Health inspection·September 25, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reviewed. The DSAS verified Resident 3's enteral feeding care plan indicated interventions to change Resident 3's dressing at the stoma site (an artificial opening created through surgery on the stomach) per doctor's orders and to clean the stoma site as ordered/per facility protocol. The DSAS also verified Resident 3 did not have an order to change the dressing at the G-tube site or an order to clean the site. The DSAS stated care plans provide interventions to situations that were resident specific. The DSAS further stated it was important to follow the care plan to prevent infection.During an interview on 9/25/25, at 5:05 p.m., with the Administrator (ADM), the ADM stated it was her expectation that care plans would be followed. The ADM further stated it was important to follow the care plan to stay consistent with resident care.During a review of the facility's policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, dated 8/25/21, the P&P indicated, .Each resident's comprehensive care plan is designed to. incorporate identified problem areas.aid in preventing or reducing declines in the resident's functional status and/or functional levels.reflect currently recognized professional standards of practice for problem areas and conditions . Event ID: Facility ID: 055735 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Oaks Post Acute 6940 Pacific Avenue Stockton, CA 95207 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided to prevent potential further decline in range of motion (ROM; the extent to which a joint can move through its entire range of motion without pain or restrictions) for one of three sampled residents (Resident 1), when Resident 1's ordered Restorative Nursing Program (program to help ensure that residents retain the skills gained in physical therapy and prevent declines that can impact the quality of a resident's life) to provide passive range of motion (PROM; when another person or a machine moves a patient's limb or joint through its full range of motion without the patient's active muscle contraction or effort) to Resident 1's bilateral lower extremities (BLE; both legs) was discontinued on 2/5/25 without an updated referral from the therapy department. This failure had the potential to result in decreased ROM for Resident 1 and for Resident 1's contractures (a body part that gets stuck in a bent or shortened position because of permanent tightening of muscles, tendons, ligaments, or skin that prevents a body part, most often a joint, from moving freely) to worsen.Findings:Review of Resident 1's functional mobility (a person's capacity to move safely and independently to perform activities of daily living (ADLs) such as walking, standing, sitting, and transfers between surfaces) care plan, initiated 4/21/25, in the section titled Focus, indicated .[Resident 1] exhibits or is at risk for alterations in functional mobility related to contracture deformity [a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part]: Prevent and Treatment: B [bilateral; both sides] UE/LE [upper extremity (arm)/lower extremity (leg)] contractors. In the section titled Goals, indicated, .[Resident 1] will not have a decrease in ROM times 90 days.[Resident 1] will have no increase in contractures X [times] 90 day [sic].A review of Resident 1's Minimum Data Set (MDS, an assessment tool), in the section titled, Section GG - Functional Abilities, dated 8/3/25, indicated Resident 1 was dependent on staff for all care needs including eating, toileting, bathing, personal hygiene, and dressing.During a concurrent interview and record review on 9/24/25, at 11:28 a.m., with Restorative Nurse Assistant (RNA) 1, Resident 1's document titled, RNA Orders & Referral Form, dated 12/6/24, was reviewed. Review of Resident 1's RNA order, signed by the Director of Rehab (DOR), indicated to provide .Passive ROM. [checked box] RNA for PROM to BUE & BLE.Non verbal [unable to speak], increase risk of contracture related to immobility [unable to move on own], ROM. RNA 1 verified that this was Resident 1's most recent referral for RNA services and stated Resident 1 was currently only receiving PROM therapy for bilateral upper extremities three times a week. RNA 1 further stated that Resident 1 used to receive PROM for BUE and PROM for BLE but stopped receiving BLE PROM between February and March of this year (2025). During a concurrent interview and record review on 9/25/25, at 1:15 p.m., with the Director of Nursing (DON), Resident 1's physician orders were reviewed. The DON verified Resident 1's physician order for BLE PROM three times a week was discontinued on 2/5/25. The DON stated the facility should have continued both BUE and BLE PROM therapy and Resident 1's order for BLE PROM should not have been discontinued without a new referral from therapy. The DON further stated that without receiving the BLE PROM Resident 1 was at risk of experiencing worsening contractures and potentially pain associated with the joints and immobility.During an interview on 9/25/25, at 2:05 p.m., with Physical Therapy Assistant (PTA) 1, PTA 1 stated Resident 1 would not be able to maintain range of motion or mobility without BLE PROM. PTA 1 noted that Resident 1 was at risk for worsening contractures and potential discomfort.During a review of Resident 1's document titled, Documentation Survey Report V2 for the months of 12/24 to 8/25 indicated Resident 1 last received BLE PROM on 2/13/25.During a review of the facility's policy and procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Oaks Post Acute 6940 Pacific Avenue Stockton, CA 95207 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 0688 (P&P) titled, Restorative Nursing Services, dated 7/17, the P&P indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Oaks Post Acute 6940 Pacific Avenue Stockton, CA 95207 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on interview and record review, the facility failed to ensure a physician order was in place to indicate the appropriate care of a gastrostomy tube feeding (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) for 2 of the 3 sampled residents (Resident 1 and Resident 3) to prevent potential complications of the feeding tube when, Resident 1 and Resident 2 did not have a physician treatment order to indicate the care needed for the G-tube site.This failure had the potential for Resident 1 and Resident 3 to experience skin breakdown and infection at the G-tube site.Findings:1. Review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis including but not limited to .ENCOUNTER FOR ATTENTION TO GASTROSTOMY [this diagnosis applies to routine tasks like cleansing, dressing changes, and managing the g-tube].During a concurrent interview and record review on 9/24/25, at 3:43 p.m., with Licensed Nurse (LN) 1, Resident 1's Order Summary Report, printed on 10/24/25, was reviewed. LN 1 confirmed there was no treatment order for Resident 1's G-tube site. LN 1 stated the order should have been there, and it was part of the facility policy to provide treatment to Resident 1's G-tube site every day. LN 1 further stated if the G-tube site does not receive treatment there was a risk of infection and skin breakdown at the site.During an interview on 9/24/25, at 4:05 p.m., with the Director of Sub-Acute Services (DSAS; provides more intensive medical services and therapy than a traditional nursing home but is less intensive than acute (hospital) care), the DSAS stated it was her expectation for Resident 1 to have a physician treatment order that included g-tube treatment instructions.A review of Resident 1's, Treatment Administration Record, dated 8/24, indicated there was no documented evidence that Resident 1 received treatment to the G-tube site upon readmission to the facility on 8/9/24.2. Review of Resident 3's clinical record titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnosis including but not limited to .ENCOUNTER FOR ATTENTION TO GASTROSTOMY.During a concurrent interview and record review on 9/25/25, at 3:07 p.m., with Licensed Nurse (LN) 2, Resident 1's, Order Summary Report, with a printed date of 10/25/25, was reviewed. LN 2 verified Resident 3 had no active order for treatment for Resident 3's G-tube site from 8/20/25, until today, 9/25/25. LN 2 stated that without a treatment order for the g-tube, Resident 3 was at risk for skin breakdown and infection of the G-tube site.During a concurrent interview and record review on 9/25/25, at 4 p.m., with the DSAS, Resident 3's Order Summary Report, with a printed date of 10/25/25, was reviewed. The DSAS verified Resident 3 did not have an order to change the dressing at the G-tube site or an order to clean the site. The DSAS stated if Resident 3's G-tube site did not have a treatment order Resident 3 was at risk for infection and skin breakdown at the G-tube site.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings [a method of providing nutrition directly into the gastrointestinal (GI; includes stomach and intestines) tract through a tube] - Safety Precautions, dated 11/18, the P&P indicated, .The facility will remain current in and follow accepted best practices in enteral nutrition.Keep the skin around exit site clean, dry and lubricated. Event ID: Facility ID: 055735 If continuation sheet Page 5 of 5