Health inspection·February 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/18/25, at 11:03 AM, Licensed Nurse (LN) 3 stated that medications should not be left at a resident's bedside unless the resident had an order to self-administer medication. LN 3 stated she was allowed to leave Resident 1's medications with her since she was alert. During a concurrent interview and record review on 2/18/25, at 12:10 PM, the Minimum Data Set (a federally mandated resident assessment and screening tool which identifies care needs) Coordinator (MDSC) reviewed Resident 1's Self-Administration of Medication Assessment, dated 10/24/23. The MDSC confirmed the assessment indicated Resident 1 could safely self-administer Bengay (a cream used for muscle or arthritis pain). The MDSC further confirmed the assessment did not indicate Resident 1 could self-administer any other medications. The MDSC stated Resident 1's medications should not have been left unattended in her room. The MDSC further stated medications should be administered one hour before and one hour after they were prescribed and no later than that. During an interview on 2/18/25, at 12:34 PM, the Director of Staff Development (DSD) stated there was a risk to residents if medications were left at their bedside. The DSD further stated another resident could have entered the room and taken Resident 1's medications. The DSD stated there was also the potential for Resident 1 to choke on her medications. The DSD further stated the LN should always stay with the resident when they were taking their medications. During a concurrent interview and record review on 2/18/25, at 12:50 PM, LN 3 confirmed the medications left at Resident 1's bedside were metformin, gabapentin, aspirin, cranberry tablet, folic acid, and lisinopril. LN 3 confirmed the medications should have been administered between one hour before or one hour after their scheduled time. LN 3 stated the medications should not have been left at the bedside as she would not know if Resident 1 had taken them. LN 3 further stated medications left at the bedside could be a potential choking hazard, or another resident could enter the room and take the medications. A review of a facility policy titled, ADMINISTERING MEDICATIONS, dated 3/23, indicated, .To provide employees with guidelines for the safe and timely administration of medication per physician order .Medications must be administered in accordance with the orders .medications must be administered in accordance with state and federal guidelines . b. A review of Resident 1's clinical document titled, SBAR [Situation, Background, Assessment/Appearance, Request] : Change of Condition, dated 1/16/25, indicated, .The change in condition, symptoms, or signs I am calling about are .productive cough and sore throat .This started on 1/16/25 .Reported to MD .1/16/25 0600 [6 AM] . A review of Resident 1's Order Details, dated 1/17/25, at 3:27 PM, indicated .Chest Xray to r/o [rule out] PNA [pneumonia, an infection of the lungs] . A review of Resident 1's RADIOLOGY [x-ray] REPORT, indicated, .service date 1/19/25 .report date 1/20/25 .Conclusion: Slight bilateral upper lobe infiltrates [ a condition where substances like blood, pus, or protein build up in the upper lobes of both lungs]. Clinical correlation [connecting symptoms with test results] is advised .Clinical or repeat examination follow up is advised . A handwritten note on the radiology report indicated, .ZPAC [ an antibiotic medication to treat infection] order carried out on 1/21/25 . A review of Resident 1's Order Details, dated 1/21/25, at 7:02 AM, indicated, .Azithromycin [antibiotic] Tablet 250 mg [milligrams] .for infection . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's progress notes dated 1/23/25, at 10:19 AM, indicated, .Reached out to [Business name] Labs re: CXR [regarding chest x ray] for resident performed on 1/19/25. Confirmed routine order received from our MD [Medical Doctor] for CXR on 1/17/25, order placed via business email by LN. [Business name] confirmed closed Friday and Saturdays for Labs, but open 24/7 [24 hours per day/7 days per week] for x-rays. Stated routine (normal) x-ray orders done within 8-24hrs [hours] and would only be rescheduled by [Business name] if no staff available to come out to facility. [Business name] rep [representative] confirmed they have no notes on file for any request by facility to reschedule CXR from date order was submitted on 1/17/25 and that no confirmation was sent to facility about rescheduling . During an interview on 2/18/25, at 11:03 AM, LN 3 stated when an x-ray was ordered a requisition was sent to the x-ray provider. LN 3 further stated the provider was not open on Fridays and Saturdays. LN 3 stated they had to be on top of them and good communication was needed to get x-rays done. During an interview on 2/18/25, at 12:10 PM, the MDSC stated when an x-ray was ordered and had not been completed in a timely manner the nurse on each shift should call the x-ray provider and follow up. The MDSC further stated if the x-ray still was not done the LN should escalate the issue to the Director of Nurses. The MSDC stated it was her expectation that the LNs would have followed up on Resident 1's x-ray order to prevent a delay in her care. A review of a facility job description titled, Licensed Vocational Nurse (LVN), dated 10/16, indicated, .The licensed Vocational Nurse (LVN) is responsible for managing the residents' care plans and supervising resident care activities. Both care management and supervisory responsibilities must be executed in accordance with state and federal regulations and facility policies and procedures .Report all care ordered but not delivered .to the Director of Nursing .Complete medication and treatment passes as applicable in a timely manner and in accordance with state and federal regulation and facility policy . A review of a facility policy titled, LABORATORY SERVICES, dated 3/23, indicated, .Laboratory, radiology, or other diagnostic services ordered by the physician will be completed in a timely manner; and abnormal results will be reported to the physician in a timely manner to ensure results can be acted upon quickly .The facility strives to meet the needs of residents with regard to the quality and/or timeliness of providing laboratory services and reporting laboratory results . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 3 of 3