Health inspection·August 22, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly prevent the spread of COVID-19 when one direct care staff member, (Certified Nursing Assistant [CNA] 1) did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, face masks, or respirators worn to prevent the spread of germs and infection) prior to entering the room of residents who were COVID-19 positive (Resident 1 and Resident 2). This failure had the potential for CNA 1 to become infected with COVID-19 and to spread COVID-19 to other facility residents, staff, and visitors. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility in 2024 with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), malignant neoplasm of left kidney (kidney cancer; occurs when healthy cells in the kidney grow out of control and form a lump), and anxiety disorder (a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks, that interferes with daily living).A review of Resident 1's Progress Note, dated 8/22/25, at 10:25 a.m., indicated that Resident 1 tested positive for COVID-19.A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2022 with diagnoses which included osteoarthritis of left and right hip (a degenerative joint disease where the cartilage in the hip joint wears down causing pain and stiffness), and anemia (a condition in which the body doesn't have enough red blood cells and hemoglobin to carry sufficient oxygen to the body tissues).A review of Resident 2's Change in Condition SBAR (situation, background, assessment, and recommendation) and Progress Note Form, dated 8/20/25, at 2 p.m. indicated that Resident 2 tested positive for COVID-19.During a concurrent observation and interview on 8/22/25, at 3:12 p.m., CNA 1 was observed in a COVID-19 isolation room with Resident 1 and Resident 2 wearing a surgical mask (a single-use, non-sterile mask that filters out large droplets, splashes and the wearer's own respiratory droplets. Fit-tested N-95 masks provide better protection against COVID-19 infection). A sign posted near the room door indicated that hand hygiene (cleaning hands with either soap and water or approved hand sanitizer) was required prior to room entry. The sign near the room door further indicated that a gown, N-95 mask, face shield, and gloves were required to be worn on room entry. With CNA 1 outside the residents' room, CNA 1 stated that there was PPE available for use near the room door. CNA 1 confirmed that the isolation sign outside the room door indicated the PPE required to be worn when entering the room. CNA 1 further confirmed that both residents in the room had tested positive for COVD-19. CNA 1 stated that she didn't know why she entered the room without the proper PPE. CNA 1 further stated that she should have had the proper PPE on while in the room with the residents. CNA 1 stated that she knew the risk of not wearing the proper PPE in the room with residents who tested positive for COVID-19.During an interview on 8/22/25, at 3:15 p.m. with the Infection Preventionist (IP), the IP stated that her expectation was that staff washed and/or sanitized their hands between residents, and that staff wore the PPE required when entering an isolation Residents Affected - Few Page 1 of 2 055735 055735 08/22/2025 Delta Oaks Post Acute 6940 Pacific Avenue Stockton, CA 95207

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room of a resident that was positive for COVID-19. The IP further stated that the risk was the spread of COVID-19 to others. The IP acknowledged that the facility policy was not followed.During a review of a facility policy and procedure (P&P) titled, COVID-19 Management, effective January 2025, the P&P indicated, .Policy Statement.To provide a safe environment and to prevent the development and transmission of COVID-19.2. Infection Prevention and Control.II. Staff.ii. When COVID-19 hospitalization levels are high or when in an outbreak, all staff should wear.(N-95 respirator) for source control when providing resident care, Working [sp] with a resident in-person.b. Transmission Based Precautions and Personal Protective Equipment.II. COVID-19 transmission based [sp] precautions will use the following PPE.i. N 95 respirator, gloves, gown, and eye protection.During a review of a facility P&P titled, Isolation Categories of Transmission-Based Precautions, revised September 2022, the P&P indicated, .Policy Statement.Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Policy Interpretation and Implementation.5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door.so that personnel and visitors are aware of the need for and the type of precaution.a. The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. 055735 Page 2 of 2