The Assistant Director of Nursing at Fulton Gardens Post Acute told federal inspectors in November that Resident 4's disruptive behavior included "cursing of others, disruptive sounds, disruptive screaming, and aggression." The behaviors intensified during night and morning shifts, when other residents were trying to sleep or rest.
Staff had previously assigned a one-on-one aide to provide constant supervision for Resident 4. But sometime during summer 2024, the facility discontinued that support.
The ADON could not explain why.
"The ADON explained she was not sure if administration conducted an IDT (interdisciplinary team meeting) prior to discontinuing Resident 4's one-on-one support and through review of Resident 4's electronic record, the ADON acknowledged she could not locate a progress note regarding this," inspectors wrote.
The facility's own policies require interdisciplinary teams to develop comprehensive care plans with "corresponding interventions for care" and "measurable objectives." Those plans must address residents' "medical, physical, mental and psychosocial needs" and account for how facility decisions affect other patients.
None of that happened before staff stopped supervising Resident 4.
Meanwhile, his roommates suffered the consequences. The ADON told inspectors that Resident 4's roommates "tended to be confused and not alert" — making them particularly vulnerable to the disruption.
The screaming affected residents throughout the hallway. "The ADON stated residents could hear him yelling," the inspection report noted. Nurses reported the yelling was "constant" at night, and residents complained they couldn't sleep.
When those residents asked to be moved to quieter rooms, staff refused.
"The ADON stated we have told residents they cannot move them to another location or room," inspectors found.
The facility's homelike environment policy, revised just months before the inspection, promises to "provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident." It pledges that the "facility environment should enhance the quality of life for residents, in accordance with resident preferences."
But Resident 4's neighbors found themselves trapped in a situation that violated both promises.
The ADON acknowledged the contradiction between policy and practice. She told inspectors "the expectation for residents was they can rest at night and have a relaxing day and not listen to constant yelling."
She also said staff should respond immediately when residents become disruptive. "The expectation was if a resident was yelling staff needs to attend to that resident right away as yelling can be a stressor to others."
Yet the facility had removed the very intervention — one-on-one supervision — that could have addressed Resident 4's behavior before it escalated to screaming.
Current monitoring consisted only of staff "charting Resident 4's behavior including cursing of others, disruptive sounds, disruptive screaming, and aggression." Writing down the problems did nothing to solve them.
The ADON said the disruption "came up recently" in discussions, and she believed Social Services was supposed to address the situation. But she could not recall when administrators last discussed the issue in their daily morning meetings.
Federal inspectors cited the facility for failing to provide a homelike environment that meets residents' needs and preferences. The violation affected multiple residents who were forced to endure sleep disruption and stress from their neighbor's untreated behavioral issues.
The inspection found that discontinuing Resident 4's supervision without proper evaluation or alternative interventions left vulnerable residents — including his confused and non-alert roommates — without protection from his aggressive and disruptive behavior.
Staff continued monitoring and documenting the screaming, but offered no solutions to residents who complained they couldn't sleep through the constant yelling that echoed through their hallway each night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fulton Gardens Post Acute, LLC from 2025-11-18 including all violations, facility responses, and corrective action plans.
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