Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fulton Gardens Post Acute, Llc during CMS and state inspections, most recent first.
A resident's medications were left unattended at her bedside, and a diagnostic test to determine the cause of her illness was delayed. The resident, with type 2 diabetes and hypertension, was unable to take her medications due to coughing, and the LN left them assuming it was permissible. The facility's policy required timely administration and completion of diagnostic services, which was not adhered to, leading to potential risks.
The facility did not follow the planned menu and recipes during lunch preparation, affecting 94 residents. The DSS substituted ingredients without RD approval, using insufficient cucumbers and unapproved items for the Asian Cucumber Salad. The Asian [NAME] Rice was served without necessary ingredients, and the Asian Smooth Sauce was not prepared, impacting residents needing specific food consistencies.
The facility failed to provide meals according to the dietary needs of 94 residents during a lunch meal. Residents on various diets, including regular, chopped, pureed, large portion, CCHO, and fortified diets, received incorrect portion sizes or missing items. These deficiencies were observed during a lunch tray line and confirmed through staff interviews and document reviews.
The facility failed to maintain proper food safety and sanitation standards, with issues including unclean kitchen equipment, improper food storage, and inadequate temperature monitoring. Spoiled produce and food stored beyond use-by dates were found, and a visibly ill employee prepared food without proper hand hygiene. Unwashed mushrooms were also served, increasing the risk of foodborne illness for residents.
The facility failed to implement proper infection control measures, including the use of PPE and EBP signage, for residents with indwelling devices. A nurse did not wear a gown while providing G-tube care, and another stored an open sterile dressing improperly. Additionally, a resident's room lacked EBP signage and PPE supplies, and a nurse did not wear a gown when accessing a PICC line, all of which increased the risk of infection.
The facility failed to follow its Antibiotic Stewardship Program, resulting in deficiencies in monitoring and optimizing antibiotic use. A resident was prescribed antibiotics without following the McGeer Criteria, as no laboratory specimen was sent for testing. The facility's documentation was incomplete, lacking details on the duration of antibiotic therapy and outcomes. The Pharmacist Consultant highlighted the risk of antibiotic resistance due to the lack of diagnostic tests, which could lead to incorrect medication prescriptions.
A resident's right to dignity was violated when two CNAs spoke a foreign language over her while providing care, making her feel uncomfortable. The facility's policy required staff to speak English to ensure residents' emotional comfort, which was not adhered to in this instance.
Two residents permitted to self-administer medications had their medications stored unsafely, with expired and unsecured medications accessible at the bedside and in a tote bag. The facility failed to follow its policy requiring medications to be stored in a locked container, increasing the risk of overdose and reduced efficacy. The residents' cognitive impairments and the presence of other residents with wandering behavior further heightened the risk.
A facility failed to implement an individualized care plan for a resident with dementia and schizophrenia by not incorporating PASRR Level II recommendations. The PASRR Level II screening was completed but not uploaded to the resident's EMR, and the recommendations were not included in the care plan, posing a risk of not receiving necessary specialized services.
A resident with a history of stroke and aphasia did not receive consistent Assisted Active ROM (AAROM) services as required by their care plan. The resident's right hand was contracted, and documentation of AAROM was often marked as 'Not Applicable' or missing. Staff interviews confirmed the inconsistency in performing and documenting AAROM, and the Therapy Director noted the need for a splint. The facility's leadership acknowledged the failure to adhere to policies, which could have affected the resident's hand function and quality of life.
Three shaving razors were left unattended on the counter in a shared bathroom used by four residents, posing a risk of injury and infection. A nurse confirmed the hazard, and interviews with the Director of Staff Development and the DON highlighted the violation of facility policy, which requires the containment of hazards to protect residents.
The facility failed to ensure safe pharmaceutical services by not replacing an opened emergency kit and inaccurately documenting narcotic medication use for a resident with intervertebral disc degeneration. The emergency kit was not replaced in a timely manner, and the required confirmation fax was not found. Additionally, the Medication Administration Record did not reflect the narcotic dosages signed out for the resident, indicating a failure to follow facility policy.
A resident was prescribed Ciprofloxacin for a UTI without meeting the McGeer Criteria for continued use, as no urine specimen was collected. The facility's policies on infection prevention and antibiotic stewardship were not followed, leading to unnecessary antibiotic use. The absence of urinalysis results and physician progress notes further highlighted the deficiency.
The facility failed to secure liquid controlled substances in a locked refrigerator, as required by policy, increasing the risk of unauthorized access. A nurse found the refrigerator unlocked and secured it immediately. The DON confirmed the policy breach, which mandates controlled medications be stored securely with limited access.
The facility failed to maintain closed garbage bins, as observed during an inspection with the Dietary Service Supervisor (DSS). The bins were found open, contrary to the facility's policy on sanitary garbage disposal, which aims to prevent pest infestations. The DSS confirmed that the dumpsters should be kept closed to avoid attracting pests.
A resident's medical records were mistakenly placed in another resident's EHR, breaching confidentiality. The Director of Medical Records and the Administrator confirmed the error, acknowledging it as a HIPAA issue. Despite using a software program to manage records, the facility failed to follow its Privacy and Confidentiality Policy, leading to potential exposure of private information.
A facility failed to coordinate care with a hospice agency for a resident receiving end-of-life care. After an incident involving the resident, the IDT recommended a medication review by hospice, but the facility did not follow up, leaving the review undocumented in the resident's record. The hospice agency confirmed the review was done and faxed to the facility, but it was not received due to staff oversight during shift changes. The DON admitted the facility's service agreement and policy for hospice services were not followed.
A resident experienced a delay in receiving physician-ordered Tramadol for pain management due to pharmacy prescription requirements, despite its availability in the E-kit. The resident endured moderate pain levels, and Tylenol was provided as an inadequate substitute.
Two residents did not receive scheduled showers, with one going a week and the other six days without one. Despite needing assistance, the facility failed to provide showers as per policy, leading to family members intervening. Staff confirmed the oversight and lack of documentation for missed showers.
Medication Mismanagement and Delayed Diagnostic Testing
Penalty
Summary
The facility failed to maintain professional standards of quality care for a resident when 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. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hypertension, was observed with her medications left in a plastic cup on her tray table. The resident stated she could not take her morning medications due to excessive coughing. The Licensed Nurse (LN) left the medications with the resident, assuming it was permissible since the resident was alert, despite the absence of an order allowing the resident to self-administer these medications. The Minimum Data Set Coordinator confirmed that the resident's assessment only permitted self-administration of Bengay, not other medications. The Director of Staff Development highlighted the risks associated with leaving medications unattended, such as potential access by other residents and the risk of choking. The LN acknowledged that the medications should not have been left at the bedside and should have been administered within the prescribed time frame. The facility's policy on administering medications emphasized the need for safe and timely administration per physician orders and compliance with state and federal guidelines. Additionally, there was a delay in completing a diagnostic chest X-ray ordered to rule out pneumonia. The order was placed on January 17, but the X-ray was not performed until January 19, with the report dated January 20. The delay was attributed to the X-ray provider's limited operating hours and a lack of follow-up by the facility staff. The facility's policy on laboratory services required timely completion of diagnostic services and prompt reporting of abnormal results to ensure quick action. The Licensed Vocational Nurse's job description also emphasized the responsibility to manage care plans and report any undelivered care to the Director of Nursing.
Failure to Follow Menu and Recipes During Meal Preparation
Penalty
Summary
The facility failed to adhere to the planned menu and recipes during lunch meal preparation, affecting 94 residents. The Dietary Service Supervisor (DSS) substituted ingredients without approval from the Registered Dietician (RD), which included using only eight cucumbers instead of the required three gallons for the Asian Cucumber Salad. The DSS also added unapproved ingredients like three-bean salad and Italian dressing, deviating from the standard recipe that required rice vinegar, honey, sesame oil, red crushed pepper, and salt. The RD confirmed that these substitutions were not approved and could lead to poor intake and weight loss among residents. Additionally, the facility did not follow the recipe for Asian [NAME] Rice, as it was served without the necessary ingredients such as low sodium chicken stock, soy sauce, sesame oil, and sliced green onions. Furthermore, the Asian Smooth Sauce, which was required for residents needing soft, bite-sized, minced, moist, and ground consistency, was not prepared. This oversight meant that no alternative was provided for these residents, potentially impacting their dining experience and nutritional intake.
Failure to Meet Dietary Needs During Meal Service
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the dietary needs of 94 residents during a lunch meal. Residents on regular portion diets received less than the required amount of food, as the kitchen staff used a #10 scoop instead of the #8 scoop specified in the facility's serving directions. Additionally, residents with orders for chopped, easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct portion sizes of Beef and Broccoli. Residents on pureed diets received incorrect portions of Asian Beef and Broccoli and did not receive Potstickers as required. Furthermore, three residents on large portion diets did not receive the correct amount of Asian Beef and Broccoli and Asian Rice. Residents on Consistent Carbohydrate Diets (CCHO) received incorrect portion sizes of Asian Rice, and 14 residents requiring fortified diets did not receive the additional items needed to increase their caloric intake. These deficiencies were observed during a lunch tray line observation and confirmed through interviews with dietary staff and a review of facility documents, indicating a failure to follow the established dietary guidelines and serving sizes.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by multiple observations of unsanitary conditions and improper handling of food. The stove and oven were found to have significant grease and food particle buildup, and the cleaning schedule was not adhered to due to staffing issues. Over-ripe and spoiled produce was found in the walk-in refrigerator, and food items were stored beyond their use-by dates or not kept at the required temperatures. Additionally, food labeled to be kept frozen was improperly stored in the refrigerator. The walk-in refrigerator and freezer were not maintaining the correct temperatures, posing a risk of food spoilage. The external and internal thermometers showed temperatures outside the safe range, and the facility's maintenance team had to adjust the equipment settings. Unit refrigerators and freezers at various nurse stations were also found to be unclean, with missing temperature logs and improperly labeled resident food. These conditions were confirmed by the Dietary Service Supervisor and other staff members, who acknowledged the risks of foodborne illness to residents. A visibly ill employee was observed preparing food without following proper hand hygiene protocols, such as washing hands after coughing. This employee was allowed to work despite showing symptoms of illness, and there was no clear policy for excluding sick staff from food preparation duties. Additionally, unwashed mushrooms with visible dirt were prepared and served, contrary to the facility's policy and FDA guidelines. These deficiencies in food safety practices placed residents at risk for foodborne illnesses.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for several residents, leading to potential health risks. In one instance, a Licensed Nurse (LN) did not wear the required personal protective equipment (PPE) while providing gastrostomy tube care to a resident on Enhanced Barrier Precautions (EBP). Despite the presence of a sign indicating EBP isolation, the nurse only wore gloves and failed to don a gown, which is necessary to prevent cross-contamination and the spread of multi-drug resistant organisms. Another deficiency was observed when a sterile wound dressing was improperly stored in an open state within a treatment cart. A nurse admitted to opening the dressing package in preparation for a procedure that was postponed, and acknowledged that the dressing should have been discarded to prevent infection risks. The facility's policy mandates the disposal of unused opened dressings to avoid cross-contamination, which was not followed in this case. Additionally, a resident's room lacked the necessary EBP signage and PPE supplies outside the door, despite the resident having a permacath that required such precautions. Staff members, including a Certified Nurse Assistant (CNA), were unaware of the EBP requirements and did not use PPE when assisting the resident, increasing the risk of infection. Furthermore, another LN failed to wear a gown while accessing a PICC line for a resident, contrary to the EBP guidelines, which require gown and glove use during high-contact care activities involving indwelling devices.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) and national standards, resulting in deficiencies in monitoring and optimizing antibiotic use. Specifically, the facility did not follow the McGeer Criteria for prescribing antibiotics to Resident 31, as no laboratory specimen was sent out for testing despite the criteria indicating that two infection criteria were met. Additionally, the facility did not consistently document the duration of antibiotic therapy or monitor the outcomes of antibiotic use, which are essential components of the ASP. During the review of the facility's ASP spreadsheet, it was found that the documentation was incomplete and inconsistent. The spreadsheet did not include the duration of antibiotic therapy, the date of diagnostic tests ordered, or the outcomes of antibiotic use. The Infection Preventionist (IP) confirmed that the spreadsheet used to include this information but no longer did. Furthermore, the IP acknowledged that outcome monitoring was not being conducted, and the McGeer Criteria marked as met for Resident 31 was done in error. The Pharmacist Consultant emphasized the importance of conducting diagnostic tests when prescribing antibiotics to prevent antibiotic resistance. The facility's failure to order culture and sensitivity tests when prescribing antibiotics could lead to prescribing incorrect medications, contributing to the development of Multiple Drug Resistant Organisms (MDRO). The facility's policy on the Antibiotic Stewardship Program, which aims to limit antibiotic resistance and improve treatment efficacy, was not being followed, as evidenced by the lack of infection surveillance data analysis and outcome measurement.
Violation of Resident's Right to Dignity Due to Language Barrier
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when two CNAs spoke a foreign language over the resident while providing care. During an observation, the CNAs were seen on opposite sides of the resident's bed, engaging in a conversation in a foreign language that was audible from outside the room. The conversation was personal and unrelated to the resident's care, which was confirmed by the CNAs during a joint interview. The resident expressed discomfort and dissatisfaction with the situation, stating that the CNAs should not have spoken in a foreign language over her. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility's policy required staff to speak English to avoid making residents feel emotionally uncomfortable. The facility's policy on dignity and respect emphasized the importance of treating residents with kindness, respect, and dignity at all times. The incident was identified as a violation of the resident's right to dignity, as it made the resident feel excluded and uncomfortable during care.
Failure to Secure Medications for Self-Administering Residents
Penalty
Summary
The facility failed to ensure that two residents, who were permitted to self-administer medications, had their medications stored safely. For Resident 16, a variety of both prescribed and over-the-counter medications were found unlocked and accessible at the bedside, some of which were expired. Despite having a physician's order to self-administer only Vitamin D3 and Centrum Silver, Resident 16 had numerous other medications, including Tylenol, Aspirin, and Metformin, which were not secured. The facility did not have a system to track the self-administration of these medications, and the medications were not stored in a locked container as required by the facility's policy. Resident 16's roommates were noted to have cognitive impairments, increasing the risk of accidental ingestion of the unsecured medications. The facility's Licensed Nurse confirmed that the medications should have been locked and acknowledged the risk of overdose and reduced efficacy due to expired medications. The facility's policies on medication storage and self-administration were not followed, as evidenced by the presence of expired medications and the lack of secure storage. Similarly, Resident 60 was found carrying medications in a tote bag on her walker, which was accessible to other residents. Although Resident 60 had a locked box for medications in her room, the medications were not stored securely when outside the room. The facility's Regional Nurse Consultant and Assistant Director of Nursing confirmed that the facility's policy was not followed, as medications should have been stored in a locked container to prevent access by other residents.
Failure to Implement PASRR Recommendations in Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan intervention for a resident who had recommendations from a PASRR Level II screening. This screening is designed to identify additional resources needed for residents with mental illness, intellectual, or developmental disabilities. The resident, who was admitted in 2023, had diagnoses including dementia and schizophrenia. Although the PASRR Level I screening results were present in the resident's electronic medical record (EMR), the PASRR Level II report was not attached. The Minimum Data Set Coordinator confirmed that the PASRR Level II screening was completed but not uploaded to the EMR, and the recommendations were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the facility's policy was not followed, as the PASRR Level II recommendations should have been added to the resident's care plan. The facility's policy and procedure for developing comprehensive care plans emphasize the need to incorporate PASRR recommendations to address the resident's medical, physical, mental, and psychosocial needs. The failure to include these recommendations in the care plan posed a risk that the resident would not receive the necessary specialized services or rehabilitative services as identified by the PASRR Level II evaluation.
Failure to Provide Consistent ROM Services
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to Resident 12, who had a history of stroke and aphasia, resulting in limited mobility and a contracted right hand. The resident's care plan included Assisted Active ROM (AAROM) exercises for both upper and lower extremities during daily activities, but these were not consistently documented or performed. Observations and interviews revealed that the resident's right hand was contracted, and AAROM exercises were not regularly conducted or recorded, as evidenced by multiple instances where documentation was marked as 'Not Applicable' or missing. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), confirmed that AAROM exercises were not consistently performed or documented. The CNA admitted to not performing AAROM on a specific date, and the LN acknowledged the importance of these exercises in maintaining the resident's hand function. The lack of documentation for refusals of AAROM further indicated a failure to adhere to the facility's policy and procedures, which required reasons for not providing ROM services to be documented in the medical record. The Therapy Director assessed the resident and noted the stiffness in the resident's right thumb, suggesting the need for a splint, which had not been provided. The facility's Administrator and Director of Nursing reviewed the records and acknowledged the failure to ensure that AAROM was performed as required. This deficiency in care could have impacted the resident's ability to use his right hand effectively, potentially affecting his quality of life.
Unattended Razors Pose Risk in Shared Bathroom
Penalty
Summary
The facility failed to ensure the safety of residents by leaving three shaving razors unattended on the counter in a shared bathroom used by four residents. This oversight was observed during a survey on January 7, 2025, at 10:20 AM. The razors were accessible to residents, which posed a risk of injury and infection, particularly for those who might be confused or disoriented. Licensed Nurse 8 confirmed the presence of the razors and acknowledged the potential danger they posed to residents. Further interviews with the Director of Staff Development and the Director of Nursing reinforced the concern that leaving razors unattended in a shared bathroom was against facility policy and posed a risk of injury and infection. The facility's policy, dated March 2023, emphasized the importance of maintaining a resident environment free from accident hazards and ensuring adequate supervision. The policy specifically mentioned the need to contain hazards to protect residents from harm, highlighting the facility's failure to adhere to its own guidelines.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by two main deficiencies. Firstly, the emergency kit (E-kit) for oral medications was opened and resealed on January 2, 2025, but had not been replaced by January 7, 2025. During an observation and interview, a licensed nurse (LN) confirmed that medications were removed from the E-kit, and the required confirmation fax receipt from the pharmacy was not found. The Director of Nursing (DON) confirmed that the facility policy, which required the form to be faxed to the pharmacy within 24 hours and followed up to ensure receipt, was not followed. Secondly, the facility failed to accurately document the use of narcotic medication for a resident. The Controlled Drug Record (CDR) indicated that Hydrocodone-Acetaminophen was signed out for the resident on two occasions, but the Medication Administration Record (MAR) did not reflect these dosages. The DON acknowledged this discrepancy and confirmed that the facility policy was not followed, which required accurate documentation of medication administration. The resident involved had a medical history of intervertebral disc degeneration, which can cause significant pain. The failure to document narcotic medication use accurately could lead to unsafe medication practices and potential drug diversion. The facility's policies and procedures for administering medications and handling controlled substances were not adhered to, as confirmed by the DON.
Failure to Adhere to Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically antibiotics, as part of their drug regimen. Resident 31 was prescribed Ciprofloxacin for a urinary tract infection (UTI) without meeting the established McGeer Criteria for continued use of the antibiotic. The Infection Preventionist (IP) confirmed that the resident was started on the antibiotic based on an SBAR assessment tool, but a urine specimen was not collected to confirm the infection, which was a requirement for meeting the McGeer Criteria. The review of Resident 31's records revealed that there were no urinalysis results for December, and no physician progress notes addressed the assessment of a new infection or the review of antibiotic effectiveness. The Director of Medical Records confirmed the absence of urinalysis results, and the Pharmacist Consultant emphasized the importance of diagnostic tests to prevent antibiotic resistance. The facility's policy required a review of antibiotics 48 hours after initiation, but this was not documented in the resident's records. The facility's Infection Prevention and Control Program policy, as well as the Antibiotic Stewardship Interventions policy, were not adhered to in this case. The policies required maintaining records of infections and corrective actions, as well as performing a review of antibiotics to ensure appropriate use. The failure to collect a urine specimen and review the antibiotic regimen led to the unnecessary continuation of antibiotic therapy for Resident 31, which could contribute to the development of multi-drug resistant organisms.
Failure to Secure Controlled Medications in Locked Storage
Penalty
Summary
The facility failed to ensure the safe storage of medications, specifically liquid controlled substances, for a census of 104 residents. During an observation and interview, it was found that the refrigerator in the Medication Storage Room, which contained liquid narcotic medications and an emergency kit, was unlocked. A Licensed Nurse acknowledged that the refrigerator should have been locked and immediately secured it. The risk identified was that unauthorized individuals could access the medications if the refrigerator remained unlocked. Further interviews and record reviews with the Director of Nursing confirmed that the facility's policy was not followed. The facility's policy and procedure documents indicated that controlled medications should be stored separately and securely, with access limited to authorized personnel. The policy also specified that controlled medications requiring refrigeration must be stored within a locked, permanently affixed box inside the refrigerator. The failure to adhere to these policies increased the risk of drug diversion.
Failure to Maintain Closed Garbage Bins
Penalty
Summary
The facility failed to maintain a closed garbage (dumpster) bin, which had the potential to lead to insect and rodent infestation. During an observation and interview with the Dietary Service Supervisor (DSS), it was noted that the lids of the garbage bins were not in place, and the dumpsters were open. The DSS acknowledged that the garbage dumpsters should be kept closed to avoid pests. A review of the facility's policy titled 'Adequate Sewage Disposal and Plumbing,' dated 2019, indicated that improperly disposed of garbage is a source of unsanitary practices and unpleasant odors, and it can harbor vermin, flies, rodents, and cockroaches. The policy outlined practices to prevent this, including providing garbage containers in adequate supply to hold all garbage between collections and ensuring lids are tight-fitting and secure.
Confidentiality Breach in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, specifically for one resident whose records were mistakenly placed in another resident's electronic health record (EHR). This error was identified during an interview and record review with the Director of Medical Records (DMR), who confirmed that the Preadmission Screening and Resident Review (PASSR) forms for the affected resident were found in another resident's EHR. The DMR acknowledged that this was a Health Insurance Portability and Accountability Act (HIPAA) issue and noted that this type of error had been an ongoing problem, which she had been addressing as they were discovered. The Administrator (ADM) also confirmed the error, acknowledging that the facility had been using a specific software program to scan medical records into the EHR for a year, but despite this, records were still being uploaded incorrectly. The ADM confirmed that the affected resident's records were removed from the incorrect chart and uploaded to the correct one. The facility's Privacy and Confidentiality Policy, which aligns with HIPAA standards, was not followed in this instance, leading to the potential exposure of private and confidential information to unauthorized individuals.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the hospice agency for a resident receiving end-of-life care. The resident, who was admitted with diagnoses including palliative care and Alzheimer's disease, was involved in an incident where they scratched another resident. Following this, the interdisciplinary team (IDT) recommended a medication review by the hospice agency on a specific date. However, the facility did not follow up on the outcome of this review, resulting in the medication review not being available in the resident's clinical record. During interviews and record reviews, it was confirmed that the hospice agency had conducted the medication review and faxed the report to the facility. However, the facility staff, particularly during shift changes, did not receive the faxed report. The Director of Nursing (DON) acknowledged that the facility's service agreement with the hospice agency and the facility's policy and procedure for hospice services, which required documentation of communication between the facility and hospice provider, were not followed. This oversight had the potential to impact the quality of care provided to the terminally ill resident.
Delayed Administration of Pain Medication
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice and the comprehensive care plan for a resident when a physician-ordered pain medication, Tramadol, did not arrive from the pharmacy until three days after the resident's admission. Despite the availability of Tramadol in the E-kit, the medication was not administered, leaving the resident at risk for increased, uncontrolled pain. The resident's medication administration record indicated a start date for Tramadol on the day of admission, with instructions to monitor and document pain levels. However, the resident experienced moderate pain levels of 5 on a 0-10 scale on the days following admission. The nursing staff attempted to address the issue by contacting the pharmacy and the physician, but the Tramadol prescription was delayed due to the need for a triplicate prescription. The resident was instead given Tylenol, which was deemed inadequate for the reported pain level. Interviews with nursing staff revealed that the resident repeatedly requested Tramadol, and there was an acknowledgment that uncontrolled pain could lead to other health concerns. The Tramadol prescription was eventually signed by the facility physician, and the medication was delivered to the facility, but not until after the resident had endured days of moderate pain.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents, resulting in missed showers over a period of several days. Resident 1, admitted with generalized weakness and difficulty walking, did not receive a shower for a week, from June 19 to June 26, 2024. Despite needing partial to moderate assistance with bathing, Resident 1 reported that showers were sometimes only offered once a week, and bed baths were given without the option of a shower. The resident expressed a preference for showers and had never refused one. Family Member 1 had to intervene multiple times to ensure Resident 1 was scheduled for showers. Resident 2, admitted for generalized weakness and rehabilitation, also experienced missed showers, going six days without one. CNA 1 confirmed that showers were supposed to be given twice a week but acknowledged that new admissions might not be scheduled correctly, leading to missed showers. Resident 2's family member had to provide a shower after complaints to the staff went unaddressed. Both the Licensed Nurse and the Director of Staff Development confirmed the missed showers and acknowledged the lack of documentation for refusals or reasons for the missed showers. The facility's policy on dignity and respect, which emphasizes grooming according to residents' preferences, was not adhered to in these cases.
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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 Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Noble Care Center | 0.5 mi | — | 5 | 0 |
| Hampton Post Acute | 0.6 mi | — | 14 | 0 |
| Oak Grove Post Acute | 0.8 mi | — | 61 | 0 |
| Good Samaritan Rehab And Care Center | 1.4 mi | — | 1 | 0 |
| Riverwood Health Care | 1.4 mi | — | 60 | 0 |
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