Health inspection·February 3, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to ensure care plans (a written, personalized document that outlines a resident's health needs, goals, and the specific services or actions required to address them) were developed and implemented when three of four sampled residents (Resident 1, Resident 2, and Resident 3), with diagnosed substance abuse disorder (SUD, a chronic disease characterized by the continued, compulsive use of alcohol or drugs despite experiencing severe, harmful, and negative consequences), did not have care plans in place for SUD.These failures placed Resident 1, Resident 2, and Resident 3 at risk for exit seeking behavior (the purposeful, often repeated, and urgent attempt by a resident to leave the facility) related to the urge to get drugs or alcohol, lack of interventions in place to support the possible withdrawal symptoms, (vomiting, diarrhea, nausea, paranoia) and potentially could have resulted in injury and/or psychosocial harm. a. A review of Resident 1's clinical document titled, admission RECORD, dated 1/15/26, indicated Resident 1 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:20 AM, Resident 1's care plans were reviewed. The DON confirmed Resident 1 did not have a care plan in place for SUD prior to 2/3/26 and there should have been a SUD care plan in place. The DON stated the importance of Resident 1 having a care plan for SUD was to monitor any potential withdrawals (physical and mental symptoms that a person has when they suddenly stop the use of an addictive substance, such as drugs or alcohol) and any drug seeking behavior. The DON explained the risk to Resident 1 of not having the SUD care plan was not having his psychosocial well-being monitored.b. A review of Resident 2's clinical document titled, admission RECORD, dated, 2/14/25, indicated Resident 2 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:35 AM, Resident 2's care plans were reviewed. The DON confirmed Resident 2 did not have a care plan in place for SUD prior to 2/3/26 and there should have been a care plan in place. The DON stated the importance of Resident 2 having a care plan for SUD was to monitor for any potential withdrawals and any drug seeking behavior. The DON explained the risk to Resident 2 not having a SUD care plan was not having his psychosocial well-being monitored.c. A review of Resident 3's clinical document titled, admission RECORD, dated 7/27/23, indicated Resident 3 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:40 AM, Resident 3's care plans were reviewed. The DON confirmed Resident 3 did not have a care plan in place for SUD prior to 2/3/26 and should have had one in place. The DON stated the importance of Resident 3 having a care plan for SUD was to monitor any potential withdrawals and any drug seeking behavior. The DON explained the risk to Resident 3 not having a SUD care plan in place was not having her psychosocial well-being monitored.During a concurrent phone interview and record review with the DON on 2/6/26 at 11:37 AM, the facility's policies titled, LAWN Evaluation & Management - Leave of Absence without Notice (LAWN), undated; Wandering and Elopements, revised 3/19; and Goals and Objectives, Care Plans, revised 4/09, were reviewed. The LAWN Page 1 of 2 056324 056324 02/03/2026 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Evaluation & [and] Management - Leave of Absence without Notice (LAWN), policy indicated, . The interdisciplinary team member (IDT - a collaborative group of professionals-including doctors, nurses, social workers, and therapists-who work together to create and implement a unified, holistic care plan for a resident) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice . Elopement occurs when a resident leaves the premises or a safe area without notice/authorization . and/or any necessary supervision to do so . Residents will be evaluated . for possible leave of absence without notice/authorization upon admission . A resident deemed at risk for Leave of Absence without Notice . are to consider the following measures . Initiate/update plan of care . Identify measures necessary to avoid leaving the facility without notice/authorization . The Wandering and Elopements policy indicated, . the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm . If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . The Goals and Objectives, Care Plans policy indicated, . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . Care plan goals and objectives are defined as the desired outcome for a specific resident problem . Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment . Are resident oriented . Are behaviorally stated . Are measurable . The DON confirmed the facility did not follow their, LAWN Evaluation & Management - Leave of Absence without Notice (LAWN), Wandering and Elopements, and Goals and Objectives, Care Plans policies. The DON confirmed Resident 1, Resident 2, and Resident 3 did not have SUD care plans in place. The DON explained the importance of developing and implementing care plans was so specific problem areas and diagnoses were addressed. The DON explained regarding SUD, the risk to the residents was drug seeking behavior and drug withdrawal. 056324 Page 2 of 2