Windsor Hampton Care Center

F-F755).

These failures placed the safety of residents at risk.

Findings:

1. A review of the facility document titled, NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, dated 12/13/24, indicated LN 8 was scheduled for the NOC (night 11 PM to 7:30 AM) shift. A handwritten notation on the staffing sheet indicated a different LN was a No call no show, which would require LN 8 to take report from the evening shift and accept the keys to pass medications.

During an interview on 1/7/25, at 12:40 PM, with LN 3, LN 3 stated when she arrived at 3 AM to assist on 12/13/24, she had to pass all medications for the [NAME] 1 medication cart and the East 1 medication cart as they had not been given prior to her arriving, and they were due at 12 AM. LN 3 further stated LN 8 was would not answer her when she asked if the residents had received their medications. LN 3 stated the keys for the [NAME] 1 medication cart were still in the binder (this indicated the nurse did not take them for medication administration) and LN 8 would not give her report.

During an interview on 1/7/25, at 4:33 PM, with LN 6, LN 6 stated she worked the evening shift on 12/12/24 and was not able to endorse the medication cart to LN 8 because LN 8 did not want to take over the cart.

During an interview on 1/7/25, at 4:40 PM, with LN 7, LN 7 stated LN 8 wanted to be Unit Manager and not pass medications. LN 7 stated LN 8 appeared angry about the change in the assignment.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During an interview on 1/29/25, at 9:05 AM, with the Administrator (ADM), the ADM stated he received a phone call during the night shift on 12/13/24 from a PM shift staff member, still on duty past their off time, Level of Harm - Minimal harm or stating LN 8 was unwilling to take responsibility of the medication cart. The ADM explained he instructed LN potential for actual harm 8 to take the keys for the medication cart, as she was not just a desk nurse. The ADM explained his expectation was that LN 8 assume responsibility for the medication cart. Residents Affected - Some 2. A review of the facility document titled, NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, dated 12/15/24, indicated LN 3 was scheduled for the NOC (night 11 PM to 7:30 AM) shift. A handwritten notation on the staffing sheet indicated, Left because she didn't like her assignment, with an arrow pointing to LN 3's name.

During an interview on 1/9/25, at 1:55 PM, with LN 4, LN 4 stated LN 3 left her shift because she did not want her assignment.

During an interview on 1/29/25, at 9:05 AM, with the ADM, the ADM stated there was some disagreement regarding assignments for NOC shift on 12/15/24. The ADM stated from what he understood, LN 8 informed LN 3 if she did not want her assignment she could go home right now. The ADM explained he called LN 3 to let her know his expectation was for her to go back to the facility and complete her assignment. LN 3 informed the ADM that she had taken sleep medication and would be unable to return that evening.

A review of the facility document titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), revised 5/22, indicated, .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care .Maintain Documentation of all nursing care and services provided to the residents .Administer medications within the scope of practice and according to practitioner orders. Report adverse consequences, side effects or any medication errors .Cooperate with other personnel to achieve department objectives and maintain good employee, interdepartmental and public relations .

A review of the facility document titled, Registered Nurse (RN), revised 5/22, indicated, .Provide oversight of . licensed nurses .Maintain Documentation of all nursing care and services provided to the residents . Administer medications according to practitioner orders and report any adverse consequence, side effect or any medication errors .Cooperate with other personnel to achieve department objectives and maintain good employee, interdepartmental and public relations .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 40583

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) environment was free of potential hazards when Resident 1's footboard was not in place to keep the mattress secure, and Resident 1's mattress was positioned approximately 6 inches (unit of measurement) over the foot of the bed and left a 12-inch gap at the head of the bed.

This failure resulted in Resident 1 experiencing anxiety about sliding out of the bed and had the potential to result in injury.

Findings:

A review of Resident 1's ADMISSION RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD a lung disease that makes it difficult to breath) and MORBID (SEVERE) OBESITY WITH ALVEOLAR HYPOVENTILATION [a respiratory condition that occurs when someone who is morbidly obese has difficulty breathing].

During a concurrent observation and interview on 1/7/25, at 8:40 AM, with Resident 1, Resident 1's call light was on when entering the room. Resident 1 was in bed, with her bed in a flat position. The end of Resident 1's mattress was hanging over the end of the bedframe by approximately 6 inches, and the head of Residents 1's mattress was approximately 12 inches away from the headboard. The footboard for Resident 1's bed was not attached to the bedframe. It was leaning against the wall. Resident 1 appeared to be breathing heavily and stated she was not comfortable lying flat, but was worried if she raised her head, the mattress would slide more.

During a concurrent observation and interview on 1/7/25, at 8:42 AM, four staff members entered Resident 1's room, Licensed Nurse (LN) 1, the Activities Director (AD), LN 2, and Certified Nursing Assistant (CNA) 1. LN 1, LN2, CNA 1, AD, attempted to push/pull the mattress back into place with Resident 1 still in the bed, but they were not able to move the mattress. Resident 1 was on a bariatric mattress (a heavy-duty mattress designed to support the weight of larger people).

During a concurrent observation and interview on 1/7/25, at 8:50 AM, with the Maintenance Director (Mnt Dir), the Mnt Dir stated Resident 1's footboard had been off her bed since she returned from her previous hospital stay, 11 days prior. The Mnt Dir stated the footboard was missing a screw and he would go fix it.

During an interview on 1/7/25, at 8:52 AM, with LN 1, LN 1 stated she could not remember how long the footboard had been off Resident 1's bed. LN 1 explained it was not safe for the bed not to have a footboard and stated, The mattress slid all the way like that pointing to where the mattress had slid over and off the bedframe. LN 1 further explained without the footboard the mattress could slide all the way off and it was unsafe.

During an interview on 1/7/25, at 8:54 AM, with Resident 1, Resident 1 stated the footboard had been off her bed since the day she returned from the hospital a couple of weeks ago.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 1's medical record indicated Resident 1 returned from her previous hospital stay on 12/27/24. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/7/25, at 9:03 AM, with CNA 1, CNA 1 stated it was not safe for the footboard to be off the bedframe as there was nothing to keep the mattress in place and the mattress and resident could fall Residents Affected - Few off the bed.

During an interview on 1/7/25, at 9:06 AM, with Resident 1, Resident 1 stated she felt like she was going to fall with her mattress hanging over the end of the bed.

A review of the facility policy titled, Maintenance Service, revised 12/09, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner .Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 40583

Residents Affected - Some Based on interview, and record review, the facility failed to ensure medications were administered according to physician orders for five of eight sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) when:

1. Resident 3, and Resident 4 missed medication doses on 12/11/24 and 12/20, and Resident 5 missed a dosage of medication on 12/20/24; and,

2. Resident 2, Resident 3, Resident 4, and Resident 6's medications were administered late.

These failures had the potential to negatively affect the health and well-being for Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6, and the efficacy of the medications being administered.

Findings:

1a. A review of Resident 3's ADMISSION RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included muscle weakness and partial paralysis to the dominant right side following a stroke (lack of blood flow to part of the brain) and aphasia (language disorder that makes it difficult to communicate).

A review of Resident 3's physician orders, dated 3/30/23, indicated, .Baclofen [used to relieve muscle spasms] Tablet 10 MG [milligrams a unit of measure] Give 1 tablet by mouth every 6 hours for MUSCLE SPASM .

A review of Resident 3's clinical document titled, Medication Administration Record, (MAR) dated 12/1/24 through 12/31/24, indicated, .Baclofen Tablet 10 MG Give 1 tablet by mouth every 6 hours for MUSCLE SPASM ., indicated the following doses were not administered:

12/11/24 6 AM dose

12/20/24 12 AM dose

During a telephone interview on 1/28/24, at 11:55 AM, with the Infection Preventionist (IP), the IP reviewed Resident 3's record and stated Baclofen was not administered on the above dates and times. The IP stated there were no progress notes to indicate why the medication was not administered. The IP further stated the physician was not notified of the omitted medication administrations.

b. A review of Resident 4's ADMISSION RECORD, indicated Resident 4 was admitted to the facility with diagnoses which included aphasia, diabetes (problems with blood sugar regulation), quadriplegia (significant paralysis below the neck) persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves), and autonomic dysreflexia (a dangerous syndrome involving overreaction of the autonomic nervous system -part of the nervous system that controls involuntary body functions).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A review of Resident 4's physician orders for Baclofen and Gabapentin (a medication used for seizures or nerve pain), dated 8/10/24, indicated, .Baclofen Oral Tablet 10 MG .Give 1 tablet .every 6 hours for muscle Level of Harm - Minimal harm or relaxant r/t [related to] autonomic dysreflexia ., and .Gabapentin Oral Solution 250 MG/5ML [milliliters a unit potential for actual harm of volume] .Give 14 ml .for neuropathy [nerve damage that can cause pain, numbness, tingling or weakness] .

Residents Affected - Some A review of Resident 4's MAR dated 12/1/24 through 12/31/24, indicated the following medications were not administered:

i.Baclofen Oral Tablet 10 MG .Give 1 tablet .every 6 hours for MUSCLE RELAXANT R/T [related to] AUTONOMIC DYSREFLEXIA .Start Date .08/10/2024 .

The MAR indicated Resident 4's Baclofen was not administered on the following dates and times:

12/11/24 6 AM dose

12/20/24 12 AM dose

ii.Gabapentin Oral Solution 250 MG/ML .Give 14 ml .every 8 hours .Start Date .08/10/2024 .

The MAR indicated Resident 4's Gabapentin was not administered on the following dates and times:

12/11/24 6 AM dose

12/20/24 12 AM dose.

During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 4's record and stated Baclofen and Gabapentin were not administered to Resident 4 on the above dates and times. The IP stated there were no progress notes to indicate why the medications were not administered. The IP further stated the physician was not notified of the missed medication administrations.

c. A review of Resident 5's ADMISSION RECORD, indicated Resident 5 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breath).

A review of Resident 5's physician's orders, dated 10/8/22, indicated, .Ipratropium-Albuterol [medication used to help control symptoms of lung diseases] Solution .1 vial inhale orally every 8 hours for COPD .

A review of Resident 5's MAR dated, 12/1/24 through 12/31/24, indicated Resident 5 did not receive his Ipratropium-Albuterol treatment on 12/11/24 at 6 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 5's record and stated the Ipratropium-Albuterol treatment was not administered to Resident 5 on the above date and time. Level of Harm - Minimal harm or The IP stated there were no progress notes to indicate why the medication was not administered. The IP potential for actual harm further stated the physician was not notified of the missed medication administration. The IP stated the process to follow when medications were not administered was to write a progress note and notify the Residents Affected - Some physician to let him know the medication was not administered and to see if he wanted to continue, discontinue or change the medication to something else.

2a. A review of Resident 2's ADMISSION RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included multiple sclerosis (condition that affects the central nervous system) and paraplegia (inability to voluntarily move the lower parts of the body).

During an interview on 1/8/25, at 11:08 AM, with Resident 2, Resident 2 stated during a one-week period in December 2024, he received his midnight Baclofen and Gabapentin late, at around 3 AM or 4 AM in the morning. Resident 2 explained the first time it was late was on 12/13/24 and he couldn't remember the date of the second time but stated it was within a week or two of the first time.

A review of Resident 2's physician orders, dated 6/12/24, indicated:

i.Baclofen Oral Tablet 10 MG .Give 3 tablet by mouth three times a day for Muscle Spasms .; and,

ii.Gabapentin Oral Tablet 600 MG .Give 2 tablet by mouth three times a day for Neuropathy [nerve pain] .

A review of Resident 2's untitled report provided by the facility, dated 12/9/24 through 12/22/24 and 12/10/24 through 12/22/24 respectively, indicated the medications Baclofen and Gabapentin were administered late

on the following dates and times:

i. 12/13/24 12 AM dose administered at 2:43 AM; 12/20/23 12 AM dose administered at 3:59 AM; and,

ii. 12/13/24 12 AM dose administered at 2:43 AM; 12/20/23 12 AM dose administered at 3:59 AM.

During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 2's record and stated Baclofen and Gabapentin were administered late for Resident 2 on the above dates and times. The IP stated there were no progress notes to indicate why the medication was administered late and the physician should have been notified.

b. A review of Resident 3's ADMISSION RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included muscle weakness and partial paralysis to the dominant right side following a stroke and aphasia.

A review of Resident 3's physician orders, dated 3/30/23, indicated, .Baclofen Tablet 10 MG Give 1 tablet by mouth every 6 hours for MUSCLE SPASM .

A review of Resident 3's untitled report provided by the facility, with dates 12/4/24 through 12/23/24, for the medication Baclofen Tablet 10 MG ., indicated the following doses were administered late:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 12/13/24 12AM dose was administered at 2:47 AM. The subsequent dose was administered on 12/13/24, at 6:19 AM, 3 hours and 32 minutes after her previous dose. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 3's record and stated Baclofen was administered late for Resident 3, on the above date and time. The IP stated there were Residents Affected - Some no progress notes to indicate why the medication was administered late. The IP further stated the physician was not notified of the late administration and stated he may have instructed the next dose be held or delayed.

c. A review of Resident 4's ADMISSION RECORD, indicated Resident 4 was admitted to the facility with diagnoses which included aphasia, diabetes, quadriplegia and persistent vegetative state.

A review of Resident 4's physician orders for Baclofen and Gabapentin, both dated 8/10/24, indicated:

i.Baclofen Oral Tablet 10 MG .Give 1 tablet .every 6 hours for muscle relaxant r/t autonomic dysreflexia .; and,

ii.Gabapentin Oral Solution 250 MG/5ML Give 14 ml .for neuropathy .

A review of Resident 4's untitled report provided by the facility, with dates 12/8/24 through 12/21/24, for the medications, Baclofen Oral Tablet 10 MG, and Gabapentin Oral Solution 250 MG/5ML, were administered late on the following dates and times:

i. Baclofen due on 12/13/24 at 12 AM, administered at 1:58 AM;

Baclofen due on 12/15/24 at 12 AM, administered at 2:47 AM.

ii. Gabapentin due on 12/13/24 at 12 AM, administered at 1:58 AM;

Gabapentin due on 12/15/24 at 12 AM, administered at 2:48 AM.

During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 4's record and stated Baclofen and Gabapentin were administered late for Resident 4 on the above dates and times. The IP stated there were no progress notes to indicate why the medication was administered late. The IP further stated the physician should have been notified of the late administration but was not.

d. A review of Resident 6's ADMISSION RECORD, indicated Resident 6 was admitted to the facility with diagnoses which included hemiplegia and hemiparesis, aphasia, and stroke.

A review of Resident 6's physician orders, dated 10/14/24, indicated, .Cyproheptadine HCI [medication used relieve allergic symptoms] Oral Tablet 4 MG .Give 1 tablet by mouth every 6 hours for generalized itching .

A review of Resident 6's untitled report provided by the facility, dated 12/10/24 through 12/21/24, indicated

the medication Cyproheptadine 4 MG was administered late on the following date and time:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 12/15/24 12 AM dose administered at 2:27 AM.

Level of Harm - Minimal harm or During a telephone interview on 1/28/24, at 11:55 AM, with the IP, the IP reviewed Resident 6's record and potential for actual harm stated Cyproheptadine was administered late for Resident 6, on the above date and time. The IP stated there were no progress notes to indicate why the medication was administered late. The IP explained the Residents Affected - Some importance of writing a progress note for late administration of medications was to mitigate any potential issues such as overlapping medication administration. The IP further explained it was important for the physician to be notified, as subsequent doses may not be safe to administer if given too close together.

A review of the facility titled, Medication Administration Schedule, revised 11/20, indicated, .Scheduled medications are administered within one (1) hour of their prescribed time .The exact time of medication administration is documented in the MAR. If medication is administered early, late (beyond the allowable interval), or is omitted, the reason is also documented .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 056324 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056324 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Hampton Care Center 442 Hampton Street Stockton, CA 95204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 40583 Residents Affected - Few Based on observation, interview, and record review, the facility failed to store medication safely when a bubble pack of Hydralazine (a medication used to control high blood pressure), containing 24 tablets, was left unsecured on top of the medication cart, and the cart was unattended.

This failure had the potential for other residents to take the medication, causing harm to the person ingesting

the medication.

Findings:

During an observation on 1/7/25, at 4:18 PM, there was a bubble pack of hydralazine 10 milligram (unit of measure) tablets on top of the cart in the west hall. The pack contained 24 tablets. The Licensed Nurse (LN) was not in view of the medication cart.

During a concurrent interview and observation on 1/7/25, at 4:28 PM, with LN 1, LN 1 returned to the medication cart. LN 1 stated the medication should not have been left on top of the cart and confirmed she had left it there. LN 1 explained another patient could walk by and grab the medication. LN 1 further explained if the resident ingested the medication their blood pressure could go dangerously low.

During an interview on 1/7/25, at 4:34 PM, with the Assistant Director of Nursing (ADON), the ADON stated medications should not be left on top of the medication cart where they can be taken by people who are not supposed to be handing them. The ADON explained hydralazine was a high blood pressure medication and could cause low blood pressure to a resident who accidentally took it.

A review of the facility policy titled, Security of Medication Cart, revised April 2007, indicated, .The medication cart shall be secured during medication passes .The nurse must secure the medication cart

during the medication pass to prevent unauthorized entry .Medication carts must be securely locked at all times when out of the nurse's view .When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 056324