Fulton Gardens Post Acute, Llc

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

roommate safe. The ADON stated Resident 4's roommates tended to be confused and not alert. The ADON stated staff, including CNAs and LNs, were currently monitoring and charting Resident 4's behavior including cursing of others, disruptive sounds, disruptive screaming, and aggression. The ADON stated Resident 4's behaviors tend to manifest more during the night and morning shift. The ADON stated Resident 4 does not currently have a one-on-one staff member assigned to him providing constant supervision and was not sure when it was discontinued but thought it was sometime in the summer of

1. 2024. 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. The ADON stated she felt like the disturbance Resident 4's yelling caused other residents was mentioned in the daily stand-up morning meetings and administration meetings but could not recall when it was last discussed.

The ADON explained Resident 4's yelling mostly affected the residents in the rooms next to him or located

in the same hall. The ADON stated residents could hear him yelling. The ADON stated we have told residents they cannot move them to another location or room. The ADON stated the nurses have told her Resident 4 yelled at night, and it was constant, and residents complained they were not able to sleep. The ADON stated the issue came up recently and she felt like the Social Services was in charge of addressing

the situation. The ADON stated the expectation for residents was they can rest at night and have a relaxing day and not listen to constant yelling. The ADON stated 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. During a review of a facility policy and procedure (P&P) titled HOMELIKE ENVIRONMENT, revised 1/2025, the document indicated, .The facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression.DEFINITIONS: Homelike Environment: is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment . facility environment should enhance the quality of life for residents, in accordance with resident preferences.

Facility personnel strive for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable. During a review of

a facility P&P titled DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS POLICY STATEMENT, revised 1/2025, indicated, .The facility develops a person-centered comprehensive care plan that are culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Resident's Goal: The resident's desired outcomes and preferences for admission, which guide decision making during care planning.Interventions: Actions, treatments, procedures, or activities designed to meet an objective.Person-Centered Care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.The interdisciplinary team develops the care plan with corresponding interventions for care that is in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences.Care plans shall include the discipline providing care or services, measurable objectives, and timeframes in order to evaluate the resident's progress toward his/her goal(s).

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fulton Gardens Post Acute, LLC

537 E. Fulton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property .PURPOSE .To provide staff guidelines to ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse.Serious bodily injury: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse (see sections 2011(19)(A) and (B) of the Act).PREVENTION. The facility strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property through.Providing residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed.Identification, correction, and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.Deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure the staff assigned have knowledge of the individual residents'

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fulton Gardens Post Acute, LLC

537 E. Fulton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

where she was going to live when she leaves because she doesn't want to go back to living on the streets.

Resident 2 stated she would like to have drug counseling while at the facility. Resident 2 stated she loved

the feeling of being sober and because of being sober her daughter had come around to visit her at the facility. Resident 2 explained it had been three years since she had spoken with her children. Resident 2 stated she was scared she was going to relapse. Resident 2 stated staff had not offered help with addiction, behavior, or housing support. Resident 2 stated she had been diagnosed with anxiety and was taking medications to help with it. Resident 2 stated she had PTSD and felt sad and would start to cry randomly.During an interview on 9/11/25, at 2:53 p.m., with the SSD and the ADON, the SSD stated the facility can provide transportation for residents with outside medical or other appointments and the assistant administrator helps with this. The ADON stated nursing staff could help schedule medical appointments.

The SSD stated she could help with locating substance abuse programs and scheduling appointments for residents. The SSD stated for residents with a history of substance abuse within the last six months, staff would want to address this with the residents and develop interventions to be used in a care plan. The SSD explained residents who were agreeable to participate in a drug or alcohol abuse pro

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Facility ID:

If continuation sheet