Hampton Post Acute: Nursing Staff Medication Chaos - CA
The December 13 incident at Hampton Post Acute exposed deeper staffing problems that left residents missing doses of muscle relaxers, seizure medications, and breathing treatments across multiple shifts.
Licensed Nurse 8 arrived for her overnight shift but refused to accept the medication cart keys from the evening nurse, according to federal inspection records. When Licensed Nurse 3 arrived at 3 AM to help, she found medications that were due at midnight still hadn't been given to residents.
"LN 8 would not answer her when she asked if the residents had received their medications," inspectors wrote. The keys for one medication cart were still sitting in a binder, indicating no nurse had taken them for medication administration.
Licensed Nurse 6, who worked the evening shift, told inspectors she "was not able to endorse the medication cart to LN 8 because LN 8 did not want to take over the cart."
The administrator received a phone call during the night from an evening shift staff member who was still on duty past their scheduled time, reporting that LN 8 was unwilling to take responsibility for the medication cart. He instructed LN 8 to take the keys, explaining she was not just a desk nurse.
Licensed Nurse 7 told inspectors that LN 8 "wanted to be Unit Manager and not pass medications" and appeared angry about the assignment change.
Two nights later, another nurse walked off her shift because she didn't want her assignment. Licensed Nurse 3 left the facility on December 15 after being told by LN 8 that if she didn't want her assignment, she could go home. The administrator called LN 3 to return and complete her shift, but she said she had taken sleep medication and couldn't return.
The staffing chaos created widespread medication errors. Five residents missed critical doses or received medications hours late during this period.
Resident 3, who has muscle weakness and partial paralysis from a stroke, missed two doses of Baclofen muscle relaxer on December 11 and December 20. Resident 4, who has quadriplegia and autonomic dysreflexia, missed the same medication plus Gabapentin for nerve pain on the same dates.
Resident 5, who has chronic obstructive pulmonary disease, missed his Ipratropium-Albuterol breathing treatment on December 11.
Resident 2, who has multiple sclerosis and paraplegia, told inspectors he received his midnight medications at 3 AM or 4 AM during a week in December. "The first time it was late was on 12/13/24," he said, adding it happened again within a week or two.
Records confirmed his Baclofen and Gabapentin were administered at 2:43 AM on December 13 and 3:59 AM on December 20, both more than two hours late.
Other residents experienced similar delays. Medications were consistently administered two to three hours late during the overnight shifts when staffing problems occurred.
The Infection Preventionist reviewing the records told inspectors there were no progress notes explaining why medications were missed or delayed, and physicians were never notified of the problems. "The process to follow when medications were not administered was to write a progress note and notify the physician," she explained.
The facility's own policy requires medications to be given within one hour of their prescribed time, with documentation if they're early, late, or omitted.
Meanwhile, safety hazards endangered residents in other ways. A morbidly obese resident with severe breathing problems lay in bed for 11 days with her mattress hanging six inches over the end of the bedframe. The footboard that would secure the mattress had been removed and was leaning against the wall.
The resident told inspectors she was "worried if she raised her head, the mattress would slide more" and felt like she was "going to fall with her mattress hanging over the end of the bed."
Four staff members tried to push the heavy bariatric mattress back into place with the resident still in bed, but couldn't move it. The Maintenance Director said the footboard had been missing a screw since the resident returned from the hospital 11 days earlier.
In another incident, a licensed nurse left a bubble pack containing 24 tablets of Hydralazine blood pressure medication on top of an unattended medication cart. The nurse acknowledged "another patient could walk by and grab the medication" and explained that if a resident accidentally ingested it, "their blood pressure could go dangerously low."
The Assistant Director of Nursing confirmed medications should never be left where unauthorized people could take them, especially blood pressure drugs that could cause dangerous drops in residents who don't need them.
The facility's policy requires medication carts to be locked whenever they're out of a nurse's view, but the Hydralazine sat exposed in the hallway while the nurse was elsewhere.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hampton Post Acute from 2025-01-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
HAMPTON POST ACUTE in STOCKTON, CA was cited for violations during a health inspection on January 7, 2025.
When Licensed Nurse 3 arrived at 3 AM to help, she found medications that were due at midnight still hadn't been given to residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.