Other·September 7, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigations of complaint #CA00567190 and facility self reported incident CA#00567525. Representing the Department of Public Health: HFEN, 36586. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility.

F552 SS=G Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 09/22/2018 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 1 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility policy review, the facility failed to inform 1 of 2 residents/(RP 1 - Resident 1's Responsible Party) of planned treatment and treatment options when: 1. RP 1 was not contacted to verify informed consent for medications including psychotherapeutics (medications used to treat mental disorders), and 2. RP 1 was not informed by the facility of the medication administration errors. These failures deprived Resident 1 of the right to make informed decisions and prevented: 1. RP 1 from being informed about medications administered to Resident 1 and the opportunity to stop the administration of erroneous medications, and 2. RP 1 from making informed and timely decisions that had the potential to minimize or correct the medication administration error that resulted in Resident 1's death from acute morphine toxicity. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 2 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE providing relief for their usual caregivers) in December 2017 with diagnoses including renal failure, high blood pressure, heart disease and diabetes. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated 12/14/17, reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. Review of the faxed document for Patient 1, dated 12/28/17, titled Physician's Orders/Medication Status - [hospice name] and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) Morphine Sulfate (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) Morphine Sulfate Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) Morphine Sulfate Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) [lorazepam] (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 3 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for anxiety, 5) Nitroglycerin (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) [bisacodyl] (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) mirtazapine 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) metoprolol tartrate 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) furosemide, 20 mg tablet, 1 tablet, by mouth, as needed for edema 10) methimazole (medication used to treat thyroid disease), 5 mg tablet, 1 tablet, by mouth, every day 11) hydralazine hydrochloride, 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) [omeprazole], 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) sucralfate, 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) amlodipine besylate, 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) clonidine hydrochloride, 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) isosorbide mononitrate extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) haloperidol lactate concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated 12/18/17, titled Physician Orders Sheet [hospice name] reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1's facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 4 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documents titled Administration Record Reports Administration Record Report (MAR Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of 12/29/17: 1) [lorazepam] 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - 12/31/17 GIVEN at 12:01 a.m. 2) morphine extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - 12/29/17 GIVEN at 6 p.m., - 12/30/17 NOT GIVEN, at 12 a.m. with reason "waiting for medication delivery," and 6 a.m. with reason "Will call [hospice name] to follow up medication," REFUSED [by Resident] at 12 p.m., GIVEN at 6 p.m., - 12/31/17 GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - 1/1/18 GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as "Unable to swallow." 3) morphine 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - 12/31/17 GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - 1/1/18 GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) gabapentin (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 5 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 5) dexamethasone (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - 12/30/17 GIVEN at 9 a.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., - 1/1/18 GIVEN 9 a.m. 6) baclofen 10 mg tablet, 1/2 tablet, by mouth, three times a day for spasms - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 7) [famotidine], 40 mg tablet, 1 tablet, by mouth twice a day for stomach - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by patient] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 8) [quetiapine fumarate] (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - 12/29/17 NOT GIVEN at 5 p.m. with reason "awaiting delivery from pharmacy", - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 10) [quetiapine fumarate], 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) [temazepam], 30 mg capsule, 1 capsule, as needed at bedtime for insomnia - 1/1/18 GIVEN at 12:26 a.m. 12) [bisacodyl] (medication used to treat constipation) 8.6-50 mg tablet, 2 tablets by mouth twice a day for constipation, NOT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 6 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) [bisacodyl] rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if [bisacodyl] ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated 12/29/17, reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected medications prescribed for Patient 1 were not given, and medications prescribed for Patient 2 were administered to Patient 1. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days (12/29/17 - 1/1/18). The Order Summary Report additionally indicated the following: - [lorazepam] tablet 1 mg, Give 1 tablet by mouth every 4 hours as needed for ANXIETY M/B (manifested by) SOB (shortness of breath), "ICO [informed consent] by MD [medical doctor] from RP." - [quetiapine fumarate] Tablet 50 mg, Give 1 tablet by mouth two times a day for anxiety M/B FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 7 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verbalization of anxiety, "ICO by MD from RP." - [quetiapine fumarate] Tablet 50 mg, Give 1 tablet by mouth every 4 hours as needed for anxiety M/B verbalization of anxiety, "ICO by MD from RP." - restoril capsule 30 mg, Give 1 capsule by mouth as for inability to sleep due to insomnia, "ICO by MD from RP." - Oxygen at 2L/min via NC per concentrator (a device that concentrates oxygen from the air to supply an oxygen-enriched flow) as needed for SOB (shortness of breath) 1. Review of the documents titled Facility Verification of Informed Consent, signed and dated 12/29/17, reflected verification on three separate forms for [lorazepam], restoril and [quetiapine fumarate]. All three forms were signed by Resident 1 indicating the resident had received information for the medications and had given consent to receive the medication. The form further revealed Licensed Nurse (LN) 1 was the facility representative executing the verification. Review of the hospice face sheet indicated RP 1 was the PCG (primary care giver), NOK (next of kin), POA (power of attorney), and EC (emergency contact). Review of the facility document titled Notice of Admission/ Re-Admission indicated Resident 1 was not their own Responsible Party. Review of Resident 1's document titled Physician Orders for Life-Sustaining Treatment (POLST - medical orders dictating treatments to be provided based on the patient/ resident's wishes during a medical emergency) dated 10/21/17 was signed by Resident 1's POA. During a concurrent interview and document review on 1/5/18 at approximately 2:45 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 8 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LN 1 confirmed the hospice face sheet, the facility admission notice and the POLST all indicated Resident 1 was not their own Responsible Party. LN 1 further concurred RP 1 should have been contacted for the Verification of Informed Consent. In a telephone interview on 1/5/18 at 1:30 p.m., RP 1 confirmed they were not contacted for verification of informed consent and further stated, "[Resident 1] was not on those medications [restoril or quetiapine fumarate]." Review of the facility policy titled Psychotropic [medications used to treat mental disorders] Medication Management, revised 1/24/17, stipulated, "It is the policy of this facility that residents in need of psychotherapeutic medications receive appropriate assessment and intervention in order to achieve their highest practicable level of functioning... When psychoactive medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnosis... Informed Consent for the use of a psychoactive [medications used to treat mental disorders] medication must be contained in the medical record (following verbal verification from the physician), a statement from the physician documented in the progress notes or on the physician orders, or a signed consent form from the resident, family, or legal representative...The Director of Nursing or designee, will be responsible for reviewing new psychoactive medication orders for clinical compliance with federal regulations..." 2. During an interview with the Assistant Director of Nursing (ADON) on 1/3/18 at 11:10 a.m., the ADON stated, "...the family knew [of the medication error] before [Resident 1's] death... because the hospice nurse told them." The ADON further stated he was unaware of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 9 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE any discussion of naloxone (medication used to temporarily reverse the effects of opioid medicines) and it would have been a "hospice physician decision." During an interview with LN 4 on 1/5/18 at 3:45 p.m., LN 4 stated no one considered naloxone and further stated it would not have occurred to him to use naloxone for a morphine error. A record review of Resident 1's document titled Administration Record Report (MAR Medication Administration Report) revealed the following: - Resident 1's pain assessments (using a pain scale with 0 = no pain, 1-3 = mild pain, 4 - 6 = moderate pain, 7 - 9, 10 = worst+) indicated a pain level of 0 on 1/1/18 at midnight, at 4 a.m., and at 8 a.m. - Resident 1 received on 1/1/18 morphine 100 mg at midnight and restoril at 12:26 a.m. for insomnia. - Resident 1 received on 1/1/18 2 ml of morphine 20 mg/ml [40 mg] at 3:59 a.m. - On 1/1/18, Resident 1 did not receive the scheduled morphine for 6 a.m. with a notation of "9" which indicated "other/ see nurse notes." A record review of Resident 1's document titled Progress Notes revealed the following: - On 1/1/18 at 4:49 a.m., LN 4 indicated a Medication Administration Note, "Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 2 ml by mouth every 2 hours... Pain Scale was: 0." - On 1/1/18 at 5:14 a.m., LN 4 indicated a Medication Administration Note, "Morphine Sulfate ER Tablet Extended Release 100 MG Give 1 tablet by mouth every 6 hours for PAIN Unable to swallow." - On 1/1/18 at 6:39 a.m., LN 4 indicated a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 10 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Medication Administration Note, "OXYGEN 2L/MIN [a unit of measure for flow rate] VIA NC [nasal cannula - a means of delivering oxygen into the nose] PER CONCENTRATOR as needed for SOBPRN [shortness of breath as needed]" - On 1/1/18 at 6:59 a.m., LN 4 indicated a Medication Administration Note, "Restoril Capsule 30 mg...PRN Administration was: Effective." - On 1/1/18 at 7:40 a.m., LN 4 indicated a Health Status Note, "Resident in bed placed on continuous O2 [oxygen] @ 2L/min. Morphine solution given as patient now unable to open mouth and swallow pills. [Agency name] hospice notified of change in status. [RP 1] made aware." During an interview and concurrent record review of the above with LN 4 on 1/5/18 at 3:55 p.m., LN 4 stated he did not consider a change of condition when Resident 1 could not express her pain for the 3:39 a.m. liquid morphine and at 5:14 a.m. when Resident 1 could not open their mouth or swallow a pill. LN 4 additionally stated Resident 1's change of condition was reported to the hospice agency around 7:30 a.m. after Certified Nursing Assistant (CNA) 1 and CNA 2 reported Resident 1 was unresponsive. LN 4 stated the hospice agency notified the hospice physician (HMD). During a telephone interview on 1/5/18 at 1:30 p.m., RP 1 confirmed the facility left a message about 7:30 a.m., on 1/1/18, that "[Resident 1] was not doing well and was on oxygen." RP 1 stated they returned the call to the facility when they heard the message at approximately 10:00 a.m. RP 1 stated there was no mention of a significant medication error when they arrived at the facility at approximately 12:00 p.m. LN 2 from hospice explained the significant medication error at about 12:15 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 11 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE RP 1 further stated at no time was the family offered the option of treatment, like naloxone, or a transfer to the hospital. RP 1 stated Resident 1 died about 30 minutes after they arrived to the facility at approximately 12:30 p.m. on 1/1/18. Review of the facility policy titled Medication Errors, revised November 2017, stipulated, "It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative... Resident and resident representative should be notified and all actions taken to rectify the situation." Review of the facility policy titled Change of Condition, Resident, revised 11/2017, stipulated, "It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner...in the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and provide possible transport to an acute hospital."

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 09/22/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 12 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 13 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE policy review, the facility failed to ensure accurate and timely notification of an acute change in condition (COC) for 1 of 2 residents (Resident 1) when: 1. Resident 1's Responsible Party (RP 1) was not notified of a significant medication administration error, and 2. Resident 1's facility attending physician (FMD) was not notified of a decline in condition, a significant medication administration error, and Resident 1's death. These failures prevented RP 1 and FMD from making informed and timely decisions that had the potential to minimize or correct the medication administration error that resulted in Resident 1's death from acute morphine toxicity. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in December 2017 with diagnoses including renal failure, high blood pressure, heart disease and diabetes. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated 12/14/17, reflected Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 14 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. Review of the faxed document for Patient 1, dated 12/28/17, titled Physician's Orders/Medication Status - [hospice name] and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) Morphine Sulfate (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) Morphine Sulfate Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) Morphine Sulfate Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) [lorazepam] (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) Nitroglycerin (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) [bisacodyl] (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 15 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 7) mirtazapine 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) metoprolol tartrate 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) furosemide, 20 mg tablet, 1 tablet, by mouth, as needed for edema 10) methimazole (medication used to treat thyroid disease), 5 mg tablet, 1 tablet, by mouth, every day 11) hydralazine hydrochloride, 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) [omeprazole], 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) sucralfate, 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) amlodipine besylate, 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) clonidine hydrochloride, 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) isosorbide mononitrate extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) haloperidol lactate concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated 12/18/17, titled Physician Orders Sheet [hospice name] reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1's facility documents titled Administration Record Reports Administration Record Report (MAR Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of 12/29/17: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 16 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1) [lorazepam] 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - 12/31/17 GIVEN at 12:01 a.m. 2) morphine extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - 12/29/17 GIVEN at 6 p.m., - 12/30/17 NOT GIVEN, at 12 a.m. with reason "waiting for medication delivery," and 6 a.m. with reason "Will call [hospice name] to follow up medication," REFUSED [by Resident] at 12 p.m., GIVEN at 6 p.m., - 12/31/17 GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - 1/1/18 GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as "Unable to swallow." 3) morphine 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - 12/31/17 GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - 1/1/18 GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) gabapentin (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 5) dexamethasone (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - 12/30/17 GIVEN at 9 a.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., - 1/1/18 GIVEN 9 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 17 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6) baclofen 10 mg tablet, 1/2 tablet, by mouth, three times a day for spasms - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 7) [famotidine], 40 mg tablet, 1 tablet, by mouth twice a day for stomach - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by patient] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 8) [quetiapine fumarate] (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - 12/29/17 at NOT GIVEN at 5 p.m. with reason "awaiting delivery from pharmacy", - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 10) [quetiapine fumarate], 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) [temazepam], 30 mg capsule, 1 capsule, as needed at bedtime for insomnia - 1/1/18 GIVEN at 12:26 a.m. 12) [bisacodyl] (medication used to treat constipation) 8.6-50 mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) [bisacodyl] rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if [bisacodyl] ineffective, NOT GIVEN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 18 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's facility document titled Order Summary Report, dated 12/29/17, reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days (12/29/17 - 1/1/18). Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected medications prescribed for Patient 1 were not given, and medications prescribed for Patient 2 were administered to Patient 1. 1. Review of Resident 1's document titled Order Summary Report dated 12/29/17 2:09 p.m., reflected the facility entered medication orders into the facility eMR, then faxed a copy of the report to the pharmacy. The pharmacy faxed the same report to the Facility physician (FMD) to be signed for verification. The form was then returned, signed by the FMD, to the pharmacy for distribution. Review of the hospice face sheet, dated 12/14/17, indicated RP 1 was the PCG (primary care giver), NOK (next of kin), POA (power of attorney), and EC (emergency contact). Review of the facility document titled Notice of Admission/ Re-Admission, dated 12/29/17, indicated Resident 1 was not their own Responsible Party. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 19 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's document titled Physician Orders for Life-Sustaining Treatment (POLST - medical orders dictating treatments to be provided based on the patient/ resident's wishes during a medical emergency) dated 10/21/17 was signed by Resident 1's POA. During a concurrent interview and document review on 1/5/18 at approximately 2:45 p.m., Licensed Nurse (LN) 1 confirmed the hospice face sheet, the facility admission notice and the POLST all indicated Resident 1 was not their own Responsible Party. During a concurrent interview with the Director of Nursing (DON) and the Administrator (ADM) on 1/3/18 at 8:40 a.m., the DON stated facility Licensed Nurse (LN) 4 notified LN 2 from hospice of Resident 1's change of condition around 7:40 a.m. on 1/1/18. The DON stated LN 2 arrived at the facility at approximately 8:45 a.m. and reviewed the orders in Resident 1's paper chart (hard copy medical record) and discovered Resident 2's orders in Resident 1's chart. The ADM stated LN 2 then compared the paper copy of Resident 1's and Resident 2's physician orders to the orders entered by the facility into the eMR and reported the medications errors to LN 4. LN 2 then notified the hospice physician (HMD) and all medications were discontinued by the HMD. During an interview with the Assistant Director of Nursing (ADON) on 1/3/18 at 11:10 a.m., the ADON stated "the family knew" of the medication error "before [Resident 1's] death... because the hospice nurse told them." During a telephone interview with LN 2 on 1/4/18 at 9:05 a.m., LN 2 confirmed the call from the facility regarding the Resident 1's COC, arrival time at the facility, and discovery FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 20 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of the medication administration errors. LN 2 notified the HMD. LN 2 stated the family was not present when she left, but the family was there when she returned at 12:15 p.m. after notification of Resident 1's death. LN 2 stated the family was not aware of the specific medication errors and explained the discovery of the order and administration errors. During a telephone interview on 1/5/18 at 1:30 p.m., RP 1 confirmed the facility left a message about 7:30 a.m., on 1/1/18, that "[Resident 1] was not doing well and was on oxygen." RP 1 stated they returned the call to the facility when they heard the message at approximately 10:00 a.m. RP 1 stated there was no mention of a significant medication error when they arrived at the facility at approximately 12:00 p.m. LN 2 from hospice explained the significant medication error at about 12:15 p.m. RP 1 further stated at no time was the family offered the option of treatment, like naloxone, or a transfer to the hospital. RP 1 stated Resident 1 died about 30 minutes after they arrived to the facility at approximately 12:30 p.m. on 1/1/18. 2. During a concurrent interview with the Director of Nursing (DON) and the Administrator (ADM) on 1/3/18 at 8:40 a.m., the DON stated the FMD is the attending physician for respite residents while they are in the facility. During an interview with the Assistant Director of Nursing (ADON) on 1/3/18 at 11:10 a.m., the ADON stated the FMD, was notified on 1/1/18 at 1:00 p.m. of the medication administration errors, 30 minutes after Resident 1 died. Review of Resident 1's eMR facility document titled Progress Notes reflected a late entry by the ADON, dated 1/2/18 at 5:08 p.m., indicating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 21 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE attending physician was notified at 1:00 p.m. of Resident 1's death and the medication administration errors. A record review of Resident 1's document titled Administration Record Report (MAR Medication Administration Report) revealed the following: - Resident 1's pain assessments (using a pain scale with 0 = no pain, 1-3 = mild pain, 4 - 6 = moderate pain, 7 - 9, 10 = worst+) indicated a pain level of 0 on 1/1/18 at midnight, at 4 a.m., and at 8 a.m. - Resident 1 received on 1/1/18 morphine 100 mg at midnight and restoril at 12:26 a.m. for insomnia. - Resident 1 received on 1/1/18 2 ml of morphine 20 mg/ml [40 mg] at 3:59 a.m. - On 1/1/18, Resident 1 did not receive the scheduled morphine for 6 a.m. with a notation of "9" which indicated "other/ see nurse notes." A record review of Resident 1's document titled Progress Notes revealed the following: - On 1/1/18 at 4:49 a.m., LN 4 indicated a Medication Administration Note, "Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 2 ml by mouth every 2 hours... Pain Scale was: 0." - On 1/1/18 at 5:14 a.m., LN 4 indicated a Medication Administration Note, "Morphine Sulfate ER Tablet Extended Release 100 MG Give 1 tablet by mouth every 6 hours for PAIN Unable to swallow." - On 1/1/18 at 6:39 a.m., LN 4 indicated a Medication Administration Note, "OXYGEN 2L/MIN [a unit of measure for flow rate] VIA NC [nasal cannula - a means of delivering oxygen into the nose] PER CONCENTRATOR [a device that concentrates oxygen from the air to supply an oxygen-enriched flow] as needed for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 22 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SOBPRN [shortness of breath as needed]." - On 1/1/18 at 6:59 a.m., LN 4 indicated a Medication Administration Note, "Restoril Capsule 30 mg...PRN Administration was: Effective." - On 1/1/18 at 7:40 a.m., LN 4 indicated a Health Status Note, "Resident in bed placed on continuous O2 [oxygen]@ 2L/min. Morphine solution given as patient now unable to open mouth and swallow pills. [Agency name] hospice notified of change in status. [RP 1] made aware." During an interview and concurrent record review of the above with LN 4 on 1/5/18 at 3:55 p.m., LN 4 stated he did not consider a change of condition when Resident 1 could not express her pain for the 3:39 a.m. liquid morphine and at 5:14 a.m. when Resident 1 could not open their mouth or swallow a pill. LN 4 additionally stated Resident 1's change of condition was reported to the hospice agency around 7:30 a.m. after Certified Nursing Assistant (CNA) 1 and CNA 2 reported Resident 1 was unresponsive. LN 4 stated the hospice agency notified the HMD. LN 4 confirmed the FMD was not notified until after Resident 1 had died. Review of the facility policy titled Medication Errors, revised November 2017, stipulated, "It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative...When first discovered, the medication error shall immediately be reported to the physician for appropriate actions to be taken... Resident and resident representative should be notified and all actions taken to rectify the situation..." Review of the facility policy titled Change of Condition, Resident, revised 11/2017, stipulated, "It is the policy of this facility to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 23 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner...in the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and provide possible transport to an acute hospital." Review of the facility document titled Skilled Nursing Facility Services Agreement dated April 16, 2015 and signed by representatives from the facility and [Agency Name] Hospice stipulated, "Attending Physician means the doctor of medicine...duly licensed ... is identified by a hospice patient (or such patient's legal representative) as having the most significant role in the determination and delivery of such Hospice Patient's medical Care....Hospice Services...include...physician services to the extent these services are not covered by the attending physician."

F755 SS=F Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 09/22/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 24 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility policy review, the facility failed to develop procedures to ensure medications were acquired, dispensed and administered as prescribed by the physician for 1 of 2 residents (Resident 1) when: 1. Orders entered into the eMR (electronic medical record) by Licensed Nurse (LN) 1 were not verified, and 2. The pharmacy did not receive a copy of the original orders for verification, and 3. Medications prescribed by the hospice physician (HMD), including medications for blood pressure and heart function, for Resident 1 were not transcribed to the pharmacy for acquisition, and 4. Medications prescribed by the HMD for Resident 2, including medications for pain (high dose morphine), nerve pain, and psychiatric disorders, were transcribed to the pharmacy for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 25 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE acquisition, verified by the facility attending (FMD) and were dispensed and administered to Resident 1. The failure to assure the accurate acquisition, dispensation and administration of medications resulted in Resident 1's death from acute morphine toxicity. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in December 2017 with diagnoses including renal failure, high blood pressure, heart disease and diabetes. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated 12/14/17, reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. During a concurrent interview and record review with the Administrator (ADM) and Director of Nursing (DON) on 1/3/18 at 8:40 a.m., the ADM stated two faxes (one for Resident 1 and one for Resident 2) were received on 12/18/17 from the referring hospice agency one right after the other. The two faxes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 26 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were bundled together as one packet and processed as one resident. A third fax was received on 12/28/17 for Resident 1. Review of the above faxed documents, presented by the ADM, reflected the following: - Admission request for Resident 1 received on 12/18/17 at 3:32 p.m., with a cover sheet with Resident 1's name on the cover sheet and with the notation "Thank you for your review for respite." Supporting documentation for Resident 1 was also included in the fax totaling 21 pages with Resident 1's name on each page. Documentation included the resident's hospice face sheet, medical history, prescriber orders and nursing notes. - Admission orders for Resident 2 received on 12/18/17 at 3:40 p.m., with a cover sheet with Resident 2's name and the notation "respite orders." Resident 2's prescriber orders were included in the fax totaling 3 pages with Resident 2's name on each page. - Admission orders for Resident 1 received on 12/28/17 at 11:35 a.m., with a cover sheet with Resident 1's name on it. Resident 1's prescriber orders were included in the fax totaling 4 pages with Resident 1's name on each page. After review of the faxed documents, the ADM further stated, the hospice agency faxes the request for respite care to the facility; once accepted, the hospice agency sends the final orders to the facility the day before admission. During the same interview on 1/3/18 at 8:40 a.m., the DON explained the admission process as the following: - The admission packet was sent to admissions from the referring agency and was placed in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 27 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident's chart. - The chart was then sent to the nurses' station the day of admission. - The Unit Manager or Admissions Nurse received the chart and reviewed the admissions orders and history, and if needed, would contact the prescriber for any clarification. Orders were then entered in to the eMR (electronic medical record). - The medication orders that had been entered into the facility eMR, were then printed and signed by the entering nurse attesting the orders entered were from prescriber written orders. This form was then faxed to the facility pharmacy to be dispensed. - Comfort medications (usually medications for pain, anxiety, antipsychotic and bowel care) were usually supplied to the facility by the hospice provider. Medications not covered by the hospice provider were supplied from the facility pharmacy. During an interview on 1/3/18 at 11:45 a.m., Licensed Nurse (LN) 1, who was the Admission Nurse for Resident 1, verified the admission process and confirmed Patient 1's original orders were not faxed to the pharmacy. LN 1 further confirmed no other facility staff double checked the orders entered into the eMR. LN 1 stated comfort medications were usually delivered to the facility by the hospice pharmacy the day of admission, however, there was a miscommunication and Resident 1's medications were refused in the morning by the facility and hospice had them resent later in the day. LN 1 further stated when Resident 1 arrived at the facility, the hospice nurse was notified. In a telephone interview on 1/4/18 at 9:05 a.m., LN 2 (hospice nurse) stated hospice was notified by the facility of Resident 1's arrival. LN 2 stated upon arrival to the facility, Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 28 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was assessed. LN 2 stated admission orders had not yet been entered in to the eMR to double check. LN 2 further indicated Resident 1's admission orders were reviewed with LN 1 from the admission orders faxed on 12/28/17 and the corresponding hospice eMR orders; the review included the comfort medications to be delivered later due to this earlier miscommunication and the medications not covered by hospice. LN 2 stated further explanation to LN 1 was discussed regarding the medications with an "X" marked next to them indicated medications not covered by hospice that would need to be either ordered from the facility pharmacy or medications from home would be brought to the facility by the family to be used. During a follow up interview with LN 1 on 1/5/18 at approximately 2:45 p.m., LN 1 confirmed the review of medications with LN 2. LN 1 further stated the orders entered in the facility eMR were the hand written orders "...because the orders are not usually printed from hospice [eMR], I skipped over them and went to the next page of hand written orders..." LN 1 stated he did not see Resident 2's name on the handwritten medication orders he transcribed into the facility eMR. LN 1 confirmed Resident 1 received medications prescribed for Resident 2. Review of the faxed document for Patient 1, dated 12/28/17, titled Physician's Orders/Medication Status - [hospice name] and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 29 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MAR and were not administered to Patient 1. 1) Morphine Sulfate (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) Morphine Sulfate Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) Morphine Sulfate Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) [lorazepam] (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) Nitroglycerin (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) [bisacodyl] (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) mirtazapine 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) metoprolol tartrate 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) furosemide, 20 mg tablet, 1 tablet, by mouth, as needed for edema 10) methimazole (medication used to treat thyroid disease), 5 mg tablet, 1 tablet, by mouth, every day 11) hydralazine hydrochloride, 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) [omeprazole], 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) sucralfate, 1 gm tablet, 1 tablet, by mouth, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 30 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE twice a day for stomach 14) amlodipine besylate, 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) clonidine hydrochloride, 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) isosorbide mononitrate extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) haloperidol lactate concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated 12/18/17, titled Physician Orders Sheet [hospice name] reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1's facility documents titled Administration Record Reports Administration Record Report (MAR) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of 12/29/17: 1) [lorazepam] 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - 12/31/17 GIVEN at 12:01 a.m. 2) morphine extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - 12/29/17 GIVEN at 6 p.m., - 12/30/17 NOT GIVEN, at 12 a.m. with reason "waiting for medication delivery," and 6 a.m. with reason "Will call [hospice name] to follow up medication," REFUSED [by Resident] at 12 p.m., GIVEN at 6 p.m., - 12/31/17 GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - 1/1/18 GIVEN at 12 a.m., NOT GIVEN at 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 31 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m. with reason at 5:14 a.m. as "Unable to swallow." 3) morphine 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - 12/31/17 GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - 1/1/18 GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) gabapentin (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 5) dexamethasone (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - 12/30/17 GIVEN at 9 a.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., - 1/1/18 GIVEN 9 a.m. 6) baclofen 10 mg tablet, 1/2 tablet, by mouth, three times a day for spasms - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 7) [famotidine], 40 mg tablet, 1 tablet, by mouth twice a day for stomach - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by patient] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 8) [quetiapine fumarate] (an antipsychotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 32 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - 12/29/17 NOT GIVEN at 5 p.m. with reason "awaiting delivery from pharmacy", - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 10) [quetiapine fumarate], 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) [temazepam], 30 mg capsule, 1 capsule, as needed at bedtime for insomnia - 1/1/18 GIVEN at 12:26 a.m. 12) [bisacodyl] (medication used to treat constipation) 8.6-50 mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) [bisacodyl] rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if [bisacodyl] ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated 12/29/17, reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days (12/29/17 - 1/1/18). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 33 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In a telephone interview with LN 3, on 1/4/18 at 9:20 a.m., LN 3 stated she had cared for Resident 1 since October of 2017 for the hospice agency and had last seen the resident on 12/27/17. LN 3 further stated Resident 1 was alert and oriented to person and place, was able to feed self, ate about 50% of meals, and was able to ambulate to the bathroom in the home. LN 3 additionally stated Resident 1 had received 10 mg of morphine once after a fall, but did not like the feeling and did not receive any additional narcotics. LN 3 verified Resident 1 was opioid (narcotic) naive (not chronically receiving opioids on a daily basis). In a telephone interview with the Pharmacy Manager (PM) of the facility contracted pharmacy, on 1/5/18 at 10:15 a.m., the PM stated controlled medications like narcotics required the prescribing physician to verify the narcotic order either verbally or by signature. The PM further stated a copy of the printed eMR orders received from the facility was faxed to the facility attending physician (FMD) for verification and not to the original prescribing hospice physician (HMD). The PM indicated FMD returned the signed orders to the pharmacy on 12/29/17 at 4:57 p.m. The PM stated there was not a pharmacy policy requiring original orders nor was there a policy regarding providing hospice covered medications. During an interview with LN 1 on 1/5/18 at approximately 2:40 p.m., LN 1 confirmed the original HMD orders were not sent to the pharmacy, only the orders printed from the eMR. LN 1 stated original orders were not sent to the FMD. Review of Resident 1's document titled Order Summary Report dated 12/29/17 2:09 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 34 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reflected the facility entered medication orders faxed to the pharmacy and returned to the pharmacy for distribution, were signed by the FMD and returned to the pharmacy. Review of the facility policy titled Record Content - Medication and Treatment Administration Record, dated 11/2017, stipulated, "Medications and treatments shall be administered as prescribed by the physician..." Review of the facility policy titled Medication Errors, dated November 2017, stipulated, "...A medication error is defined as administration to a resident: To the wrong patient, at the wrong time, at the wrong dose, by the incorrect route, which is not prescribed by a physician, omission if [sic] the prescribed medication..." Review of the facility document titled Skilled Nursing Facility Services Agreement dated April 16, 2015 and signed by representatives from the facility and [Agency Name] Hospice stipulated, "Attending Physician means the doctor of medicine...duly licensed... is identified by a hospice patient (or such patient's legal representative) as having the most significant role in the determination and delivery of such Hospice Patient's medical Care....Hospice Services...include...physician services to the extent these services are not covered by the attending physician." During a telephone interview with the county deputy coroner on 5/1/18 at 9:30 a.m., the coroner stated the morphine level for Resident 1 was 0.27 mg/liter. He further stated the "reference ranges for morphine for a narcotic naive person was 0.01 mg/ liter is therapeutic and 0.05 - 0.4 mg/ liter was lethal...the cause of death for [Resident 1] was acute morphine toxicity." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 35 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the toxicology screen, dated 1/5/18 and received from the county coroner's office on 5/8/18, reflected a morphine level of 0.27 mg/ liter for Resident 1. Review of the death certificate, amended on 4/28/18, reflected Resident 1's cause of death as "Acute morphine toxicity."

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 09/22/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility policy review, the facility failed to administer medications as prescribed by the physician for 1 of 2 residents (Resident 1) when: 1. Resident 1 did not receive medications prescribed by the admitting physician, including medications for blood pressure and heart function, and 2. Resident 1 received medications prescribed for Resident 2 including medications for pain (high dose morphine), nerve pain, and psychiatric disorders. These medication administration errors resulted in an acute morphine toxicity which resulted in Resident 1's death. Findings: Review of Resident 1's facility face sheet (document containing patient demographics FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 36 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in December 2017 with diagnoses including renal failure, high blood pressure, heart disease and diabetes. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated 12/14/17, reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. During a concurrent interview and record review with the Administrator (ADM) and Director of Nursing (DON) on 1/3/18 at 8:40 a.m., the ADM stated two faxes (one for Resident 1 and one for Resident 2) were received on 12/18/17 from the referring hospice agency one right after the other. The two faxes were bundled together as one packet and processed as one resident. A third fax was received on 12/28/17 for Resident 1. Review of the above faxed documents, presented by the ADM, reflected the following: - Admission request for Resident 1 received on 12/18/17 at 3:32 p.m., with a cover sheet with Resident 1's name on the cover sheet and with the notation "Thank you for your review for respite." Supporting documentation for Resident 1 was also included in the fax totaling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 37 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 21 pages with Resident 1's name on each page. Documentation included the resident's hospice face sheet, medical history, prescriber orders and nursing notes. - Admission orders for Resident 2 received on 12/18/17 at 3:40 p.m., with a cover sheet with Resident 2's name and the notation "respite orders." Resident 2's prescriber orders were included in the fax totaling 3 pages with Resident 2's name on each page. - Admission orders for Resident 1 received on 12/28/17 at 11:35 a.m., with a cover sheet with Resident 1's name on it. Resident 1's prescriber orders were included in the fax totaling 4 pages with Resident 1's name on each page. After review of the faxed documents, the ADM further stated, the hospice agency faxes the request for respite care to the facility; once accepted, the hospice agency sends the final orders to the facility the day before admission. During the same interview on 1/3/18 at 8:40 a.m., the DON explained the admission process as the following: - The admission packet was sent to admissions from the referring agency and was placed in the resident's chart. - The chart was then sent to the nurses' station the day of admission. - The Unit Manager or Admissions Nurse received the chart and reviewed the admissions orders and history, and if needed, would contact the prescriber for any clarification. Orders were then entered in to the electronic medical record (eMR). - The medication orders were transcribed and then entered into the facility eMR, were then printed and signed by the entering nurse attesting the orders entered were from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 38 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prescriber written orders. This form was then faxed to the facility pharmacy to be dispensed. - Comfort medications (usually medications for pain, anxiety, antipsychotic and bowel care) are usually supplied to the facility by the hospice provider. Medications not covered by the hospice provider are supplied from the facility pharmacy. During an interview on 1/3/18 at 11:45 a.m., Licensed Nurse (LN) 1, who was the Admission Nurse for Resident 1, verified the admission process and confirmed Resident 1's original orders were not faxed to the pharmacy. LN 1 further confirmed no other facility staff double checked the orders entered into the eMR. LN 1 stated comfort medications were usually delivered to the facility by the hospice pharmacy the day of admission, however there was a miscommunication and Resident 1's medications were refused in the morning by the facility and hospice had them resent later in the day. LN 1 further stated when Resident 1 arrived at the facility, the hospice nurse was notified. In a telephone interview on 1/4/18 at 9:05 a.m., LN 2 (hospice nurse) stated hospice was notified by the facility of Resident 1's arrival. LN 2 stated upon arrival to the facility, Resident 1 was assessed. LN 2 stated admission orders had not yet been entered in to the eMR to double check. LN 2 further indicated Resident 1's admission orders were reviewed with LN 1 from the admission orders faxed on 12/28/17 and the corresponding hospice eMR orders; the review included the comfort medications to be delivered later due to the earlier miscommunication, and the medications not covered by hospice. LN 2 stated further explanation to LN 1 was discussed regarding the medications with an "X" marked next to them indicated medications not covered by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 39 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospice that would need to be either ordered from the facility pharmacy or medications from home would be brought to the facility by the family to be used. During an interview on 1/5/18 at 2:00 p.m., the DON stated "I'm not disputing the order mix up." During a follow up interview with LN 1 on 1/5/18 at approximately 2:45 p.m., LN 1 confirmed the review of medications with LN 2. LN 1 further stated the orders entered in the facility eMR were the hand written orders "...because the orders are not usually printed from hospice [eMR], I skipped over them and went to the next page of hand written orders..." LN 1 stated he did not see Resident 2's name on the handwritten medication orders he transcribed into the facility eMR. LN 1 confirmed Resident 1 received medications prescribed for Resident 2. Review of the faxed document for Patient 1, dated 12/28/17, titled Physician's Orders/Medication Status - [hospice name] and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) Morphine Sulfate (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 40 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE breath), 2) Morphine Sulfate Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) Morphine Sulfate Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) [lorazepam] (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) Nitroglycerin (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) [bisacodyl] (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) mirtazapine 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) metoprolol tartrate 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) furosemide, 20 mg tablet, 1 tablet, by mouth, as needed for edema 10) methimazole (medication used to treat thyroid disease), 5 mg tablet, 1 tablet, by mouth, every day 11) hydralazine hydrochloride, 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) [omeprazole], 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) sucralfate, 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) amlodipine besylate, 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) clonidine hydrochloride, 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) isosorbide mononitrate extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 41 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE every day for heart 18) haloperidol lactate concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated 12/18/17, titled Physician Orders Sheet [hospice name] reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1 ' s facility documents titled Administration Record Reports Administration Record Report (MAR Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of 12/29/17: 1) [lorazepam] 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - 12/31/17 GIVEN at 12:01 a.m. 2) morphine extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - 12/29/17 GIVEN at 6 p.m., - 12/30/17 NOT GIVEN, at 12 a.m. with reason "waiting for medication delivery," and 6 a.m. with reason "Will call [hospice name] to follow up medication," REFUSED [by Resident] at 12 p.m., GIVEN at 6 p.m., - 12/31/17 GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - 1/1/18 GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as "Unable to swallow." 3) morphine 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - 12/31/17 GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 42 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and pain rating of 2, - 1/1/18 GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) gabapentin (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 5) dexamethasone (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - 12/30/17 GIVEN at 9 a.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., - 1/1/18 GIVEN 9 a.m. 6) baclofen 10 mg tablet, 1/2 tablet, by mouth, three times a day for spasms - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED [by Resident] at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 7) [famotidine], 40 mg tablet, 1 tablet, by mouth twice a day for stomach - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by patient] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 8) [quetiapine fumarate] (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - 12/29/17 NOT GIVEN at 5 p.m. with reason "awaiting delivery from pharmacy", - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED [by Resident] at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 43 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10) [quetiapine fumarate], 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) [temazepam], 30 mg capsule, 1 capsule, as needed at bedtime for insomnia - 1/1/18 GIVEN at 12:26 a.m. 12) [bisacodyl] (medication used to treat constipation) 8.6-50 mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) [bisacodyl] rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if [bisacodyl] ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated 12/29/17, reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/181/31/18 reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days (12/29/17 - 1/1/18). In a telephone interview with LN 3, on 1/4/18 at 9:20 a.m., LN 3 stated she had cared for Resident 1 since October of 2017 for the hospice agency and had last seen the resident on 12/27/17. LN 3 further stated Resident 1 was alert and oriented to person and place, was able to feed self, ate about 50% of meals, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 44 of 45 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056324 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAMPTON POST ACUTE 442 E Hampton Street Stockton, CA 95204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and was able to ambulate to the bathroom in the home. LN 3 additionally stated Resident 1 had received 10 mg of morphine once after a fall, but did not like the feeling and did not receive any additional narcotics. LN 3 verified Resident 1 was opioid (narcotic) naive (not chronically receiving opioids on a daily basis). Review of the facility policy titled Record Content - Medication and Treatment Administration Record, dated 11/2017, stipulated, "Medications and treatments shall be administered as prescribed by the physician..." Review of the facility policy titled Medication Errors, dated November 2017, stipulated, "...A medication error is defined as administration to a resident: To the wrong patient, at the wrong time, at the wrong dose, by the incorrect route, which is not prescribed by a physician, omission if [sic] the prescribed medication..." During a telephone interview with the county deputy coroner on 5/1/18 at 9:30 a.m., the coroner stated the morphine level for Resident 1 was 0.27 mg/liter. He further stated the "reference ranges for morphine for a narcotic naive person was 0.01 mg/ liter is therapeutic and 0.05 - 0.4 mg/ liter was lethal...the cause of death for [Resident 1] was acute morphine toxicity." Review of the toxicology screen, dated 1/5/18 and received from the county coroner's office on 5/8/18, reflected a morphine level of 0.27 mg/ liter for Resident 1. Review of the death certificate, amended on 4/28/18, reflected Resident 1's cause of death as "Acute morphine toxicity." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HETZ11 Facility ID: CA030000039 If continuation sheet 45 of 45