Other·October 20, 2020

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 the investigation of complaint #CA00700184. Representing the Department of Public Health: Health Facilities Evaluator Nurse 29821 Public Health Nutrition Consultant III 34975 Public Health Nutrition Consultant III41838 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 10/30/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced 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: CZD511 Facility ID: CA030000075 If continuation sheet 1 of 15 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 09/30/2020 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 by: Based on interview and document review, the facility failed to provide required nutrition and hydration care and/or services to five of 14 sampled Residents (Residents 1, 2, 3, 4 and 5) when: 1) Resident 1's initial plan of care did not include specific interventions to prevent weight loss and dehydration, known from his medical history to be risks for the resident, 2) After a severe weight loss of more than 15 pounds (6.9% of his previous weight) in a week, Resident 1 was not assessed by nurses in a timely manner and the physician was not promptly notified, 3) Plan of care interventions were not implemented or reassessed to prevent further weight loss and decline, contributing to an additional loss of 20 pounds (9.7% of Resident 1's previous weight), and 4) Following the identification of severe weight loss for Residents 1, 2, 3, 4 and 5, written care plans were not personalized and lacked parameters and identified timeframes for the evaluation or the success of interventions. These failures contributed to severe weight loss for Resident 1, the potential for inadequate nutritional intake resulting in significant health problems for Residents 2, 3, 4 and 5, and possible significant harm up to and including the death of residents. Findings: 1) Review of the "Admission Record" indicated Resident 1 came to the facility on 6/20/20 with diagnoses including heart failure, diabetes mellitus (a disease characterized by high blood sugar levels) with chronic kidney disease, anemia (lack of sufficient healthy red blood cells to carry adequate oxygen to body tissues), hypothyroidism (underactive thyroid), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 2 of 15 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 09/30/2020 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 anorexia (eating disorder causing weight loss), swallowing difficulty, adult failure to thrive (FTT, a condition which may be caused by one or more chronic illnesses resulting in poor appetite, weight loss, increased fatigue and progressive functional decline), Stage 2 pressure injury (wound caused by unrelieved pressure resulting in damage to underlying tissue; a Stage 2 wound involves partial thickness skin loss with an inner skin layer exposed), muscle weakness, and depression. Additionally, he was diagnosed with a urinary tract infection on 7/22/20 and COVID-19 (a potentially life threatening viral illness) on 8/1/20. Resident 1 was being treated with medications which cause fluid loss including Lasix and as-needed lactulose. 1A) Review of Resident 1's initial care plan reflected a 6/21/20 intervention for "Dietary consult [consultation by an RD- Registered Dietitian]" and other actions as follows: "Monitor meal intake. Date Initiated: 6/20/20," "Diet as ordered and monitor % of intake and appetite. Date Initiated: 6/21/10," "Encourage fluid intake and meal intake. Date Initiated: 6/21/20," "Encourage fluids as tolerated if not contraindicated. Date Initiated: 6/21/20," "Monitor for poor appetite/intake and notify MD [Medical Doctor] PRN [as needed]. Date Initiated: 6/21/20," "Monitor/document/report to MD PRN for...weight loss...Date Initiated: 6/21/20," "Monitor Weight and notify MD of significant weight changes. Date Initiated: 6/21/20," "Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications [medications used to treat thought disorder processes or alter behavior]: refusal to eat...loss of appetite, weight loss...Date Initiated: 6/21/20," and "Monitor/record/report to nurse loss of appetite, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 3 of 15 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 09/30/2020 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 refusal to eat and weight loss. Date Initiated: 6/22/20." The initial care plan did not include specific guidelines for identifying the presence of a problem with appetite, meal intake or weight loss, or when and how staff should intervene for suspected problems, including physician notification and the frequency of weights. The facility's RD initially assessed Resident 1 on 6/26/20. In the 11:11 a.m., 6/26/20 initial "Nutritional Risk Assessment," the RD noted in the "Identification of Risk Factors" section that prior to his admission, Resident 1 had previously experienced an unplanned weight loss of " >5% [greater than 5 per cent] in 1 month; [or] >7.5% in 3 months; [or] >10% in 6 months." The resident's "Current Food and Fluid Intake" was described as "<50%." The "Pressure Sore & [and] Other Skin Condition" and "Swallowing difficulties" sections were marked "No." Resident 1 was noted to have "Nutritional Risk Related to...CHF [congestive heart failure]...T2DM [Type 2 diabetes mellitusadult onset diabetes], Depression...Hypothyroidism...Anemia, Adult FTT, Anorexia...Generalized Muscle Weakness, Poor appetite/intake ongoing several months, reported significant weight loss." Nutritional goals included improved intake of "51 to 100%" of meals taken, 2160 milliliters [ml, a unit of measure] of daily fluid intake, and "no sig wt variance x 90 days [no significant weight variance for 90 days]." During a 12:58 p.m., 9/8/20 interview, the RD indicated that difficulty swallowing was also a risk for developing a nutritional problem. She indicated Resident 1 was at risk for further weight loss at the time of her initial assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 4 of 15 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 09/30/2020 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 In a 1 p.m., 9/11/20 email communication, the RD calculated that Resident 1's average meal intake in the period immediately prior to her initial assessment, 6/21/20 - 6/25/20, had been only 25% and his fluid intake from meals averaged only 600 ml daily. In an 8:34 a.m., 9/9/20 interview, the RD stated she was not aware Resident 1 had been admitted with a pressure injury. The RD indicated that with pressure injuries, residents often need "increased protein in the diet," "multivitamins, Vitamin C, and protein supplements." In a 10:06 a.m., 9/15/20 interview, the RD confirmed that on 6/26/20 she had set a goal of "51% - 100%" for Resident 1's meal intake. However, she described the intake goal range as "just a reference for my progress" which was "not typically communicated to nursing." No additions to or changes in the nutritional care plan were noted in the record by the RD on the initial care plan. On 7/9/20, two interventions were added to Resident 1's nutritional care plan: "Nutritional approaches per RD recommendations and ordered by physician," and "Encourage good nutrition and hydration in order to promote healthier skin." During the 9/9/20 interview, the RD acknowledged that the initial care plan did not address Resident 1's nutritional risk. The RD noted that she "could have added 'at nutritional risk' to the care plan." 2) Review of Resident 1's "Weight Summary" revealed a weight of 221.6 pounds on 7/6/20. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 5 of 15 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 09/30/2020 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 On 7/12/20, his weight was measured at 206.3, a "loss of 15.3# [pounds]/6.9% in one week" according to 1:23 p.m., 7/16/20 "IDT [Interdisciplinary Team] Progress Notes Weight Variance & Nutritional Condition." In a 12:58 p.m., 9/8/20 interview, the RD stated this was considered a significant weight loss for Resident 1. Review of 7/12/20 to 7/16/20 "Assessments," "Progress Notes" and "Miscellaneous" sections of the medical record were reviewed and reflected no further documentation of Resident 1's weight loss until the 7/16/20 IDT notes which stated, "Appetite remains poor. Still with coccyx [lower back] stage 2 pressure wound. Started on health shake [a calorie-dense dietary supplement] TID [three times daily]. Weekly weights and RD consult." There was no documentation indicating a review of percentages of meal intake, snacks and fluids had taken place. In addition, no plan was outlined to address possible causes of weight loss and review preferences for intake with the resident. A 1:58 p.m., 7/16/20 "SBAR [Situation/Background/Assessment or Appearance/Request] - Change of Condition Progress Note" documented physician notification of the weight loss. Orders were given between 1:32 p.m. - 1:45 p.m., 7/16/20 for a daily multivitamin, health shakes three times daily, Vitamin C and two dietary supplements to aid in wound healing, as well as for monitoring the percentage of Resident 1's meal intake. In a 10:06 a.m., 9/15/20 interview, the Director of Nursing (DON) confirmed the significant weight loss of 7/12/20 but was unable to locate medical record documentation indicating the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 6 of 15 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 09/30/2020 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 physician had been notified of the change prior to 7/16/20. The DON stated that a physician should be notified of a significant weight loss "as soon as you note the weight loss." The facility's 8/13/19 "Assessment and Management of Resident Weights" policy indicated, "The DNS [Director of Nursing Services] or licensed nurse will...Notify the physician and dietitian of significant weight changes; and...Document notification in the nurses' notes...." The 1/1/17 "Change of Condition Notification" policy reflected, "The Facility will promptly inform...the resident's Attending Physician...when the resident endures a significant change in their condition...The Licensed Nurse will notify the resident's Attending Physician when there is...A change in weight of five pounds or more within a 30day period...." 3) After the 7/12/20 weight loss, the RD reassessed the resident on 7/17/20. In a 10:54 a.m., 7/17/20 progress note, the RD noted that Resident 1 should continue to be weighed weekly and that oral intake and weights should be monitored. During the 10:06 a.m., 9/15/20 interview, the DON confirmed that IDT intended weekly weights of Resident 1 to continue after the 7/12/20 weight loss. In the same interview, the RD confirmed her expectation that weekly weights would continue after 7/17/20 for at least an additional four weeks and until the resident was stable. Weekly weights recommended by the IDT and RD were not documented after that time, however. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 7 of 15 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 09/30/2020 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 After the 7/12/20 weight loss, Resident 1 was next weighed on 7/19/20 with a documented measurement of 207.9 pounds. Another weight was not noted until 5:06 p.m., 8/7/20, after the Department's 12:35 p.m., 8/7/20 visit. The resident's weight was measured at 187.8 pounds, a loss of an additional 20.1 pounds (9.7% decrease since 7/19/20) later noted by the RD in a 6:45 p.m., 8/13/20 "Progress Note" to be a significant (severe) 15.3% weight loss over 30 days. In an 10:06 a.m., 9/15/20 interview, the DON confirmed there were no weights documented in the medical record between 7/19/20 - 8/7/20. In a 2:11 p.m., 8/13/20 interview, the RD stated she did not reassess Resident 1's nutritional status during weekly 7/24/20, 7/31/20 or 8/7/20 onsite or remote facility consultation days. During a 12:58 p.m., 9/8/20 interview, the RD indicated she did not automatically reassess residents with significant weight loss on her next facility workday the following week. She stated she "would assume [resident weights] were stable if they weren't triggered on the Weight Report," a tool used by nursing leadership to identify residents with significant weight changes. The RD reflected she "probably should have followed up" on Resident 1 after his initial weight loss. In a 3:02 p.m., 8/21/20 interview, the DON stated it would be an expectation that after having consulted for a significant weight loss, the RD would reevaluate the following week to determine if planned interventions had been successful. In a 1:35 p.m., 8/13/20 interview, the RD stated she was not aware of the resident's second weight loss which occurred six days earlier. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 8 of 15 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 09/30/2020 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 The RD assessed the resident soon after the interview and in a 2:11 p.m., 8/13/20 interview stated Resident 1's appetite had been "variable" and hadn't significantly improved since his admission. The RD identified that Resident 1 didn't like the texture of the health shakes ordered on 7/16/20 and that a substitution would be requested. In addition, the RD recommended additional staff assistance with the resident's meal, snack and fluid intake as needed, and increasing the frequency of Resident 1's iron and Vitamin C supplements. In a 12:58 p.m., 9/8/20 interview, the RD noted that Resident 1's intake didn't improve after the initial 7/6/20 - 7/12/20 weight loss. The RD reported, "He had more refusals [of meals]. He didn't like the food." The RD stated of the 7/20/20 - 8/7/20 period, "There were lots of '0 25%s' [meals in which the resident ate less than 25% of the serving]. There were lots of refusals [of meals]." The RD indicated snack intake during this time included "some refusals at the end of July and more refusals in early August." Supplement intake decreased with the resident "refusing health shakes at the beginning of August." In a 1 p.m., 9/11/20 email communication, the RD calculated that Resident 1's meal intake between 7/20/20 - 8/7/20 averaged only 33% of the meals served and 25% of the snacks offered. On 7/16/20, Resident 1's physician ordered 4ounce (120 ml) sugar-free health shakes, a dietary supplement, three times daily. Review of the Medication Administration Record (MAR) indicated that on 8/4/20, the resident began to consume less than the intended 12 ounces (360 ml) daily. Intake amounts were as follows: - 8/3/20, 240 ml, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 9 of 15 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 09/30/2020 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 - 8/4/20, 120 ml, and - 8/5/20 - 8/7/20, 180 ml, During the 10:06 a.m., 9/15/20 interview, the DON was unable to find medical record documentation that the physician or RD had been notified of Resident 1's continuing poor oral intake prior to discovery of the second severe weight loss documented on 8/7/20. Review of the facility's 8/13/19 "Assessment and Management of Resident Weights" policy indicated, "Weights are obtained upon admission...then weekly for four (4) weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT)...Significant weight changes are...5% in one (1) month...Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight...loss including goals for care...The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change...." 4) Review of care plans for Residents 1, 2, 3, 4, and 5 reflected failures to 1) establish monitoring parameters for nutritional care interventions, including conditions for which the licensed nurse, RD, and/or physician should be notified, and 2) set target dates by which interventions should be reevaluated for success. During an 8:34 a.m., 9/9/20 interview the RD stated that "nurses and the Dietary Manager take on care planning for the most part." She added that she had "the liberty to add" to the care plan as needed. 4A) Following the identification of Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 10 of 15 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 09/30/2020 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 first severe weight loss on 7/12/20, his nutritional care plan was revised by a nurse on 7/16/20 with interventions including: - "Diet as ordered" [no details as to action to be taken if resident was not eating adequately, and setting the point at which action should be taken], - "Snacks," [no details regarding how to monitor consumption], and - "Supplements/nourishment as ordered´ [no details regarding how to monitor consumption and when/to whom to report if resident was not taking per physician order]. After the second severe weight loss of 8/7/20, Resident 1's nutritional care plan reflected no RD participation until 8/18/20, when the following interventions were added: - "Monitor weekly weights then qmonth [sic, every month] if stable," [no detail as to action to be taken for weight changes and at what point that action should take place], and - "Offer substitute if intake < / = [less than or equal to] 75%," In an 8:34 a.m., 9/9/29 interview, the RD acknowledged she did not add to Resident's care plan until August. 2020 and stated she "could have added 'at nutritional risk' " to an earlier care plan. 4B) Review of Resident 2's "Admission Record" indicated diagnoses including heart failure, Type 2 diabetes mellitus and generalized muscle weakness. The resident was also diagnosed with COVID-19 on 7/31/20. During a 9:16 a.m., 9/9/20 interview, the RD acknowledged the "Weight Summary" reflected Resident 2 had decreased from 157.5 pounds on 7/1/20 to 148.4 pounds (9.1 pounds) on 8/7/20. The RD confirmed that her 5:24 p.m., 8/14/20 "Dietary/Nutritional Progress Note" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 11 of 15 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 09/30/2020 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 described this loss as a 5.8% decrease in one month and confirmed it was a significant weight loss. Review of the medical record reflected that after the severe weight loss was identified, nursing staff members updated the resident's nutritional care plan beginning 8/7/20. Interventions included: - "Monitor for S/S [signs/symptoms] of dehydration" [no guidelines for how to monitor and the action to be taken if observed], - "Encourage >75% [more than 75%] intake of each meal" [no guideline for what to do if intake was not >75% or how long to monitor intake before taking action], - "Snacks," and - "Supplements/nourishment as ordered." The nutritional care plan did not reflect RD participation. In a 9:16 a.m., 9/9/20 interview, the RD stated, "It doesn't look like we...updated the care plan for the recent weight loss." 4C) The "Admission Record" listed dementia (a chronic degenerative loss of brain function), heart disease, gastric ulcer (sore in the stomach lining) and muscle weakness among the diagnoses for Resident 3. COVID-19 was later diagnosed on 7/27/20. During a 9:20 a.m., 9/9/20 interview, the RD acknowledged Resident 3's "Weight Summary" reflected a decreased from 221 pounds on 7/4/20 to 208.4 pounds (12.6 pounds) on 8/7/20. The RD indicated her 7:49 a.m., 8/14/20 "Dietary/Nutritional Progress Note" described the loss as a 5.7% decrease in one month and confirmed it as a significant weight loss. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 12 of 15 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 09/30/2020 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 An 8/7/20 nutritional care plan developed by nurses after the resident's severe weight loss included the following among its interventions: - "Encourage >75% intake of each meal," - "Snacks," and - "Supplements/nourishment as ordered." The weight loss care plans did not reflect RD input until 9/10/20. In a 9:20 a.m., 9/9/20 interview, the RD indicated there were "not enough interventions" in the weight loss care plan and said she "missed that [care plan] again." 4D) The "Admission Record" for Resident 4 listed diagnoses including a swallowing disorder, anemia, generalized muscle weakness, mental illness, communication disorder and, as of 7/27/20, COVID-19. The resident had a feeding tube into his stomach for a previous eating problem but the tube was not currently being used for nutrition. During a 9:25 a.m., 9/9/20 interview, the RD acknowledged the "Weight Summary" reflected Resident 4 had decreased from 167.1 pounds on 7/1/20 to 150.4 pounds (16.7 pounds) on 8/7/20. The RD confirmed that her 8:27a.m., 8/14/20 "Dietary/Nutritional Progress Note" described this 16.7 pound loss as a 10% decrease from his previous measurement and confirmed it was a significant weight loss. An 8/7/20 nutritional care plan written by nursing staff members after the resident's 8/7/20 severe weight loss reflected the following interventions: - "Encourage >75% intake of each meal," and - "Supplements/nourishment as ordered." The weight loss care plan did not reflect RD participation in development. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 13 of 15 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 09/30/2020 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 During a 9:25 a.m., 9/9/20 interview, the RD stated there should have been a care plan for the resident's history of weight gain and losses. 4E) Resident 5's "Admission Record" noted diagnoses including dementia, breast cancer, and a past stroke (episode of blood flow loss to an area of the brain, causing damage to body functions controlled by that area). The resident was diagnosed with COVID-19 on 7/31/20. In a 9:35 a.m., 9/9/20 interview, the RD acknowledged Resident 5's "Weight Summary" reflected a decrease from 144 pounds on 7/5/20 to 131.6 pounds (12.4 pounds) on 8/7/20. The RD indicated her 12:06 p.m., 8/14/20 "Dietary/Nutritional Progress Note" described this loss as a 8.6% decrease in one month and confirmed it was a significant weight loss. A care plan developed on 8/7/20 by nursing staff after Resident 5's severe weight loss of 8/7/20 included the following interventions: - "Encourage >75% intake of each meal," - "Snacks," and - "Supplements/nourishment as ordered." There was no evidence of RD contribution to the weight loss care plan until 9/11/20. In a 9:35 a.m.., 9/9/20 interview, the RD acknowledged that she "could have added to the care plan." Review of the facility's 11/1/17 "Care Planning" policy reflected, "The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing...needs...The resident has the right to receive the services and/or items included in the plan of care...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CZD511 Facility ID: CA030000075 If continuation sheet 14 of 15 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 09/30/2020 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: CZD511 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000075 (X5) COMPLETE DATE If continuation sheet 15 of 15