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Complaint Investigation

Fulton Gardens Post Acute, Llc

November 18, 2025 · Stockton, CA · 537 E. Fulton Street
Citations 3
CMS Rating 2/5
Beds 116
Provider ID 055833
Healthcare Facility
Fulton Gardens Post Acute, Llc
Stockton, CA  ·  View full profile →
Inspection Summary

FULTON GARDENS POST ACUTE, LLC in STOCKTON, CA — inspection on November 18, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0584
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fulton Gardens Post Acute, LLC

537 E.

Fulton Street Stockton, CA 95204

SUMMARY STATEMENT OF DEFICIENCIES

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'

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fulton Gardens Post Acute, LLC

537 E.

Fulton Street Stockton, CA 95204

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STOCKTON, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FULTON GARDENS POST ACUTE, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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