durable Power of Attorney, but there was no documented assessment of their capacity to consent to sexual relationships. The Nursing Home Administrator was aware of the incident within an hour of its occurrence but delayed reporting to the State Agency due to a lack of details, misunderstanding the reporting requirements.
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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 Perrinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Carson City | 7.7 mi | — | 1 | 0 |
| Ashley Healthcare Center | 11.3 mi | — | 18 | 0 |
| Hazel I Findlay Country Manor | 13.6 mi | — | 12 | 0 |
| Michigan Masonic Home | 16.3 mi | — | 17 | 0 |
| Riverside Healthcare Center | 17.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.