A list of the most recent deficiencies for Fulton Gardens Post Acute, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-15 | 2024-01-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-15 | 2024-01-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-15 | 2024-01-14 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-15 | 2024-01-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-12-15 | 2024-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-18 | 2024-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-29 | 2023-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-13 | 2023-05-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-21 | 2022-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-21 | 2022-03-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-21 | 2022-03-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-21 | 2022-03-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-21 | 2022-03-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-21 | 2022-03-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-21 | 2022-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-21 | 2022-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-21 | 2022-03-20 | N |
| Use approved construction type or materials. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-24 | 2022-03-10 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-10-14 | 2021-11-19 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-08 | 2021-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-30 | 2021-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-27 | 2021-05-26 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-24 | 2019-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-24 | 2019-06-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-24 | 2019-06-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-24 | 2019-06-18 | N |
