Other·May 28, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00628057. Representing the Department of Public Health: HFEN, 40327 HFEN, 40911 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 05/28/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TRR11 Facility ID: CA030000075 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055833 (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FULTON GARDENS POST ACUTE, LLC 537 E. Fulton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, record review, and facility policy, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) when Resident 1's sister reported an incident of alleged abuse to the facility. This failure placed Resident 1 at potential risk of further abuse and prevented a timely and independent investigation by the Department. Findings: Resident 1 was a long term resident of the facility with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). According to the most recent quarterly Minimum Data Set (MDS-an assessment tool) dated 2/21/19, Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status indicating he was cognitively intact. In an interview on 3/12/19, at 10:46 a.m., Resident 1 stated licensed nurse (LN) 1 threw an inhaler (delivers medication into the body via the lungs) on his chest and used profanity that made him uncomfortable. Resident 1 added, he informed his sister of the incident and his sister reported the incident to the facility a few weeks ago. Resident 1 confirmed LN 1 still provided care to him since the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TRR11 Facility ID: CA030000075 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055833 (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FULTON GARDENS POST ACUTE, LLC 537 E. Fulton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE incident occurred. In an interview on 3/12/19, at 11:11 a.m., LN 1 stated she was aware of Resident 1's allegations against her. LN 1 added, she had a discussion with the facility management regarding the alleged incident and asked the director of nurses (DON) and administrator (ADM) if she could be removed off the schedule while the alleged incident was being investigated by the facility. LN 1 confirmed she was not taken off the schedule and still continued to provide care to Resident 1. In a concurrent interview and record review on 3/12/19, at 11:57 a.m., the director of staff development (DSD) stated she was made aware of the allegations by Resident 1's sister when she came to the facility on 2/27/19. The DSD further stated a grievance form was completed and the alleged incident was investigated by the DON and the ADM. A review of the facility document titled, "Complaint/Grievance Report Form" dated 2/27/19, indicated, LN 1 threw an inhaler at Resident 1. LN 1 used profanity in front of Resident 1 while providing his medication. The Complaint/Grievance Report Form was signed by the DON on 2/27/19, ADM on 2/28/19 and social services on 3/1/19. In an interview on 3/12/19, at 12:06 p.m., the DON stated she had spoken to Resident 1's sister and LN 1 regarding the allegations. The DON acknowledged LN 1 was not taken off the schedule and was still assigned to provide care to Resident 1 since the day of the alleged incident. The DON validated the alleged incident was investigated by the facility, but not reported to the Department and stated, "We did not report [Resident 1's allegations]. It was not abuse." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TRR11 Facility ID: CA030000075 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055833 (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FULTON GARDENS POST ACUTE, LLC 537 E. Fulton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy titled, "Abuse Prohibition and Prevention Program" dated 6/1/2011, indicated, "...4.0 Definitions of Abuse Every client has the right to be free from verbal, sexual, physical, and mental abuse...Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to clients ...Examples of verbal abuse include...saying things to frighten a client, or conversation that would make the client uncomfortable...5.5 Investigation Any allegations involving mistreatment, neglect, or abuse...will immediately be reported to the Executive Director, Agency Administrator or designee and appropriate state enforcement/regulatory agencies." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TRR11 Facility ID: CA030000075 If continuation sheet 4 of 4