Fulton Gardens Post Acute, LLC

In the surveyor’s words

From the most serious findings on record at Fulton Gardens Post Acute, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 1, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 103 residents when;1) Staff did not have their facial hair covered while present in the kitchen;2) Opened cake mix, olive oil, shredded cheese, and five bags of pasta, were not labeled completely and accurately with open dates, use-by dates, or discard dates, and one previously opened bag of pasta was not securely sealed after opening; 3) The dry storage floor was worn with a black discoloration;4) Frozen hotdogs stored in the reach-in freezer had moderate ice crystal buildup or freezer burn, frozen turkey stored in the walk-in freezer had heavy ice crystal buildup or freezer burn, and frozen pork chops… […]

• No harm, potential for more than minimal, patternF695May 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure supplemental (additional) oxygen was administered in accordance with professional standards of practice for 2 out of 29 sampled residents (Resident 19 and Resident 80) when:1.Resident 19's oxygen humidifier bottle (a device designed to add moisture to dry oxygen from a concentrator, preventing irritation to the nose, throat, and airways during oxygen therapy) was empty and labeled with a date of 4/7/26 (observation was on 4/28/26) and there was no medical doctor order for the use of a humidifier to be used with oxygen therapy; and2.Resident 80's oxygen humidifier bottle was observed empty and was not labeled with a date.These failures had the potential to place Resident 19 and Resident 80 at risk for… […]

• No harm, potential for more than minimal, patternF804May 1, 2026

  Based on observation, interview, and record review, the facility failed to conserve the nutritive value and flavor of pureed food (a cooked food that has been ground, pressed, or blended into a smooth, thick, and creamy paste or liquid, often with a pudding-like consistency) for a total of six out of seven residents (Resident 6, Resident 9, Resident 15, Resident 63, Resident 64, and Resident 112) who received puree food from the facility kitchen, when the facility did not follow the recipe for pureed lemon rice pilaf (seasoned rice dish).This failure had the potential to affect the nutritive value, flavor, and consistency of the pureed food, which could lead to reduced food intake, malnutrition, and negative health outcomesFindings:During a review of the facility's daily cook's menu for… […]

• No harm, potential for more than minimal, patternF880May 1, 2026

  Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 103, when:1. Resident 6 and Resident 80's urinals were not labeled to indicate whom the urinals belonged to; and2. Multiple boxes of soda were observed stored directly on the floor in Resident 19's room and the there were multiple dark brown/black stains on the floor;These failures had the potential to spread infection and cause health problems to the residents in the facility.Findings: 1a. […]

• No harm, potential for more than minimal, patternF584Nov 18, 2025

  Based on observation, interview, and record review, the facility failed to provide a homelike environment for five of five residents (Resident 4, Resident 5, Resident 6, and Resident 7, and Resident 8) when,Resident 4 displayed episodes of aggression, and repeated yelling throughout the day and night and Resident 4 behavior care plans were not person centered, and staff were not able to address it; and, Multiple residents including Resident 5, Resident 6, Resident 7, and Resident 8 were negatively affected by Resident 4's continuous yelling and had reported to staff their frustration and lack of sleep and/or rest.This deficient practice had the potential to negatively affect the psychosocial (the mental, emotional, social, and spiritual effects of a disease) and physical well-being of the… […]