Fulton Gardens Post Acute, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 103 residents when;1) Staff did not have their facial hair covered while present in the kitchen;2) Opened cake mix, olive oil, shredded cheese, and five bags of pasta, were not labeled completely and accurately with open dates, use-by dates, or discard dates, and one previously opened bag of pasta was not securely sealed after opening; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supplemental (additional) oxygen was administered in accordance with professional standards of practice for 2 out of 29 sampled residents (Resident 19 and Resident 80) when:1. Resident 19's oxygen humidifier bottle (a device designed to add moisture to dry oxygen from a concentrator, preventing irritation to the nose, throat, and airways during oxygen therapy) was empty and labeled with a date of 4/7/26 (observation was on 4/28/26) and there was no medical doctor order for the use of a humidifier to be used with oxygen therapy; and2. Resident 80's oxygen humidifier bottle was observed empty and was not labeled with a date. These failures had the potential to place Resident 19 and Resident 80 at risk for respiratory discomfort or distress that could negatively impact their health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conserve the nutritive value and flavor of pureed food (a cooked food that has been ground, pressed, or blended into a smooth, thick, and creamy paste or liquid, often with a pudding-like consistency) for a total of six out of seven residents (Resident 6, Resident 9, Resident 15, Resident 63, Resident 64, and Resident 112) who received puree food from the facility kitchen, when the facility did not follow the recipe for pureed lemon rice pilaf (seasoned rice dish). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 103, when:1. Resident 6 and Resident 80's urinals were not labeled to indicate whom the urinals belonged to; and2. Multiple boxes of soda were observed stored directly on the floor in Resident 19's room and the there were multiple dark brown/black stains on the floor;These failures had the potential to spread infection and cause health problems to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident privacy when three tray tickets were thrown into the trash for a census of 103 residents who were receiving facility-prepared meals. This failure had the potential for the residents' personal and health information to be viewed and utilized by unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and update comprehensive care plans (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) for 2 of 29 sampled residents when: 1. A care plan for shortness of breath was not updated to include new oxygen therapy interventions for Resident 74; and2. A care plan for dialysis care (a specialized medical treatment for patients with chronic kidney failure who receive treatments to filter waste and excess fluids from their blood) was not developed for Resident 124. These failures had the potential to place Resident 74 and Resident 124 at risk for not receiving effective, individualized care. As a result, these failed practices could negatively impact the health, safety, and well-being of Residents 74 and 124.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and for the prevention of a pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for 1 of 29 sampled residents (Resident 2), when Resident 2's low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not correctly adjusted according to Resident 2's current weight. This deficient practice had the potential to delay wound healing and placed Resident 2 at increased risk for developing pressure injury and/or skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safe use of the medications for one out of five sampled residents (Resident 59) who's medical records were reviewed for the use of unnecessary medications, when Resident 59's physician's order for a lidocaine patch (a numbing agent used as a topical patch placed on the skin) did not follow the doctor's order and/or the manufacture specification for use. This failed practice could contribute to unsafe medication use, ineffective pain relief, and an adverse drug reaction (a harmful, unintended response to a medication occurring at normal doses).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (percentage - number or ratio that expressed as a fraction of 100) with a census of 103 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 3 errors out of 32 opportunities which resulted in a facility wide medication error rate of 9.38 % for 3 out of 9 residents (Resident 19, Resident 27, and Resident 28) during medication administration observation. These failures may result in unsafe use of medications, medication errors, and not following the doctor's orders and manufacturer specifications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication cart and treatment cart (a secured cart that contains wound care treatment supplies) for a resident census of 103 when:1. The [NAME] Station treatment cart contained expired wound care supplies, and a one-time use normal saline (a sterile-germ free- mixture of water and salt) for wound care was found to be open and not discarded; and2. The [NAME] Station medication cart stored fleet enema (medications designed for insertion into the rectum) and was co-mingled with oral medications. These failures could result in unsafe and unsanitary medication storage and the risk of residents receiving contaminated or spoiled product or supplies.

Inspectors wroteBased on interview and record review, the facility failed to ensure long term antibiotic use was clinically justified for safe use with monitoring and a nursing plan of care for 1 out of 29 sampled residents (Resident 56), when Resident 56 was prescribed doxycycline (an antibiotic, a medication used to treat infection) with full dosing regimen for over one year. This failed practice could contribute to unsafe antibiotic use, risk of developing resistance bugs (when antibiotic no longer can kill or suppress the bug), and ineffective use with side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for five of five residents (Resident 4, Resident 5, Resident 6, and Resident 7, and Resident 8) when,Resident 4 displayed episodes of aggression, and repeated yelling throughout the day and night and Resident 4 behavior care plans were not person centered, and staff were not able to address it; and, Multiple residents including Resident 5, Resident 6, Resident 7, and Resident 8 were negatively affected by Resident 4's continuous yelling and had reported to staff their frustration and lack of sleep and/or rest. This deficient practice had the potential to negatively affect the psychosocial (the mental, emotional, social, and spiritual effects of a disease) and physical well-being of the facility's residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 3) right to be free from physical abuse and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) when, 1. Resident 3, with a diagnosis of paraplegia (inability to feel or move your legs, making it impossible to stand or walk) was placed in Resident 4's room as his roommate even though Resident 4 had a history of aggressive behavior towards staff and other residents. Subsequently, on 5/27/25, Resident 3 called repeatedly for staff assistance due to Resident 4 coming over to his side of the room and at approximately 2:20 a.m., Resident 4 walked over to Resident 3's side of the room, pulled his room curtain, grabbed Resident 3's call light and tossed it off the bed, grabbed his throat, and began choking him. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate safety measures to ensure a safe environment free of accidents or hazards and prevent elopement (form of unsupervised wandering that leads to the resident leaving the facility) for two of two residents (Resident 1 and Resident 2) when, 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of quality care for one out of four sampled residents (Resident 1) when, Resident 1's prescribed medications were left unattended at her bedside, and a diagnostic test ordered to determine the cause of her illness was not completed in a timely manner. These failures had the potential for harm to Resident 1 and other residents who could gain access to her medications and to cause a delay in Resident 1's medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu and recipes were followed during the lunch meal preparation on 1/8/25, for 94 residents who received food prepared in the facility kitchen when: 1. The recipe for Asian Cucumber Salad was not followed; 2. The recipe for Asian [NAME] was not followed; and, 3. The Asian smooth sauce was not prepared. These failures had the potential to affect the flavor of the food, with the potential for inadequate food intake, and could negatively affect the residents' dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and served to meet the needs of 94 residents who received food from the kitchen during the lunch meal on 1/8/25 when: 1. Residents on regular portion diet received less than the required amount; 2. 12 Residents with orders for chopped and easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct amount of Beef and Broccoli; 3. Residents on a pureed diet received the incorrect portion of Asian Beef and Broccoli, and did not receive Potstickers; 4. Three Residents on a large portion diet did not receive the correct amount of Asian Beef and Broccoli and Asian [NAME] Rice; 5. Residents with orders for Consistent Carbohydrate Diet (CCHO-helps manage blood sugar levels) received the incorrect portion size of Asian [NAME] Rice; and, 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 94 residents who ate facility prepared meals when: 1. Stove and oven contained grease, build-up of food particles, and white, black, and brown colored grimy areas; 2. Over-ripe and spoiled produce was available for use in the walk-in refrigerator; 3. Food was stored in the refrigerator beyond the use by date (UBD) and food marked on the box Keep Frozen was stored in the refrigerator; 4. Food was not stored and maintained at the proper temperatures in the walk-in refrigerator and walk-in freezer; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when: 1. Licensed Nurse (LN) 1 did not wear the required personal protective equipment (PPE -gown, gloves, eye protection, and/or facemasks used to prevent the spread of germs) for Resident 72 on Enhanced Barrier Precautions (EBP - infection control intervention to reduce transmission of resistant germs through gown and glove use during high-contact resident care activities) while providing gastrostomy tube (G-tube - a feeding tube that was surgically inserted into the resident's stomach to allow access for food, fluids, and medications) care; 2. A sterile wound dressing was stored open in a treatment cart; 3. Resident 89's room did not have an EBP sign posted, and the PPE supplies were not available outside the door to the room; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) was followed based on facility policy and national standards for a resident census of 104 when: 1. McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) was not followed for prescribing antibiotic(s) for Resident 31; and, 2. Antibiotic outcomes (the result of antibiotic use for the infection) were not measured. During a concurrent interview and record review on 1/9/25, at 3:17 PM, with the Infection Preventionist (IP), an ASP spreadsheet titled, ANTIBIOTIC/INFECTION SURVEILLANCE, dated 12/24, was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 74) was treated with dignity and respect, when Certified Nursing Assistant (CNA) 3 and CNA 5 were speaking a foreign language over Resident 74 while providing care. This failure had the potential to impact Resident 74's self-esteem and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents who were permitted to self-administer medications (Resident 16 and Resident 60) had their medications stored in a safe manner, when expired and nonexpired medications were accessible to residents at their bedside and the facility failed to follow their self-medication administration Policy and Procedure (P&P). This failure had the potential for a medication overdose for Resident 16, Resident 60, and other residents in the facility, and low efficacy (decrease in effectiveness of medication) of Resident 16's expired medications.

Inspectors wroteBased on interview, and record review, the facility failed to implement an individualized care plan intervention for 1 of 22 sampled residents (Resident 44) when Resident 44 had recommendations from a PASRR level II screening (identifies additional resources needed for residents with mental illness, intellectual or development disabilities) which were not incorporated into Resident 44's plan of care. This failure had the potential for Resident 44 to not receive recommended services to support health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 12) received the appropriate range of motion (ROM - the distance and direction a joint can move) services to increase range of motion and/or to prevent further decrease in range of motion. This failure could have resulted in Resident 1's ability to use his right hand to his fullest capacity and could have led to a decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure protection from potentially hazardous items, when three shaving razors were left on the counter unattended in a shared bathroom of four unsampled residents (Resident 58, Resident 55, Resident 87, Resident 41). This failure placed the facility's residents at risk for an injury in the case of accidental access to sharp items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 104 when: 1. The emergency kit (E-kit, a box containing emergency medications for faster and easy access when needed) for oral medications was opened and resealed on 1/2/25 and had not been replaced as of 1/7/25; and, 2. Narcotic medication use was not accurately documented in the Medication Administration Record (MAR- a record of the residents' medications and treatments) when removed from the Controlled Drug Record (CDR- a paper record that kept track of narcotic opioid medication [medications used to treat pain that cause drowsiness, dull the senses, and are prone to abuse] use for accountability) sheet for Resident 73. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 31) was free from unnecessary medications when, Resident 31 continued receiving an antibiotic for a urinary tract infection (UTI- an infection in any part of the urinary system) without having met established McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) for continued use of the antibiotic as specified in the facility's Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 104 when: The refrigerator in the Medication Storage Room containing liquid controlled substances (a drug or chemical that is regulated by the government in terms of its manufacture, possession, and use) was unlocked. This failure increased the risk of drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a closed garbage (dumpster) bin. This failure had the potential to lead to insect and rodent infestation.

Inspectors wroteBased on interview, and record review, the facility failed to maintain the confidentiality of 1 of 22 sampled residents (Resident 19), when portions of Resident 19's medical records were discovered in Resident 001's medical record. This failure had the potential for exposure of Resident 19's private and confidential information to unauthorized individuals.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) who received hospice care (end of life care) had care coordinated between the facility and the hospice agency, when the facility requested a medication review recommended on 12/10/24 for Resident 2, and did not follow up on the outcome of the review. This failure resulted Resident 2's medication review not available in Resident 2's clinical record and had the potential for not providing quality care to a terminally ill resident (Resident 2).

Inspectors wroteBased on interview, and record review, the facility failed to provide care and services according to professional standards of practice and the comprehensive care plan for one of three sampled residents (Resident 1) when a physician ordered pain medication (Tramadol-used to relieve moderate to moderately severe pain) did not arrive from the pharmacy until three days after Resident 1's admission to the facility, and the medication was not administered from the E-kit (an emergency supply of medication) even though it was available. These failures put Resident 1 at risk for increased, uncontrolled pain and had the potential to affect her psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary services were provided for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 went one week (6/19/24-6/26/24) without receiving a shower and Resident 2 did not have a shower for six days. These failures placed Resident 1 and Resident 2 at risk for poor hygiene, poor skin integrity, increased risk of infection, and self-isolation.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe environment for 6 out of 29 sampled residents (Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, and Resident 462) when: 1. Resident 1, Resident 6, Resident 83, and Resident 43's smoking paraphernalia were not stored correctly, 2. Resident 43 was smoking in the designated smoking area with an oxygen tank; and, 3. Resident 101 and Resident 462's fall care plan interventions for landing mats at the bedside were not implemented. These failures had the potential to result in avoidable injuries for Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, Resident 462, and the potential to affect all residents' safety in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct measuring scoops were used when [NAME] 1 did not measure the small portion diets correctly for 8 residents who received small portions. This failure resulted in plating unknown quantites of lunch items including starch with a potential to negatively impact the residents' nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 105), was treated with dignity and respect when: 1. Certified Nursing Assistant (CNA) 2 did not knock on Resident 105's door prior to entering his room; and, 2. CNA 2 was not seated when assisting Resident 105 with his breakfast meal. These failures resulted in Resident 105 not being treated with dignity and respect and had the potential to negatively affect Resident 105's feeling of self-worth.

Inspectors wrote2. A review of Resident 61's admission RECORD indicated Resident 61 was admitted to the facility in 2022 with diagnoses which included, acute and chronic respiratory failure (disease that can cause shortness of breath, anxiety, and confusion), muscle weakness, and polyneuropathy (nerve disease that causes a decreased ability to move and feel). During an observation on 12/12/23, at 8:46 AM, Resident 61 was observed lying in bed with no call light visible. When asked to demonstrate call light use, Resident 63 attempted to reach his call light multiple times without success. During an observation and interview on 12/12/23, at 9:03 AM, the Director of Staff Development (DSD) confirmed Resident 61's call light was not in reach. The DSD obtained Resident 61's call light from underneath his pillow behind his left shoulder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 out of 29 sampled residents (Resident 63) rights related to treatment preferences were known and documented in their physician orders and care plans when: Resident 63's cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure) status order and care plan did not match the CPR preferences listed on her Physician Order for Life Sustaining Treatment (POLST, a written medical order from a physician specifying the types of treatment an individual wants to receive during a serious illness). This failure had the potential risk for Resident 63's preferences regarding emergency treatment to not be followed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 29 sampled residents' (Resident 1) Pre-admission Screening Resident Review (PASSR, a screening tool used to evaluate an individual who may have a mental disorder or intellectual disabilities) was updated when Resident 1 received an additional diagnosis, other schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), on 2/3/23. This failure had the potential to result in Resident 1 not receiving additional mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 14 residents (Resident 46) receiving oxygen in the facility, received oxygen consistent with professional standards of care when Resident 46 had an oxygen concentrator that was not free of dust and debris. This failure had the potential to result in respiratory illness and infection in Resident 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication handling for a census of 99 when: 1. Facility did not ensure safe storage and handling of hazardous medications (drugs that pose short-or long-term harm upon exposure to human via skin or inhalation); and, 2. Facility did not ensure prescription medication delivery receipts were signed and accounted for by a licensed nurse (LN). These failures could contribute to unsafe medication handling and possible drug diversion (illegal or abuse of prescription drugs).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a high dose of Ergocalciferol [Vitamin D product; helps the body absorb calcium and phosphorous (vital minerals) for healthy bones and used in the treatment of diseases caused by a hormonal imbalance like hypoparathyroidism (a hormone that regulated mineral absorption)] was reassessed for continued use in 1 out of 5 residents (Resident 95) sampled for unnecessary medications. This failure could result in unsafe medication use, accumulation of medication in the resident's body and adverse effects.

Inspectors wroteBased on interview, and record review, the facility failed to ensure antipsychotic medication (drugs used to treat mood and mental health disease) use, diagnosis (medical or mental indication), and monitoring was based on standards of practice in 2 out of 18 residents (Resident 5, Resident 61) when: 1. Resident 5 did not have a specific diagnosis for the use of an antipsychotic medication called Zyprexa (a mind-altering antipsychotic drug); and, 2. Resident 61 was documented as having a diagnosis of schizophrenia for resistive to care as documented in the medical record for use of Risperdal (a mind-altering antipsychotic drug). These failures could result in unsafe medication use and/or treatment of mental health or behavior issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 99 residents. The facility had a total of four errors out of 44 opportunities which resulted in a facility wide medication error rate of 9.09 %. Medication administration observations were conducted at varied times, in random locations throughout the facility. These failures had the potential to result in unsafe medications use and not following the doctor's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stored resident's medication and supplies) with a census of 99 when: 1. Expired (outdated) medications were stored in the medication storage room and medication carts; and, 2. A medication refrigerator located in the facility's [NAME] station was overcrowded and the temperature was 50 degrees upon opening. These unsafe medication storage practices could contribute to medication error and unsafe medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in accordance with professional standards of food service safety for 90 out of 99 residents receiving food from the kitchen when: 1. Pureed food was taste tested using the same spoon, 2. All food items for the lunch meal on 12/14/23 were not temped (process for taking temperatures of prepared food items using a calibrated kitchen thermometer); and, 3. The food preparation sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink) located under the food preparation sinks (where fruits, vegetables and other foods are prepared). These failures had the potential to expose 90 residents of a census of 99 to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control and prevention practices with a census of 99 when: 1. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care for Resident 66; and, 2. Staff did not follow hand hygiene (cleaning and sanitizing hand) in-between resident care for Resident 57 and Resident 82, and Resident 72. These failures could pose health safety risks and spread of infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate, and complete assessment for 1 of 3 sampled residents (Resident 1) when Resident 1's elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) risk assessments were not completed accurately. This failure potentially contributed in Resident 1 eloping from the facility on 10/25/23 without the facility's knowledge and was not found for over 24 hours.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect one resident's rights (Resident 2) of three sampled residents, to be free from physical abuse when Resident 1 went to Resident 2's room and pushed Resident 2 out of his wheelchair causing Resident 2 to fall. This failure resulted in Resident 1 physically attacking Resident 2, resulting in a fall and a scratch to the left cheek.