Health inspection·July 16, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure resident Interdisciplinary Team Care Conferences (IDT, a care plan meeting with the resident and/or family members where interdisciplinary team members from different healthcare disciplines discuss, identify, address, implement and review plans to meet needs regarding the resident's care) were conducted quarterly to review and/or revise care plans for one of three sampled residents (Resident 3), when no IDT Care Conferences were held after quarterly assessments were completed in 2025 for Resident 3.This failure had the potential for unmet care needs for Resident 3.Findings:A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility in 2024 with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), and quadriplegia (the condition in which both the arms and legs are paralyzed and lose normal motor function).A review of Resident 3's Minimum Data Set (MDS, a comprehensive care assessment tool), dated 5/5/25, indicated Resident 3 was dependent on others for all activities of daily living (ADLs, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom; activities related to daily care).During a phone interview on 7/15/25, at 11:25 a.m., with the Responsible Party (RP, the person designated to direct the care of a loved one admitted into a nursing facility), the RP stated that no one at the facility had communicated anything to her regarding Resident 3's care. The RP further stated that it seemed like no one cared about Resident 3.A review of resident 3's Progress Notes, indicated that there were no documented quarterly IDT meetings for the first and second quarters of 2025.During a concurrent interview and record review on 7/16/25, at 11:30 a.m., with the MDS Coordinator (MDS, a nurse that collects data related to residents in order to develop and evaluate a comprehensive care plan and to make sure the facility gets insurance payments), Resident 3's Progress Notes, were reviewed. The MDS stated that IDT care conferences for short-term residents were held within 72 hours of their admission, and IDT care conferences for long-term residents were held quarterly, and if there was a significant change in condition. The MDS confirmed that Resident 3 was a long-term resident of the facility. The MDS further confirmed that there were no IDT care conferences documented in Resident 3's Electronic Medical Record (EMR) for the first and second quarters of 2025. The MDS stated that the risk of not having quarterly IDT care conferences was that the residents, RPs and/or family would not know the plan of care.During an interview with the Administrator (ADM) on 7/16/25, at 2:37 p.m., the ADM stated that his expectation was that IDT care conferences were held quarterly for long-term care residents. The ADM acknowledged that IDT care conferences were not held in 2025 for some residents.A review of a facility policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, dated 8/25/21, the P&P indicated, .Purpose .Our facility's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .3. The resident, the resident's family and/or the resident's representative are encouraged Page 1 of 5 056324 056324 07/16/2025 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0657 to participate in the development of and revisions to the resident's care plan . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056324 Page 2 of 5 056324 07/16/2025 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) received care consistent with professional standards of practice to prevent pressure injury (localized damage to the skin and/or underlying tissue caused by staying in one position for too long) when staff failed to document that the functioning of the residents' low air loss alternating pressure mattresses (medical air mattresses designed to reduce pressure on the skin) were checked each shift daily per the physician's orders.These failures had the potential for the residents to sustain pressure injuries and decreased well-being.Findings:a. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included Alzheimer's disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die. These changes affect a person's ability to function). A review of Resident 1's Braden Scale for Predicting Pressure Sore Risk [assesses a resident's risk for developing pressure injury], dated 12/18/23, indicated that Resident 1 was at high risk for developing a pressure injury. Resident 1's Care Plan Report, indicated, .Focus .Has higher risk/potential for pressure ulcer development .revised 10/18/24 .Goal .The resident will have intact skin, free of redness, blisters, or discoloration .Interventions .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL [low air loss] MATTRESS CUSHION LEVEL @ CURRENT WT [weight] SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL [ADL; tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom] CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 1's Minimum Data Set [MDS, a comprehensive care assessment tool] Section GG-Functional Abilities, dated 6/2/25, indicated that Resident 1 was dependent on others for ADL's. A review of Resident 1's Physician Order Summary, dated 7/2/24, indicated, .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL MATTRESS CUSHION LEVEL @ CURRENT WT SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 1's Treatment Administration Record [TAR, a document listing provided treatments] - May 2025, indicated that the function of Resident 1's low air loss mattress was not checked each shift on May 18th, May 24th, May 25th, and May 27th. A review of Resident 1's TAR - June 2025, indicated that the function of Resident 1's low air loss mattress was not checked each shift on June 2nd, June 3rd, June 8th, and June 12th. A review of Resident 1's TAR - July 2025, indicated that the function of Resident 1's low air mattress was not checked each shift on July 1st, July 9th, and July 15th. b. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility with diagnoses which included fracture of lumbar vertebra (the cracking or breaking of bones in the lower back), and depression (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living). A review of Resident 2's Braden Scale for Predicting Pressure Ulcer Risk, dated 10/20/23 indicated that Resident 2 was at high risk for pressure ulcer development. A review of Resident 2's Care Plan Report, indicated, .Focus .Has higher risk/potential for pressure ulcer development .Goal .The resident will have intact skin free of redness, blisters, or discoloration .Revised on 6/2/2025 .Interventions .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL MATTRESS CUSHION LEVEL @ CURRENT WT SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 2's MDS Section Residents Affected - Some 056324 Page 3 of 5 056324 07/16/2025 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some GG-Functional Abilities, dated 5/8/25 indicated that Resident 2 was dependent on others for ADLs. A review of Resident 2's Physician Order Summary, dated 7/2/24, indicated, .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL MATTRESS CUSHION LEVEL @ CURRENT WT SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 2's TAR - May 2025, indicated that the function of Resident 2's low air loss mattress was not checked each shift on May 27th. A review of Resident 2's TAR - June 2025, indicated that the function of Resident 2's low air loss mattress was not checked each shift on June 4th and June 8th. A review of Resident 2's TAR - July 2025, indicated that the function of Resident 2's low air loss mattress was not checked each shift on July 5th and July 15th. c. A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), and quadriplegia (the condition in which both the arms and the legs are paralyzed and lose normal motor function). A review of Resident 3's Braden Scale for Predicting Pressure Ulcer Risk, dated 4/9/25 indicated that Resident 3 was at high risk for pressure injury. A review of Resident 3's Care Plan Report, indicated, Focus .Resident at risk for skin breakdown/pressure injuries .Healing Goal .the resident's wound/skin impairment will heal .Interventions .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL MATTRESS CUSHION LEVEL @ CURRENT WT SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 3's MDS Section GG-Functional Abilities, dated 5/5/25, indicated that Resident 3 was dependent on others for all ADLs. A review of Resident 3's Physician Order Summary, dated 4/3/25, indicated, .SPECIAL BED/MATTRESS: LOW AIR LOSS MATTRESS (SETTING: 10 MINUTES ALTERNATING PRESSURE) IN PLACE FOR PRESSURE REDISTRIBUTION AND SKIN MANAGEMENT. MONITOR FOR FUNCTIONING. MAY KEEP LAL MATTRESS CUSHION LEVEL @ CURRENT WT SETTINGS WHEN RESIDENT IS RESTING. MAY INFLATE TO MAXIMUM DURING ADL CARE. EVERY SHIFT AND AS NEEDED. MONITOR FOR FUNCTIONING . A review of Resident 3's TAR May 2025, indicated that the function of Resident 3's low air loss mattress was not checked each shift on May 18th, May 24th, May 25th, and May 27th. A review of Resident 3's TAR - June 2025, indicated that the function of Resident 3's low air loss mattress was not checked each shift on June 2nd, June 3rd, June 8th, June 12th, and June 22nd. A review of Resident 3's TAR - July 2025, indicated that the function of Resident 3's low air loss mattress was not checked each shift on July 1st, July 9th, and July 15th. During an interview on 7/15/25, at 2:30 p.m., with Licensed Nurse (LN) 1, LN 1 stated that she was the treatment nurse. LN 1 stated that some residents who were at increased risk for pressure injury had a low air loss mattresses ordered by the physician. During an interview on 7/16/25, at 9:28 a.m., LN 2 stated that staff turned and repositioned dependent residents (residents who need assistance for ADLs) every two hours. LN 2 stated that staff checked the low air loss mattresses if applicable to make sure that the mattresses were properly inflated to protect against skin breakdown. LN 2 further stated that she checked the low air loss mattresses every time she entered the residents' rooms because sometimes, they were accidentally unplugged. LN 2 stated that the low air loss mattresses would alarm when they were unplugged. LN 2 further stated that she checked to make sure that the low air loss mattresses were properly inflated by pressing her hand on the mattress. LN 2 stated that some residents had physician orders to check the functioning of the mattresses, and the checks were documented in the residents' TARs. LN 2 explained that if there was no order, she sometimes documented in the 056324 Page 4 of 5 056324 07/16/2025 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some progress notes that she checked the low air loss mattress. During a concurrent phone interview and record review on 7/17/25, at 4:08 p.m., with the Director of Staff Development (DSD), Physician Orders, and TARs for May, June, and July 2025 were reviewed for Resident 1, Resident 2, and Resident 3. The DSD stated that when a resident's physician order specified to check the functioning of the low air loss mattresses every shift each day, the LNs documented the checks in the residents' TARs. The DSD confirmed that Resident 1, Resident 2, and Resident 3 all had physician orders to check the low air loss mattresses functioning every shift every day. The DSD further confirmed that the low air loss mattress checks were not documented every shift every day for Resident 1, Resident 2, and Resident 3 on their TARs during the months of May, June, and July of 2025. The DSD stated that the risk of not checking the function of the low air loss mattresses was if the low air loss mattresses were not working properly then residents could develop pressure injuries. The DSD acknowledged that the facility policy was not followed. During a review of a facility policy and procedure (P&P) titled, Positioning/Transfer and Changing Resident with Airloss [sp] Mattress, revised 10/24/24, the P&P indicated, .Policy Explanation and Compliance Guidelines .1. Low air loss mattresses are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown . During a review of a facility P&P titled, Skin Integrity Management, dated 5/26/21, the P&P indicated, .Purpose .To provide safe and effective care to prevent the occurrence of pressure ulcers .Procedure .2. Complete comprehensive evaluation of the patient .2.1 Complete risk evaluation .3. Identify patient's skin integrity status and need for prevention intervention . 056324 Page 5 of 5