Health inspection·October 2, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with care .residents are supported.provided with a dignified dining experience.2a. A review of Resident 23's admission RECORD, indicated Resident 23 was admitted to the facility in Summer of 2022 with diagnoses including anxiety disorder (a mental health condition characterized by feelings of fear, worry, unease, and nervousness).A review of Resident 23's Minimum Data Set, (MDS - a resident assessment tool), Section C: Cognitive Patterns, (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) dated 9/16/25, indicated Resident 23's BIMS (BIMS - Brief Interview for Mental Status - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment] Scoring = 13-15 indicates normal intact cognitive function, 8-12 moderate cognitive impairment, 0-7 signifies severe cognitive impairment) was 15 out of 15 indicated Resident 23 had normal intact cognitive function.A review of Resident 23's MDS, Section H: Bladder [part of the body that holds urine] and Bowel [part of the body that holds feces], dated 9/16/25, indicated Resident 23 was always incontinent (when a person has no control of when they pass urine or feces) of bladder and bowel. A review of Resident 23's care plan, (a personalized document that outlines a resident's healthcare needs, goals, and interventions) revised 6/10/24, indicated, . [Resident 23] has bowel and bladder incontinence.Impaired mobility [a limitation in a person's ability to purposefully move their body, affecting their independence].Requesting x4 [4 briefs to be in the residents room] large briefs.During a concurrent observation and interview on 9/29/25, at 10:20 AM, with Resident 23, in Resident 23's room, five incontinent briefs were observed in a small clear bag located on Resident 23's bed. Resident 23 stated the briefs were returned to her today. Resident 23 was observed crying and upset. Resident 23 stated the facility ran out of briefs on 9/27/25 and 9/28/25 and that the facility had also run out of incontinent briefs a few weeks prior to 9/29/25. Resident 23 explained that Central Supply (CS 1 - the person in charge of ordering and stocking supplies) was on leave (absent from work) and when CS 1 went on leave the facility supplies were not available as usual. Resident 23 cried and explained that she should not have to worry about when she received her next incontinent brief and that she had never felt so uncared for in her life. During an interview on 9/29/25, at 1:21 PM, with CS 2, CS 2 confirmed the facility ran out of briefs on 9/27/25 and 9/28/25. CS 2 further stated the Administrator (ADM) had to borrow briefs on Monday 9/29/25, from other facilities because the delivery of the incontinent briefs was delayed.During an interview on 9/30/25, at 8:04 AM, with CNA 5, CNA 5 verified the facility ran out of incontinent briefs on 9/27/25 and 9/28/25. CNA 5 explained that when she checked other nursing stations and supply closets in the facility, the areas did not have incontinent briefs available. CNA 5 stated that she did not have any briefs to put on the residents when she changed them and told a few residents if they went in the bed she would change them. When asked if CNA 5 could recall which residents she told to go in their bed, she stated she could not recall.During a follow-up interview on 9/30/25, at 8:07 AM, Resident 23 stated the facility had run out of incontinent briefs on Sunday, 9/28/25. Resident 23 stated she had saved a couple of briefs just in case the facility ran out. Resident 23 further stated an unidentified staff member came into her room on 9/28/25 and took the incontinent briefs from her and stated the incontinent briefs were needed for another unnamed resident. Resident 23 cried and stated she had to go to the bathroom in her bed, and Resident 23 felt embarrassed, degraded, and further stated, .it took every bit of dignity I had left away. Resident 23 had three briefs left on her bed and stated she felt like she had to guard them. 2b. A review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility in mid-2024 with diagnoses including muscle weakness and difficulty walking.A review of Resident 46's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 2 of 34 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 10/02/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MDS Section C: Cognitive Pattern, dated 8/28/25, indicated Resident 46's BIMS was 15 out of 15 which showed Resident 46 had normal intact cognitive function.A review of Resident 46's MDS Section H: Bladder and Bowel, dated 8/28/25, indicated Resident 46 was always incontinent of bladder and bowel.A review of Resident 46's care plan, revised 9/29/25, indicated, .[Resident 46] has Bowel Incontinence.Resident [46] will be clean and dry with use of incontinence products and prompt incontinence care.A review of Resident 46's care plan, revised 8/24/23, indicated, .[Resident 46] has self care deficit with ADL [ADL - activities of daily living are basic routine tasks that are necessary for independent self- care] functions: bathing, personal hygiene.toileting.[Resident 46] will be clean, dry, odor free.The resident will maintain dignity and self-esteem.During an interview on 9/30/25, at 12:58 PM, in Resident 46's room, Resident 46 stated the facility ran out of incontinent briefs over the weekend (9/27/25 and 9/28/25) and further stated the shortage of incontinent briefs had happened before. Resident 46 explained she was upset because it was undignified (lacking dignity) and unsanitary (not clean) to go without incontinent briefs.During a follow-up interview on 10/2/25, at 7:15 AM, in Resident 46's room, Resident 46 stated that last Sunday (9/28/25) a Certified Nursing Assistant (CNA) whose name she could not recall, had come into her room looking for incontinent briefs and took two incontinent briefs from her dresser. Resident 46 further stated she asked the CNA what the facility was doing with the residents' money that incontinent briefs could not be provided. Resident 46 explained that the unidentified CNA did not respond to Resident 46's questions and just told Resident 46 that other unnamed residents needed them more and walked out of the room. Resident 46 stated she was upset and felt frustrated about the lack of incontinent briefs.2c. A review of Resident 86's admission RECORD, indicated Resident 86 was admitted to the facility early 2024 with diagnoses including paralytic syndrome (a condition characterized by loss of voluntary muscle control), muscle weakness, and reduced mobility (a physical impairment that restricts a person's ability to move freely/easily).A review of Resident 86's MDS Section C: Cognitive Pattern, dated 7/16/25, indicated Resident 86's BIMS was 15 out of 15 which showed Resident 86 had normal intact cognitive function.A review of Resident 86's MDS Section H: Bladder and Bowel, dated 7/16/25, indicated Resident 86 was always incontinent of both bladder and bowel.A review of Resident 86's care plan, revised 1/6/25, indicated, .Resident [86] at risk for pressure ulcer development [area of skin damage].r/t [related to] bladder and bowel Impairment.Will identify.provide treatment intervention.Follow facility policies.for the prevention/treatment of skin breakdown [a condition where the skin becomes damaged or injured leading to infection] .During a concurrent observation and interview on 9/30/25, at 8:12 AM, with CNA 3, in Resident 86's room, CNA 3 checked Resident 86's room and confirmed Resident 86 did not have any incontinent briefs. CNA 3 further confirmed that the facility ran out of incontinent briefs over the weekend (9/27/25 and 9/28/25). CNA 3 stated the facility received some briefs on 9/29/25 from other facilities, but stated it was not enough for all the residents that needed them. CNA 3 further stated their usual process for providing residents with their needed incontinent briefs was that the previous shift's (a specific block of time during which a nurse works) CNAs' were responsible to ensure each resident had the needed incontinence briefs before the CNA left for the day. CNA 3 explained on 9/28/25, CNA 3 alerted LN 9 and explained that the facility had run out of incontinent briefs. CNA 3 further explained LN 9 told her the Administrator (ADM) was contacted about the short supply of incontinence briefs.During an interview on 9/30/25, at 8:18 AM, CNA 4 stated that she worked on the weekend (9/27/25 and 9/28/25) and the facility had run out of incontinent briefs. CNA 4 further stated the facility also ran out of incontinent briefs a few weeks prior. CNA 4 explained that CS 1 normally ordered supplies but was out on leave. CNA 4 stated that after CS 1 went on leave, the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 3 of 34 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 10/02/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had problems with maintaining the supply of incontinent briefs, as well as making sure each nursing station (a centralized area in a healthcare facility for nurse coordination, patient care, and record-keeping) had enough supplies prior to the weekends. CNA 4 further explained that the CNAs from each nursing station had gone and searched the facility and in the residents' rooms for incontinent briefs. CNA 4 stated they (CNA 4 and other CNAs who worked the weekend) had to ask some residents to share their incontinent briefs with other residents, and had to tell the residents to go to the bathroom in their bed, and added they told the residents they would change them right away.During an interview on 10/1/25, at 10:21 AM, Resident 86 stated when the facility ran out of incontinence briefs, he was upset because he was handed a towel by an unidentified CNA and was told to urinate in the towel. Resident 86 further stated it made him, .feel uncomfortable. since he could not get out of bed to use the bathroom. Resident 86 further stated it was not right that he was told he had to urinate in a towel.2d. A review of Resident 56's admission RECORD, indicated Resident 56 was admitted to the facility mid-2025 with diagnoses including muscle weakness, and abnormalities of gait and mobility (a difference in a person's normal ability to walk, resulting from issues with coordination, balance or movement).A review of Resident 56's MDS Section C: Cognitive Pattern, dated 9/22/25, indicated Resident 56's BIMS was 15 out of 15 which showed Resident 86 had normal intact cognitive function.A review of Resident 56's MDS Section H: Bladder and Bowel, dated 9/22/25, indicated Resident 86 was always incontinent to both bladder and bowel.A review of Resident 56's care plan revised 8/14/25, indicated, .[Resident 56] is incontinent of urine.[Resident 56] will have incontinence care needs met by staff to maintain dignity and comfort.Use absorbent products.Utilize appropriate continent product [help manage the symptoms of poor bladder and bowel control].A review of Resident 56's care plan revised 4/4/25, indicated, .[Resident 56] is incontinent of bowel.[Resident 56] will have incontinence care need met by staff to maintain dignity and comfort and to prevent incontinence related complications.Provide privacy and comfort.Use absorbent products.Utilize appropriate continent products.During the resident council meeting (a gathering of residents in a shared nursing home to discuss concerns, rights, quality of life, and to advocate for improvement) on 10/1/25, at 10:37 AM, Resident 56 stated a staff nurse, whose name could not be recalled, went into the shared room of Resident 56 and Resident 4 and took away their incontinent briefs. Resident 56 further stated the facility ran out of incontinent briefs and that she was told to use incontinent briefs from other residents, because Resident 56 was on dialysis (a medical procedure that removes urine and excess fluid from the blood when the kidneys are unable to) and did not produce as much urine as other residents who were not on dialysis.During an interview on 10/2/25, at 7:31 AM, with Resident 56, in Resident 56's room, Resident 56 stated that on 9/27/25, and 9/28/25, a nurse whose name could not be recalled, walked into Resident 56's room without knocking, looked through her and her roommate's (Resident 4) personal belongings and took a few incontinent briefs that Resident 56 had on her dresser. Resident 56 stated the nurse did not say anything to her while she looked through her belongings, so Resident 56 stated, wait what are you doing. and explained to the nurse that she could not just walk in and take her belongings. Resident 56 stated the nurse then explained that other unidentified residents needed the incontinent briefs and told Resident 56 to share incontinent briefs with Resident 4. Resident 56 stated it made her upset, and she felt like she did not matter to the facility nursing staff. Resident 56 stated that she was a reasonable person and if the lack of supply of incontinent briefs had been explained to Resident 56 prior to taking hers, she might have been okay with what they did, instead, she felt like she was not viewed as a human. Resident 56 further explained that since CS 1 had left on leave a few weeks ago, the supplies had been very disorganized. Resident 56 stated at some point (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 4 of 34 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 10/02/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the staff brought her a few incontinent briefs to replace the ones they took, but the incontinent briefs were too small and did not fit her. Resident 56 further stated it was not until after the Department showed up for survey on Monday 9/29/25 (investigation to ensure facility compliance with rules and regulations) that their incontinent briefs were replaced.2e. A review of Resident 4's admission RECORD, indicated Resident 4 was admitted to the facility in mid-2025 with diagnoses including urinary tract infection, (UTI - and infection that affects any part of the urinary system, including the kidneys, ureters and bladder), hemiplegia and hemiparesis (hemiplegia -complete paralysis [inability to move] of one side of the body, hemiparesis -is the weakness of one side of the body), muscle weakness, and abnormalities of gait and mobility.A review of Resident 4's MDS Section C: Cognitive Pattern, dated 8/15/25, indicated Resident 4's BIMS was 15 out of 15 which showed Resident 4 had normal intact cognitive function.A review of Resident 4's MDS Section H: Bladder and Bowel, dated 7/23/25, indicated Resident 4 was frequently incontinent to both bladder and bowel. A review of Resident 4's care plan, revised 7/23/25, indicated, .[Resident 4] is incontinent of urine and bowels.Goal.Resident will have incontinence care needs met by staff to maintain dignity and comfort.During an interview on 10/2/25, at 7:39 AM, with Resident 4, in Resident 4's room, Resident 4 stated that on 9/27/25 and 9/28/25 a nurse came into her shared room with Resident 56 and took two incontinent briefs from Resident 4's dresser. Resident 4 further stated she needed the incontinent briefs because she took medication that caused her to urinate large amounts of urine. Resident 4 stated she was incontinent and did not know when she had to urinate and she urinated in bed. Resident 4 stated when she urinated in bed, it made her feel, .upset and terrible.During an interview on 10/1/25, at 8:55 AM, LN 7 verified the entire facility ran out of briefs on 9/27/25 and 9/28/25. LN 7 stated she contacted the Assistant Director of Nursing (ADON) for assistance about the lack of incontinence briefs. LN 7 further stated the ADON checked the outside storage area and found a box of briefs that were size small. LN 7 explained the small briefs were child sized and too small for most of their residents and not enough for the facility. LN 7 further explained that the CNAs, (whose names could not be remembered), went into other residents' rooms to find briefs to use for other residents when the residents they were taking the incontinent briefs from did not have enough of their own. LN 7 stated the nursing staff had to instruct some of the (unnamed) residents to urinate or have bowel movements in their beds, due to lack of incontinent briefs. LN 7 further stated the lack of briefs still had not been resolved when LN 7 had finished her shift in the afternoon on Sunday, 9/28/25. LN 7 stated the incontinent briefs were important to residents who had no control of their bladder or bowels, because the incontinent briefs helped the residents maintain their dignity and prevented the residents' skin from rashes and infections.During an interview on 10/1/25, at 10:25 AM, LN 8 verified the facility ran out of incontinent briefs for the incontinent residents on Sunday 9/28/25. LN 8 stated that the management team, (LN 8 would not state which management team members were aware), were aware the briefs were running low, and the ordering supply had not been accurate since CS 1 went on leave. LN 8 further stated the residents on her shift either had to stay dirty of urine and feces or go in their bed until they received more incontinent briefs. LN 8 explained it was not fair or right for the residents to go without the needed incontinent briefs and stated the residents deserved better.During an interview on 10/1/25 at 12:59 PM, with the ADON, the ADON verified that the person who oversaw ordering and stocking the units with supplies, CS 1, had been out of the facility for three to four weeks. The ADON stated in CS 1's absence, part of CS 2's job included distributing supplies throughout the facility and the central supply room. The ADON further stated that the ordering of necessary supplies was now being done by the Administrator (ADM) and the Sub-Acute Director (Sub-Acute -a specialized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 5 of 34 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 10/02/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete unit for patients who require more specialized treatment than a standard skilled nursing unit) (SAD). The ADON confirmed she was contacted by staff on Sunday 9/28/25 that the facility had run out of incontinent briefs. The ADON stated she went outside to check the storage Pods (temporary storage containers) for additional incontinent briefs. The ADON further stated she found three boxes of unknown sized incontinent briefs and distributed them to the units. The ADON stated they had a total of five units in the facility. The ADON stated she did not know how many incontinent briefs were in the boxes and what sizes they were. During an interview on 10/1/25 at 1:15 PM with the Sub-Acute Director (SAD), the SAD stated the facility had approximately 80-85 residents in the facility who were incontinent and that each resident used about six briefs a day. The SAD stated there were 85 residents that needed approximately six briefs a day, which amounted to 510 briefs per day that were needed for the residents who were incontinent. The SAD further stated that since CS 1 had been on leave, she and the ADM were ordering supplies twice a week in the same manner CS 1 had done. During a concurrent observation and interview on 10/1/25 at 1:27 PM with CS 2, the storage Pods (a large cargo metal box like a train box-car) was observed outside of the facility in a patio area. CS 2 showed the Department where the Central Supply Department had received their shipment of incontinent briefs on 9/30/25. CS 2 verified the boxes indicated a quantity of 32 incontinent briefs on the outside of the individual incontinent briefs box. During an interview on 10/1/25 at 1:54 PM with the Administrator (ADM), the ADM stated that she had not heard that the facility ran out of briefs over the weekend. The ADM further stated on 9/29/25 (Monday) morning, she borrowed briefs from several facilities in the area to supply the residents with until the recent order of supplies was delivered. The ADM explained the supply delivery company was behind on delivery supplies which included incontinent briefs. The ADM stated the risk to the residents for running out of incontinent briefs was that their urine and/or feces soiled clothes or sheets would not be changed timely. The ADM further stated that if the residents were not changed timely the residents would be at risk for skin breakdown, skin irritation, and could have a psychosocial effect on them mentally. A review of facility policy and procedure titled (P&P), Abuse Prohibition Policy and Procedure, effective 2/23/21, indicated, .prohibit abuse, mistreatment, neglect, misappropriation of resident property.Mental abuse includes, but is not limited to humiliation.deprivation.Mental abuse may occur through.nonverbal conduct which causes or has the potential to cause the patient to experience humiliation.shame.degradation.Mistreatment is defined as inappropriate treatment.Neglect is defined as the failure of the Center, its employees.to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Actions to prevent abuse, neglect.Identifying, correcting, and intervening in situations in which abuse, neglect.is more likely to occur. A review of facility P&P titled, Continence Management, effective 11/15/21, indicated, .To provide appropriate treatment and services for patients with urinary incontinence.To provide appropriate treatment and services for patients with incontinent of bowel. A review of facility P&P titled, Dignity, revised 2/21, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being.Residents are treated with dignity and respect at all times.facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences.Resident's private space and property are respected at all times.do not handle or move a resident's personal belongings without the resident's permission.Demeaning practices and standards of care that compromise dignity are prohibited. A review of facility P&P titled, Resident Rights, revised 12/21, indicated, .Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include.a dignified existence.free from abuse, neglect. Event ID: Facility ID: 055735 If continuation sheet Page 6 of 34 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 10/02/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission as required, to address resident-specific care needs for 1 of 35 sampled residents (Resident 76).This failure placed Resident 76 at risk for not receiving effective person-centered care, and preventing to reach the highest potential for mental, emotional, and/or psychosocial health and well-being.Findings:A review of Resident 76's admission RECORD, indicated Resident 76 was originally admitted to the facility in 2017, readmitted in 2020 and then readmitted in 2021 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung disease that cause progressive airflow obstruction and breathing difficulties), chronic diastolic congestive heart failure (a condition where the heart muscle is stiff and cannot relax properly during the filling phase called diastole. This prevents the heart from filling with enough blood, which can lead to symptoms of heart failure), hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart and leads to heart failure), type 2 diabetes mellitus with diabetic chronic kidney disease (a condition where high blood sugar from poorly controlled type 2 diabetes damages the blood vessels in the kidneys, leading to their reduced ability to filter waste from the blood).A review of Resident 76's medical record indicated that a baseline care plan had not been created within 48 hours of admission, and/or re-admissions as required.During a concurrent interview and record review on 10/1/25, at 2:07 PM, with Licensed Nurse (LN) 9, Resident 76's medical record including care plans were reviewed. LN 9 confirmed that a baseline care plan had not been created within 48 hours of Resident 76's readmission in March 2021. LN 9 stated baseline care plans should be created within 48 hours of admission, and/or re-admission. LN 9 further stated it was necessary to create a baseline care plan and follow the interventions to provide person-centered care to meet Resident 76's physical and psychosocial needs. During a concurrent interview and record review on 10/2/25, at 12:30 PM, with the Minimum Data Set Coordinator (MDS) 2, (MDS, a healthcare professional, typically a registered nurse, who manages the detailed resident assessments required for long-term care facilities to receive reimbursement), Resident 76's care plans were reviewed. The MDS 2 confirmed that a baseline care plan had not been created for Resident 76. The MDS 2 further stated that a baseline care plan should be created within 48 hours of admission, or re-admission to provide quality of care. The MDS 2 stated a baseline care plan was an instruction guide providing directions for nursing staff to collaborate and deliver effective person-centered care. The MDS 2 further stated it was a requirement to follow the facility's policy and procedure (P&P) for baseline care planning. The MDS 2 stated the facility's P&P was not followed. The MDS 2 further stated there was a risk to negatively affect Resident 76's health that could lead to a decline in his physical health and psychosocial well-being. Review of the facility's P&P titled, CARE PLAN-BASELINE, dated 8/25/21, indicated, .A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care shall be developed and implemented for each resident by the Interdisciplinary Team [a group of healthcare professionals from different fields who collaborate to create a holistic care plan for a patient].The baseline care plan is developed within 48 hours of a resident's admission.The baseline care plan includes the minimum healthcare information necessary to properly care for a resident. Event ID: Facility ID: 055735 If continuation sheet Page 7 of 34 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 10/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide a resident centered care plan for 2 of 35 sampled residents (Resident 65 and Resident 76) when:1. Resident 65 was taking a blood thinner medication and there was no care plan developed to monitor for potential side effects or risk of bleeding; and,2. Resident 76 did not have a care plan for blood thinning medications. These failures placed Resident 65 and Resident 76 at risk for potentially serious complications and not receiving effective and person-centered care. Findings: 1. Review of Resident 65's admission RECORD, indicated Resident 65 was admitted with multiple diagnoses which included but not limited to DVT (Deep Vein Thrombosis – when a blood clot forms in a deep vein, usually in the leg), hypertension (high blood pressure), and abnormalities of gait and mobility. During a concurrent interview and record review on 10/1/25, at 4:01 PM, with Licensed Nurse (LN) 3, LN 3 stated Resident 65 was taking apixaban (blood thinner medication) for DVT. LN 3 confirmed there was no order to monitor the side effects of apixaban since it was prescribed upon admission on [DATE]. LN 3 stated she never recorded monitoring of apixaban side effects in the Medication Administration Record (MAR). LN 3 further stated it was essential to monitor the side effects of apixaban, such as bleeding, tarry (black) stools, or dark urine, due to its potential adverse and serious complications. LN 3 stated further not monitoring these side effects was unacceptable. During a concurrent interview and record review on 10/2/25, at 9:36 AM, with Director of Nursing (DON), the DON stated that staff should monitor Resident 65 for bleeding each shift and check the mouth, urine, and stool for any signs of bleeding due to apixaban use. The DON confirmed there were no orders or care plans to monitor the side effects of apixaban for Resident 65. The DON stated that staff were expected to monitor the side effects, particularly since apixaban could cause serious and potentially life-threatening adverse reactions. The DON further stated without adequate monitoring, there was a risk that Resident 65 might experience internal bleeding, including the possibility of gastrointestinal (GI) bleeding (bleeding visible in the stool or vomit), which could remain undetected. During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/21, the P&P indicated, .Purpose: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident.III. Procedure 1. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas b. Incorporate risk and contributing factors associated with identified problems.5. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 2. A review of Resident 76's admission RECORD, indicated Resident 76 was readmitted in 2021 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung disease that cause progressive airflow obstruction and breathing difficulties), chronic diastolic congestive heart failure (a condition where the heart muscle is stiff and cannot relax properly during the filling phase called diastole. This prevents the heart from filling with enough blood, which can lead to symptoms of heart failure), hypertensive heart disease with heart failure (a condition where prolonged high (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 8 of 34 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 10/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood pressure damages the heart and leads to heart failure), type 2 diabetes mellitus with diabetic chronic kidney disease (a condition where high blood sugar from poorly controlled type 2 diabetes damages the blood vessels in the kidneys, leading to their reduced ability to filter waste from the blood). Review of Resident 76's medical record titled, Medication Review Report, dated 10/1/25, indicated Resident 76 had an active order for aspirin (blood thinner medication) 81 MG (milligram, unit of measurement) chewable tablet orally one time a day for DVT prophylaxis (prevention) which was started on 6/4/22, and also an active order for Eliquis (blood thinner medication) 5 MG 1 tablet orally two times a day for DVT prophylaxis that was started on 12/17/24. During a concurrent interview, and record review on 10/1/25, at 2:07 PM, with LN 9, Resident 76's medication review report and care plans were reviewed. LN 9 confirmed that Resident 76 was taking aspirin and Eliquis as blood thinner medications for DVT prophylaxis. LN 9 further confirmed that a care plan for blood thinner medications had not been created. LN explained the importance of care planning and stated a care plan was a guiding tool for nursing staff to provide person-centered care to meet Resident 76's medical and physical needs. LN 9 further stated to coordinate care, nurses should create care plans and MDS coordinator would review and revise care plans quarterly and annually to ensure care plans were applied to residents' conditions to prevent or reduce declines in residents' health status. During a concurrent interview and record review on 10/2/25, at 10:34 AM, with the DON, Resident 76's medication record, care plans, and the P&P titled, CARE PLAN COMPREHENSIVE, dated 8/25/21 were reviewed. The DON confirmed Resident 76 had active orders for blood thinner medications such as aspirin which was started on 6/4/22 and Eliquis with a start date of 12/17/24, and there was no corresponding care plan for Resident 76. The DON stated her expectation from nursing staff was to create a person-centered care plan for blood thinners and implement interventions that were applicable to Resident 76's health status. The DON further stated a care plan was a written document to communicate Resident 76's care and overall health conditions properly. Review of the facility's P&P indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.PROCEDURE 1. Each resident's comprehensive care plan is designed to.h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels.2 . The comprehensive care plan includes the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The DON acknowledged that the facility's P&P was not followed. The DON stated her expectation was not met by nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 9 of 34 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 10/02/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided when one of 35 sampled residents (Resident 97) did not receive the appropriate range of motion (ROM - the distance and direction a joint can move) services. This failure had the potential to result in decreased ROM, further functional decline, and/or pain and discomfort for Resident 97. Findings:During a review of Resident 97's clinical record titled, admission RECORD, the record indicated Resident 97 was admitted to the facility with a diagnosis that included hemiplegia (inability to move of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted), and functional quadriplegia (a person is unable to move their arms and legs, and needed total care from nursing staff).A review of Resident 97's clinical record titled, Care Plan, dated 4/23/24, indicated Resident 97 was dependent on nursing staff for activities of daily living (ADL, basic self-care tasks that individuals perform to maintain their daily lives).A review of Resident 97's clinical record titled, Section GG - Functional Abilities, (part of a comprehensive assessment) dated 8/4/25, indicated Resident 97 had impairments with ROM to both sides of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot).During a concurrent interview and record review on 10/1/25 at 1:42 p.m. with the Director of Rehab (DOR), Resident 97's clinical record titled, Joint Mobility Screen, dated 9/19/25 was reviewed. The joint mobility screen indicated Resident 97's right-wrist, left-hand, and right-hand had severe impairment (reflecting approximately 25% or less of full ROM). The DOR verified Resident 97 was not on restorative nursing therapy (a therapy program where nursing staff, often with guidance from physical and occupational therapists, works with a resident to restore or maintain their independence). The DOR stated Resident 97 should have been offered restorative nursing therapy for passive range of motion (PROM, if a person can't move their own joint, a caregiver or nurse gently moves it for them) exercises. The DOR further stated Resident 97 could potentially experience pain and discomfort due to loss of range of motion. During an interview on 10/2/2 at 10:10 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 97 should have been offered restorative nursing therapy services when he experienced a decline in ROM. The ADON further stated Resident 97 was at risk of further decline in the ROM of his joints.During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated 7/2017, the P&P indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence.Residents may be started on restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.Restorative goals may include.Developing, maintaining or strengthening his/her physiological and psychological resources. Event ID: Facility ID: 055735 If continuation sheet Page 10 of 34 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 10/02/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment when:1. Safe water temperatures were not maintained in 2 of 4 sampled resident bathrooms; and,2. Resident 10's post mobility assessment was not done after she fell in the bathroom. These failures had the potential to cause physical injuries to residents who resided in the facility.Findings: 1. During a concurrent observation and interview on 10/1/25, at 2:59 PM, with the Regional Maintenance Consultant (RMC) and the Maintenance Director (MD), the MD stated they checked the water temperature monthly. Water temperatures were checked in different areas of the facility with the RMC and the MD. During the testing, water temperatures were found to be 80 degrees Fahrenheit (°F, a measurement of temperature) in room [ROOM NUMBER], 130°F in room [ROOM NUMBER], 125°F in the kitchen and laundry, 118°F in room [ROOM NUMBER], and 135°F in room [ROOM NUMBER]. The boiler tanks were set to 120°F for the subacute (a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) and long-term areas, while the kitchen and laundry areas had boiler temperatures set to 160°F. During an interview on 10/1/25, at 3:56 PM, with the Director of Staff Development (DSD) and the Infection Preventionist (IP), both the DSD and IP stated that the water temperature on the resident bathrooms and shower rooms should be 120°F or under and if it was more than 120°F, it could cause burns on the residents. During a concurrent observation and interview on 10/1/25, at 4:10 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 was observed in the hallway with Resident 17 who was in a shower bed about to go into the shower room. CNA 1 stated the water in the shower should be warm and not hot because there would be a risk of burning the skin of the resident. During an interview on 10/1/25, at 4:15 PM, with Licensed Nurse (LN) 1, LN 1 stated the water temperature in the resident's bathroom should be below 120°F and if it did exceed 120°F it could cause skin irritation, burns and skin breakdown. LN 1 further stated the water temperature should be lukewarm and under 120°F. During an interview on 10/2/25, at 9:33 AM, with Resident 67 in room [ROOM NUMBER], Resident 67 stated the water in the bathroom would get too hot, but he did not report it. Resident 67 further stated if the water in the bathroom was too hot, he just stopped using it. Resident 67 stated he was mobile and used the bathroom by himself. During an interview on 10/2/25, at 9:11 AM, with the Sub-acute Director (SAD), the SAD stated the water should be at an appropriate temperature and it should not cause scalding. The SAD further stated if a resident or staff used the hot water, it would burn their skin. During an interview on 10/2/25, at 10:04 AM, with the Director of Nursing (DON), the DON stated the water used by the residents should be below 120°F, and if it was more than 120°F, there would be chances for burn and skin damage. The DON stated water temperature between 130°F -135°F used for showers or washing hands was not acceptable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 11 of 34 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 10/02/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the undated facility policy and procedure (P&P) titled, Safety of Water Temperatures, the P&P indicated, .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperature of no more than 120F (48.8C), or the maximum allowable temperature per state regulation. A review of the facility's P&P titled, Safety and Supervision of Residents, dated 2001, Revised July 2017, the P&P indicated, .Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include:.h. Water Temperatures. 2. A review of Resident 10's admission RECORD, indicated Resident 10 was admitted to the facility in 2024 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life; a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 10's Change in Condition SBAR [a communication tool for sharing information with teams and stands for Situation, Background, Assessment, and Recommendation or Requests] Communication Form and Progress Note, dated 5/27/25, indicated, .The change in condition.is.Falls.This started on 05/27/2025.Does the resident have pain? Yes.Description/location of pain: Left trochanter (hip),/Left thigh (front), /Left thigh (rear), /Left knee (front), /Left knee (rear), /Left lower leg (front), /Left lower leg (rear).Intensity of pain (rate on a scale of 1-10, with 10 being the worst): 10.Summarize your observations and evaluation: At 0555 [5:55 a.m.] CNA heard pt [resident] calling out yelling that she fell and is in pain. CNA entered the room and found pt sitting on the floor in the bathroom in a puddle of urine. CNA called writer and full head to toe assessment completed, no skin condition found. Pt refused to be pulled up into wheel chair [sp] stating her whole left leg and left hip hurt too much.Dr [physician].was notified and order was to send her to the ER [acute care facility emergency department]. A Review of Resident 10's Interdisciplinary Care [IDT, a group of healthcare professionals with various levels of expertise who work together toward the goals of their residents] Conference Meeting Notes, dated 5/27/25 indicated, .Type of Interdisciplinary Care Conference.Fall Incident.Name and Title of Attendees.Director of Nursing [DON], Assistant Director of Nursing [ADON], Minimum Data Set Coordinator [MDS], Health Information Management [HIM], Director of Staff Development [DSD], Social Services Assistant [SSA].Date and time of fall incident.05/27/2025 05:30 [5:30 a.m.].Fall Report.CNA reported to LN that resident is on the floor. Immediately went to assess and resident is observed sitting on the bathroom floor between the toilet and sink; puddle of urine is also noted on the floor and no urine or bm [bowel movement] is noted in toilet bowl. Resident wasn't wearing any pants and noted to be barefooted at the time of fall. Resident denies hitting head. Two CNA's [sp] and two LN [sp] attempted to transfer resident in w/c [wheelchair] but resident was in severe pain stating her left hip and left leg is hurting. RN (LN) on duty stated to not touch resident since resident is in severe pain. RN called MD [physician] and ordered for resident to be sent out. Staff stayed with resident until [ambulance] arrived. [Ambulance] then assisted resident off the floor and into the gurney.History of falls.None.IDT Recommendations.Rehab Referral.Transfer to acute care hospital for further evaluation. A review of Resident 10's Care Plan Report, dated 5/27/25, indicated .Focus.The resident has had an actual fall on 5/27/25 with left leg & hip pain.date initiated.5/27/2025.Goal.The resident's left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 12 of 34 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 10/02/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some leg pain will resolve without complication.Interventions.Educating resident on asking for assistance to the restroom.Send to ER for further eval for leg pain.Use non-skid footwear when ambulating or transferring. During an interview on 9/29/25, at 2:41 p.m., with LN 2, LN 2 stated that she was not on duty when Resident 10 fell. LN 2 stated that she would completed a fall assessment on a resident if she saw that the resident was weak, after a resident's fall incident, when the resident was admitted , and if there was a change in the resident's condition. LN 2 further stated that she would also update the resident's care plan. During a concurrent interview and record review on 9/29/25, at 4:10 p.m., with the DON, Resident 10's electronic medical record (EMR) was reviewed. The DON stated the expectation was that upon admission, staff would check the resident's history to see if they were independent or needed assistance with activities of daily living (ADLs, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom; activities related to daily care), if they had a history of falls, and if they needed assistance going to the bathroom. The DON further stated that she also expected staff to do a care plan upon admission if the resident was at risk for falls. The DON stated that the rehabilitation department (a specialized unit within an organization, such as a health care facility, that focuses on providing services and support for individuals recovering from injuries, illnesses, or disabilities) did quarterly joint mobility screens (a tool used to assess and evaluate a person's mobility and stability during movement. It identifies imbalances in mobility and stability, which can indicate functional movement deficiencies) on residents, and did the joint mobility screens after a resident had a fall. The DON confirmed that Resident 10 had a quarterly joint mobility screen done on 5/23/25, which was before Resident 10's fall. The DON further confirmed that Resident 10 did not have a joint mobility screen done after she fell. The DON stated that the risk of not completing the joint mobility screen after Resident 10 fell was that the resident would be at an increased risk of falls because the staff would not know the mobility status. The DON confirmed that the facility policy was not followed. A review of a facility P&P titled, Fall Risk Assessment, revised July 2013, indicated, .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and Implementation.1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls.2. The nursing staff will ask the resident and/or his/her family about any history of falls.5. The attending physician and nursing staff will.assess the resident for medical conditions.or sensory impairments.that may predispose to falls.9. The staff and attending physician will collaborate to identify and address modifiable risk factors. A review of a facility P&P titled, Falls Management, revised November 2012, indicated, .Policy.It is the policy of this facility that our physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls.Procedure for risk Identification/Prevention: 1. On the day of admission, each resident is assessed by a licensed nurse using a Fall Risk Assessment tool to determine possible risk of sustaining a fall.3. Residents' fall risk will be re-assessed with each significant change of condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 13 of 34 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 10/02/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure proper hydration (process of providing fluid to the body) for one of 35 sampled residents (Resident 5) when Resident 5's water was out of reach.This failure placed Resident 5 at risk of dehydration (condition where your body loses more fluid than it takes in, resulting in insufficient water for its normal functions). Findings:A review of Resident 5's, clinical record titled, admission RECORD, indicated Resident 5 was admitted to the facility with a diagnosis that included Chronic congestive heart failure (a condition where the heart can't pump blood efficiently, causing a backup of fluid in the body and leading to symptoms like shortness of breath, fatigue, and swelling).A review of Resident 5's clinical record titled, Care Plan, dated 4/24/25, indicated Resident 5 was at risk for dehydration because he used a diuretic medication (medications that increase urine output, helping the body eliminate excess fluid).During a concurrent observation and interview on 9/29/25 at 11:31 a.m., with Regional Minimum Data Set (MDS- a standardized clinical assessment) Support (RMDS, a support person who reviews MDS assessments), in Resident 5's room, Resident 5 unsuccessfully attempted to reach his water pitcher on a nightstand. RMDS stated the water pitcher should have been within Resident 5's reach. RMDS also stated water within reach was important to have access to maintain adequate hydration and without access, Resident 5 was at risk for dehydration.During a concurrent observation and interview on 10/1/25 at 10:00 a.m., with the certified nursing assistant (CNA) 8, in Resident 5's room, Resident 5's bedside table was observed against the wall with his water pitcher on the bedside table. Resident 5 stated the staff had moved the bedside table when they picked up his breakfast tray. CNA 8 verified Resident 5's water pitcher was not within reach and stated CNA 8 had moved the bedside table when he picked up the breakfast trays and forgot to put the bedside table back within reach of Resident 5.During an interview on 10/1/25 at 10:10 a.m. with the Licensed Nurse (LN) 7, LN 7 stated Resident 5 was on diuretic medication and Resident 5 was at risk of dehydration. LN 7 further stated Resident 5 should have always had a water pitcher within reach to prevent dehydration.During an interview on 10/1/25 at 2:20 p.m. with the Director of Nursing, (DON) the DON stated that because Resident 5 was on a diuretic medication, he was at increased risk for dehydration; and therefore, should have had water available at the bedside.A review of the facility's undated policy and procedure titled, Resident Hydration and Prevention of Dehydration, dated indicated, .this facility will strive to provide adequate hydration and to prevent and treat dehydration.Nurses' Aides will provide and encourage intake of bedside snack and meal fluids, on a daily routine basis. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 14 of 34 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 10/02/2025 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to provide medically- related social services for 1 of 35 sampled residents (Resident 19) when the facility failed to honor Resident 19's requests and wishes to be transferred to a facility closer to home.This failure placed Resident 19's health and psychosocial well-being at risk for potentially serious complications which could have impacted his quality of life and could have lowered his self-esteem (confidence in one's own worth or abilities). Findings:A review of Resident 19's clinical record titled, admission RECORD, indicated Resident 19's admitting diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, and posture due to brain damage) and paresthesia of skin (an abnormal sensation characterized by tingling, prickling, burning, or numbness in the skin).During an interview on 9/29/25, at 8:34 AM, with Resident 19, Resident 19 stated that before his admission to the facility, he lived in a different area of the state. Resident 19 stated that he was admitted to the facility in 2019 and since the admission date, he had requested multiple times to be transferred to a facility that was closer to his home. Resident 19 further stated he was upset that the facility was not working proactively on his transfer/discharging to a different facility. Resident 19 stated, I have the right to request to live in the area that I want.A review of Resident 19's various clinical records indicated Resident 19 expressed his desire and requested assistance to be transferred to a facility closer to home. A review of the following clinical records indicated the following:- Care Plan, date initiated on 11/23/20, indicated, .Resident [Resident 19] is requesting to discharge and live independently in [CITY NAME].,-Care Plan Meeting, dated 2/1/24, indicated, .Resident [Resident 19] also requests assistance in alternate placement, however, resident [Resident 19] does not receive any income and has no living family in the [COUNTY Name] county area.,-Social Services Assessment & Documentation, dated 2/2/24, indicated, .C. Mental Health & [and] . 5. Comments .Wellness Comments.Resident [Resident 19] mental health/ wellbeing appears compromised d/t [due to] placement in the facility far from [COUNTY NAME] where resident [Resident 19] was previously residing.,- Social Service Progress Note, dated 12/18/24, indicated, .SS [Social Services] spoke with.R/T [related to] that he [Resident 19] is requesting to be transferred back to his hometown [CITY NAME] ., - Social Service Progress Note, dated 5/5/25, indicated, .Resident [Resident 19] states he wants to be medically discharged to a financial institution in [CITY NAME].,- Nurses Progress Note, dated 7/22/25, indicated, .Resident [Resident 19] made writer aware he would like to speak with SS [Social Services] regarding his discharge.,- Nurses Progress Note, dated 9/3/25, indicated, .Resident [Resident 19] was observed laying with his feet off the bed, holding onto the side rail. Writer asked resident [Resident 19] if we can help reposition him back in bed. Resident [Resident 19] responded.I told myself September 3rd will be the day I leave.Resident [Resident 19] yelled at writer .7 years, 7 years I have been here. I'm leaving.,- Social Service Progress Note, dated 9/3/25, indicated, .The patient [Resident 19] expressed.I have been stuck in this place for seven years.I can live on the streets., - .Change in Condition Evaluation ., dated 9/24/25, indicated, .Review Findings and Provider Notifications.4.Writer was called to resident's [Resident 19] room for reported single episode of self harm. Resident [Resident 19] stated he is upset d/t [due to] not being able to live in [CITY NAME] .Resident [Resident 19] stated, It was a brief moment of sadness.,- Nurses Progress Note, dated 9/24/25, indicated, .resident [Resident 19] reported single episode of self harm. Resident [Resident 19] stated he was upset that he has not been moved back to his hometown.Resident [Resident 19] stated.it's been too long, 7 years I have been here.,- Social Service Progress Note, dated 9/25/25, indicated, .The patient [Resident 19] expressed that he has been in the facility for seven years.He has been trying to return to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 15 of 34 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 10/02/2025 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [COUNTY NAME], specifically [CITY NAME], his home city. Over the years, he [Resident 19] has met numerous staff members, but none have been able to help him achieve this goal.Patient [Resident 19] expressed that he considers himself philosophical and intelligent, but feels that no one ever wants to listen to him.he feels like he has been in this facility forever. During a concurrent interview and record review on 10/1/25, at 1:20 PM, with the Social Service Director (SSD), Resident 19's clinical records titled, Care Plan Meeting, dated 2/1/24; Social Services Assessment & Documentation, dated 2/2/24; Social Service Progress Note, dated 12/18/24; Nurses Progress Note, dated 9/3/25 and 9/24/25; and Social Service Progress Note, dated 9/25/25 were reviewed. The SSD explained the process of transfer/discharge to other facilities and stated that upon residents' requests to transfer or discharge, the SSD contacted facilities, or area that residents preferred to be transferred to, and if beds were available. The SSD stated they would send residents' medical records and social service notes to those facilities and then would follow up with the facilities for placement. The SSD confirmed that several times Resident 19 requested to be transferred to [COUNTY NAME] and specifically [CITY NAME], his home city since 11/22/20. Upon further review of Nurses Progress Note, dated 4/4/25, with the SSD, the progress notes indicated, .Resident [Resident 19] is alert and oriented x3 [person, place, time], verbalizes needs, made writer aware that he wants to be discharged to [CITY NAME] SNF. Writer made SS aware. SS states they have faxed his [Resident 19] paperwork to facility above . The SSD stated that she received Resident 19's wishful request to be transferred to one of the facilities in [COUNTY NAME] in April 2025, and added referrals were sent; however, the SSD was unable to provide documentation that the referrals were sent. The SSD confirmed that on 9/25/25, Resident 19 expressed his feeling of being upset about staying in the facility for many years and that he had been trying to return to his home city. The SSD stated she should have acted proactively to contact facilities in [COUNTY NAME] and [CITY NAME] as it was requested by Resident 19 several times prior to Resident 19 expressing his feeling of self-harm on 9/24/25. The SSD stated Resident 19's discharge goal was to be transferred closer to his home, and his wishes that were not met by the facility. The SSD further stated, feeling upset about staying in the facility affected Resident 19's psychosocial well-being, and caused him emotional distress.During a concurrent interview and record review on 10/1/25, at 2:02 PM, with Licensed Nurse (LN) 9, Resident 19's medical record titled, .Change in Condition Evaluation ., dated 9/24/25, was reviewed. Review of the record indicated, .Review Findings and Provider Notifications. 4. called to resident's [Resident 19] room for reported single episode of self harm. Resident [Resident 19] upset d/t [due to] not being able to live in [CITY NAME]. LN 9 stated Resident 19 requested to be transferred to his home city multiple times. LN 9 further stated Resident 19 was very overwhelmed after living in the facility for many years, to the point that Resident 19 expressed his feeling of self-harm. LN 9 stated the situation could have negatively affected Resident 19's health and psychosocial well-being and placed him at risk for emotional distress, anxiety, and depression. During a concurrent interview and record review on 10/1/25, at 2:20 PM, with LN 12, Resident 19's medical records titled, Nurses Progress Note, dated 4/4/25 and 7/22/25 were reviewed. The nurses notes dated 4/4/25, indicated, .Resident [Resident 19].made writer aware that he wants to be discharged to [CITY NAME] SNF.made SS aware., and review of nurses note dated 7/22/25, indicated, .Resident [Resident 19].would like to speak with SS regarding his discharge. Social Services.made aware. LN 12 confirmed Reside 19 requested to be discharged from the facility several times throughout his stay in the facility. LN 12 stated Resident 19 was upset about living in the facility for many years and was emotionally distressed about being unable to live close to his home city. LN 12 further stated Resident 19 was on every hour visual monitoring related to an episode of wanting to inflict (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 16 of 34 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 10/02/2025 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete self-harm due to being unable to live in his home city.During a concurrent interview and record review on 10/1/25, at 3:54 PM, with the Health Informative Manager (HIM, a healthcare professional responsible for managing and protecting patient health information), the HIM stated that Social Services Department was responsible for sending referrals and, upon receiving confirmation by fax, was expected to attach the confirmation and provide all related documentation to her for uploading into Resident 19's medical records. A review of Resident 19's record with HIM confirmed that the records did not include copies of the transfer or discharge referrals. HIM stated she had not received any transfer or discharge referrals from Social Service Department. The HIM further explained that such referrals were considered legal documents that must be uploaded to Resident 19's medical records and made available for review when needed.During a concurrent interview and record review on 10/2/25, at 10:34 AM, with the Director of Nursing (DON), Resident 19's medical records and the facility policy and procedure (P&P) titled, Referrals, Social Services, revised in 12/08, were reviewed. Review of the record titled, Care Plan Meeting, dated 2/1/24, indicated, .Resident [Resident 19] also requests assistance in alternate placement.in the [COUNTY NAME] SS will continue to monitor and provide assistance as needed. Review of the record titled, Social Service Progress Note, dated 9/3/25, indicated, .The patient [Resident 19] expressed, I do not want to be here. I have been stuck in this place for seven years.I want to go home. Review of the record titled, Nurses Progress Note, dated 9/24/25, indicated, .called to resident's [Resident 19] room d/t [due to] resident {Resident 19] reported single episode of self harm. Resident stated he was upset that he has not been moved back to his hometown. The DON confirmed that Resident 19 expressed his wishes to be transferred to [COUNTY NAME], and [CITY NAME] specifically several times throughout his stay in the facility. The DON stated Resident 19 was emotionally distressed and was upset when he expressed his feeling of harming self, due to the facility not working proactively on his transfer/discharge. The DON stated her expectation from Social Service department was to work proactively to find placement for Resident 19. The DON added her expectation was not met. The DON further stated Resident 19's requests and wishes to be transferred to live close to his home city were not fulfilled by the facility which placed Resident 19 at risk for emotional distress by negatively affecting his psychosocial well-being. The DON acknowledged that copies of transfer and discharge referrals were not maintained in Resident 19's records. The DON clarified that her expectation was for the SSD to proactively send referrals and furnish the medical record department with the corresponding confirmation documents was not met. A review of the facility provided P&P for referrals indicated, . Referrals, Social Services. Social services personnel shall coordinate most resident referrals with outside agencies. Policy Interpretation and Implementation. 4. Social services will document the referral in the resident's medical record. The DON confirmed that the facility's P&P was not followed by the Social Services Department, and it was essential to adhere to these policies and procedures. The DON further stated that failure to do so posed a potential risk of not meeting Resident 19's expectations and wishes regarding transfer or discharge to the requested destination closer to his home city. Event ID: Facility ID: 055735 If continuation sheet Page 17 of 34 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 10/02/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide medications which met the needs of 1 of 35 sampled residents (Resident 46) when on 10/2/25 the following medications were not administered and left on the residents bedside table:Nephro-Vite 1 tablet (used to treat vitamin deficiencies in people with kidney disease),Senna 1 tablet (used to treat constipation); and,Sevelamar - 2 tablets (used to treat high phosphate in the blood in people with kidney disease).This failure had the potential for Resident 46 to experience worsening kidney disease (a decline in kidney function over time), hyperphosphatemia (medical condition characterized by elevated levels of phosphate in the blood in people with kidney failure), and constipation (a condition in which there is difficulty in emptying the bowels or hard feces).Findings:A review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility in 2024, with diagnoses which included, chronic kidney disease stage 4 severe (CKD -kidneys are severely damaged and their function is significantly reduced) and dependence on renal dialysis (a medical treatment that artificially replaces the function of the kidneys when they are unable to do so).During a concurrent observation and interview on 10/2/25, at 7:13 AM, in Resident 46's room, a medication cup with 4 pills was observed left on Resident 46's bedside table. Resident 46 stated it was common for the nurse to leave the medications at bedside for her. Resident 46 further stated she liked to take her medications with coffee and was waiting for coffee to be delivered by her Certified Nursing Assistant (CNA).During a concurrent interview and record review on 10/2/25, at 7:23 AM, with Licensed Nurse (LN) 13, Resident 46's Medication Administration Record (MAR - a legal document that serves as a detailed log of all medications given to a patient by healthcare professionals) was reviewed and LN 13 was able to identify the 3 medications given, a total of 4 tablets. LN 13 confirmed she left the medications at bedside for Resident 46 to take when her CNA brought her coffee. LN 13 stated she knew it was against policy to leave medications unattended at bedside. LN 13 further stated the expectation for nurses administering medication was to watch and encourage the resident's to take their medications. LN 13 reviewed Resident 46's record and stated she had not been evaluated to self-administer medications and could not find documentation of it was in her care plan. LN 13 stated the risk of leaving medications unattended in a resident's room was that another resident could take the medication and not knowing whether the resident the medication was intended for, took the medication.During an interview on 10/2/25, at 11:29 AM, with the Director of Nursing (DON), the DON stated that medications should not be left at bedside, and the nurse should be present when the resident took all the medication. The DON further stated the risk of leaving medications unattended was ineffective medications if the resident did not take them, or a risk of another resident taking them. The DON explained if another resident took the medications it could affect their health and safety.A review of the facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .Medications are to be administered in a safe and timely manner.A review of the facility P&P titled, Administering Oral Medications, revised, October 2010, indicated, .22. Remain with the resident until all medications have been taken.A review of the facility P&P titled, PREPARATION AND GENERAL GUIDELINES IIA2: MEDICATION ADMINISTRATION-GENERAL GUIDELINES, effective, October 2017, indicated, .15) The resident is always observed after administration to ensure that the dose was completely ingested. Event ID: Facility ID: 055735 If continuation sheet Page 18 of 34 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 10/02/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP -the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic [when the heart beats] and diastolic [when the heart rests between beats]) and heart rate (HR -frequently of your heart beats per minute) for a medication used to treat low (hypotension) BP for two of six sampled residents (Resident 17 and Resident 80), when:1. Resident 17's physician prescribed hold parameters (a set of numbers that guide the nursing staff when to not give [hold] a medication) for Midodrine (a medication used to treat low blood pressure) were not followed 13 times between 8/15/25 and 10/1/25; and,2. Resident 80's physician prescribed hold parameters for Midodrine were not followed 13 times between 8/1/25 and 9/30/25.This failure had the potential to put Resident 17 and Resident 80 at risk of adverse drug effects including hypertension (HTN - high blood pressure) and increased Resident 17 and Resident 80's risk of having a severe medical emergency.Findings:1. A review of Resident 17's Order Details, dated 8/2025, indicated Midodrine was ordered by a physician with parameters (a measurable blood pressure value used to assess a patient's condition and guide treatment) to .Hold if SBP [SBP - systolic blood pressure] > [greater than] 100.During a concurrent interview and record review on 10/2/25, at 11:13 AM, with the Director of Nursing (DON), Resident 17's, Medication Administration Record, (MAR - a document used in healthcare setting to track and record medication given to residents) dated 8/1/25 through 10/1/25 was reviewed. The DON confirmed that Midodrine was given in error, outside of doctor ordered parameters, 13 times on the following dates:8/15/25, 8/19/25, 8/26/25, 8/27/25, 8/30/25, 9/2/25, 9/4/25, 9/6/25, 9/9/25, 9/13/25, 9/14/25, 9/28/25, and 10/1/25.2. A review of Resident 80's Order Details, dated 8/16/24, indicated Midodrine was ordered by a physician with parameters to, .HOLD FOR SBP [systolic blood pressure] GREATER THAN 100.During a concurrent interview and record review on 10/2/25, at 11:13 AM, with the DON, Resident 80's MAR dated 8/1/25 through 9/30/25 was reviewed. The DON confirmed that Midodrine was given in error, outside of doctor ordered parameters, 13 times on the following dates:8/1/25, 8/2/25, 8/5/25, 8/14/25 at 6 AM, 8/14/25 at 1 PM, 8/14/25 at 6PM, 8/17/25, 8/18/25, 8/28/25, 9/11/25, 9/19/25, 9/28/25, and 9/30/25.During an interview on 10/2/25, at 11:05 AM, with Licensed Nurse (LN) 14, LN 14 stated that Midodrine was used for Hypotension (low blood pressure). LN 14 further stated that they had parameters given by the physician that if the SBP was above 100, the nurses were expected to not give the medication to the residents. LN 14 explained it was important to not give the medication because it might make the resident's blood pressure high causing hypertension, (HTN - high blood pressure) and put the resident at risk for a stroke (a sudden interruption of blood flow to part of the brain causing brain cells to die) and other medical complications.During an interview on 10/2/25, at 11:18 AM, with the DON, the DON stated her expectation was for the LN to give the medication as ordered and that expectation included not to give the Midodrine if it did not meet the physician ordered hold parameters. The DON further stated the risk to the residents when the medication was given in error, would increase the residents blood pressure more and could affect their health status. The DON stated it could create additional medical problems for the residents.A review of the facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders.The following information is checked/verified for reach resident prior to administering medications.Vital signs [VS -include checking the residents heart rate and blood pressure]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 19 of 34 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 10/02/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% ( % percentage - number or ratio expressed as a fraction of 100) with a resident census of 104. Medication administration observations were conducted over multiple days, in random locations throughout the facility. The facility had a total of 2 errors out of 32 opportunities which resulted in a facility wide medication error rate of 6.25% for 2 of 6 residents (Resident 68 and Resident 17) observed for medication administration.These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being.Findings:a. During a medication administration observation on 9/29/25, at 9:15 AM, with Licensed Nurse (LN) 4, the following medication was observed given to Resident 68:LN 4 was observed administering 4 units of Insulin Lispro (a human-made rapid acting insulin analog to treat high blood sugar levels) subcutaneously (applied under the skin) in the upper right arm to Resident 68 on 9/29/25, at 9:15 AM.A review of Resident 68's order for, Insulin Lispro injection solution.Inject 4 units [measure of dosage] subcutaneously [applied under the skin].3 x [times] a day before meals. dated, 1/29/25, was documented as given on Resident 68's medication administration record (MAR -a legal document that serves as a detailed log of all medications given to a patient by healthcare professionals) on 9/29/25, at 8 AM.During an interview on 9/30/25, at 7:55 AM, with LN 4, LN 4 stated that Resident 68 had breakfast at 8 AM on 9/29/25 and that it was around the normal time for trays to be delivered to the rooms. LN 4 confirmed the order for Resident 68's insulin was supposed to be given before meals and that she gave it late on 9/29/25, at 9:15 AM. LN 4 stated the insulin should be given before meals and if given late the risk to the resident was that the insulin would not be as effective. b. During a medication administration observation on 10/1/25, at 8:18 AM, LN 5 administered a total of 8 medications to Resident 17, including 1 drop of Visine Dry Eye Relief, in each eye.During a record review of Resident 17's MAR, dated 10/2025, the following order indicated, Visine Dry Eye Relief Ophthalmic [an eye drop medication used to treat dry eyes].Instill 2 drop in both eyes two times a day for dry eye.During a concurrent interview and record review, on 10/1/25, at 8:45 AM, with LN 4, LN 4 reviewed Resident 17's MAR, dated 10/1/25, Visine Dry Eye Relief, order. LN 4 confirmed he was supposed to put 2 drops in each eye but only administered 1 drop in each eye. LN 4 stated he made the medication error because he had never seen an order for more than one drop in each eye before. LN 4 further stated the risk to the resident for not receiving the prescribed dose was continued dry eyes and the medication not being as effective or therapeutic. During an interview on 10/2/25, at 11:25 AM, with the Director of Nursing (DON), the DON stated her expectation was for the nurses to double check the orders and follow the rights of medication administration including, right order, right resident, right time, right dose, right route, and right documentation. The DON further stated it was important to follow the doctor's order and directions for giving insulin before meals. The DON explained the risk to the resident when insulin was given at the wrong time is that the insulin would not be as effective and it could also cause a blood glucose drop (the amount of glucose a simple sugar in the bloodstream). The DON stated it was her expectation to give the medication as ordered, for example, giving the wrong dosage of a medication like eye drops was a medication error and expected the doctor to be notified.A review of facility policy and procedure (P&P) titled, Administering Medications, revised, April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medication are administered in accordance with prescriber orders, including any required time frame.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.The individual administering the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 20 of 34 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 10/02/2025 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 0759 medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 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 21 of 34 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 10/02/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in two out of three medication rooms and four out of five medication carts when:1. An external air-conditioning (ac) unit that had a filter with grayish colored dust and debris, was placed on top of a medication refrigerator in Medication Storage room [ROOM NUMBER],2. Two bottles of Drug Buster (an eco-friendly, liquid solution designed for safe and effective disposal of unwanted or expired medications. It dissolves pills, tablets, capsules, and other forms of medication on contact, rendering them non-toxic and safe for disposal in regular trash) were found soiled and in active use in two different medication carts,3. Four pill cutters (a device used to safely and accurately divide medication tablets, vitamins, and supplements) were found with white and grayish residue in three different medication carts,4. Medications were opened in a medication cart and medication room without being labeled with an open date; and,5. A Topical medication was opened and not labeled with date opened, and sterile single use wound care supplies were opened and available for use in a treatment cart.These failures had the potential for unsafe medication use in the facility.Findings: 1. During a concurrent interview and inspection of the facility's medication storage room at Station 1, on 9/29/25, at 8:35 AM, accompanied by the Infection Preventionist (IP), an ac unit that takes air from the facility and removes it to the outside environment had a vent filter with grayish colored dust and debris placed on top of a medication refrigerator. The IP confirmed that the vent filter was dirty and had dust and debris build-up. The IP stated that the debris could get inside the medication refrigerator and that the filter should have been clean. During an interview on 10/1/25, at 9:10 AM, with the Director of Staff Development (DSD), the DSD stated that dust bunnies and spores could get inside of the medication refrigerator if the ac vent filter was dirty. The DSD further stated dirt and debris could get on the medications that were in the refrigerator. During an interview on 10/1/25 at 9:25 AM with the Director of Nursing (DON), the DON stated that the ac filter vents needed to be maintained and kept clean. The DON also stated that it could be a environmental hazard having the medication refrigerator being exposed to various dust and debris. The DON further stated that the medications could have been damaged, and that the efficacy of the medications could also be impacted. During a review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, dated 04/08, the P&P indicated, .Medication storage areas are kept clean. 2. During a concurrent interview and inspection of the facility's medication cart at Station 1, on 9/29/25, at 10:24 AM, accompanied by Licensed Nurse (LN) 3, a bottle of Drug Buster solution was observed to be soiled and dirty. LN 3 confirmed that the bottle of Drug Buster was soiled and making the medication cart dirty. LN 3 stated that it was an issue having a dirty Drug Buster available for use in the medication cart. During a concurrent interview and inspection of the facility's medication cart at Station 3, on 9/29/25, at 10:36 AM, accompanied by LN 4, a bottle of Drug Buster solution was observed to be soiled and dirty. LN 4 confirmed that the bottle of Drug Buster was soiled and making the medication cart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 22 of 34 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 10/02/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dirty. LN 4 stated that the Drug Buster solution should have been clean, and it posed a cross-contamination risk for the medications stored in the medication cart. During an interview on 10/1/25, at 9:10 AM, with the DSD, the DSD stated that the chemical solution could mix with other medications and cause unwanted drug-to-drug interactions (occur when the effect of one drug is changed by the presence of another drug. This interaction can result in the drug being less effective, more effective, or causing new, unexpected side effects to occur. During an interview on 10/1/25, at 9:25 AM, with the DON, the DON stated that having a dirty Drug Buster solution available in the medication cart would make the cart sticky and hard to clean. The DON further stated that the solution could seep into other medications and damage the cart. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 9/18/23, the P&P indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 3. During a concurrent interview and inspection of the facility's medication cart at Station 2, on 9/29/25, at 10:18 AM, accompanied by LN 2, two pill cutters were observed to have a whitish and grayish colored residue on them. LN 2 confirmed that the two pill cutters were dirty and should have been cleaned. LN 2 stated that cross-contamination of other medications could occur with the residue being on the pill cutters. During a concurrent interview and inspection of the facility's medication cart at Station 1, on 9/29/25, at 10:24 AM, accompanied by LN 3, a pill cutter was observed to have a whitish and grayish colored residue on it. LN 3 confirmed that the pill cutter was dirty. During a concurrent interview and inspection of the facility's medication cart at Station 3, on 9/29/25, at 10:36 AM, accompanied by LN 4, a pill cutter was observed to have a whitish and grayish colored residue on it. LN 4 confirmed that the pill cutter was dirty. LN 4 stated that previous medications that were cut using the pill cutter could interact with other medications. LN 4 further stated that it was a cross-contamination risk and that the pill cutter should have been clean. During an interview on 10/1/25, at 9:25 AM, with the DON, the DON stated that pill cutters should have been kept clean while in use. The DON also stated that having dirty pill cutters could increase the chances of unwanted drug-to-drug interactions. 4a. During a concurrent medication storage observation and interview on 10/1/25, at 7:59 AM accompanied by LN 5, the Sub-Acute Medication Cart 1 had one opened and undated bottle floor stock supply (supply of commonly used medications kept on hand and available for use) of Miralax (laxative powder mixed into water to help relieve constipation) available for use in the cart. LN 5 stated it was the facility stock bottle and used for multiple residents. LN 5 further stated it was facility policy to label the medication bottles with the date opened. b. During a concurrent medication storage observation and interview on 10/1/25, at 8:04 AM, accompanied by LN 5, the medication storage room located on the Sub-Acute Unit (a specialized unit for patients who require more specialized treatment than a standard skilled nursing unit) in the refrigerator, an opened and used box of Bisacodyl suppositories (a laxative used to insert into the rectum to relieve constipation) was not labeled with the date opened. LN 5 stated it was important to label (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 23 of 34 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 10/02/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medications with the date opened because some medications have a different expiration date once opened. LN 5 further stated the risk to the resident for taking expired medication was the medication would not be as effective. 5a. During a concurrent medication storage and treatment cart (a mobile, wheeled unit in a healthcare setting used to store and transport medical supplies, equipment and medications for patient care and wounds) observation and interview on 10/1/25, at 7:32 AM, accompanied by LN 6, the medication storage top drawer of the treatment care on the Sub-Acute unit, contained an opened bottle of prescription Clobetasol Propionate Topical Solution (a high-potency corticosteroid medication) that was unlabeled with the opened date. LN 6 stated it was important to label the medication with the opened date because it was only good for 28 days once opened. b. An opened single use, Suresite Transparent Film Dressing, (waterproof, breathable, comfortable dressing that protects skin and wounds) was observed opened and available for use in the treatment cart. The package instructions indicated, .Sterile (free from living microorganisms including bacteria, viruses, and fungi) in unopened, undamaged package. Single use only. LN 6 confirmed the finding and stated it the rest of the package should have been thrown away and not be available for use. LN 6 further stated the risk to the residents if was used, was that the package was opened and no longer sterile. c. An opened single use, Bordered Gauze, (three-layered wound dressing with an absorbent pad) was observed opened and available for use in the treatment cart. The package instructions reviewed with LN 6, indicated, .Single use only.Sterile in unopened undamaged package. LN 6 confirmed the finding and stated it should not be opened and available for use in the treatment cart. d. An opened single use, Gentac Silicone Island Dressing, (a medical wound dressing with a central absorbent and gentle skin-safe silicone adhesive border) was observed opened and available for use in the treatment cart. The package instruction reviewed with LN 6, indicated, .Sterile wound dressings. LN 6 confirmed the finding and stated that should have been throw out, once opened it was no longer sterile. LN 6 further stated any product that was single use only and labeled as sterile should not be opened. LN 6 explained once opened the contents were no longer sterile and the risk to the resident was infection. During an interview on 10/2/25, at 11:25 AM, the Director of Nursing (DON) stated that it was important to label all opened medications in the medication carts. The DON further stated it was important because some medications have different expiration dates once opened. The DON explained the risk to the residents for using expired medications was that the medication could not be effective. The DON stated that sterile dressings should not be opened up and put back into the treatment carts because they were no longer sterile once opened. The DON further stated once sterile supplies were opened they were exposed to the environment and the risk to the resident was delayed wound healing or could cause infection. A review of an undated facility policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, indicated, .Floor stock medications are labeled.label should include.Expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 24 of 34 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 10/02/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:1. Three tomatoes were found with mold and a discolored, flattened, and mushy apple were in the walk-in refrigerator,2. Frozen fish fillets, beef patties, meatballs, and veggie patties were left open to the environment in the reach in meat freezer,3. Small wares (three bowls and a cutting board) were not replaced when worn,4. The cool down log was not followed; and,5. The two-compartment sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink). These failures had the potential to lead to cross-contamination and food borne illness for the 85 residents eating facility prepared meals.Findings:1. During the initial kitchen tour on 9/29/25, at 8:30 a.m., a discolored, flattened, and mushy apple was found in the walk-in refrigerator.During a concurrent observation and interview on 10/1/25, at 8:52 a.m., with the Certified Dietary Manager (CDM) 1. CDM 1 verified three moldy tomatoes with a receive date of 9/25/25 were in the walk-in refrigerator. CDM 1 stated the moldy tomatoes should not have been there, if served to residents they would be at risk of getting sick from food born illness.During an interview on 10/1/25, at 9:45 a.m., with the Registered Dietitian (RD), the RD stated it was her expectation kitchen staff check food for quality daily. The RD further stated if the moldy tomatoes or apple were served would be a risk for food borne illness.2. During the initial kitchen tour on 9/29/25, at 9:15 a.m., frozen fish fillets and frozen beef patties were left open to the environment in the reach in meat freezer.During a concurrent observation and interview on 9/30/25, at 12:30 p.m., with the District Dietary Manager (DDM), frozen meatballs and frozen veggie patties were left open to the environment in the reach in meat freezer. The DDM stated the frozen meatballs and frozen veggie patties should have been completely covered to prevent food being covered in frost. DDM further stated food open to the environment in the reach in freezer could potentially affect the quality and nutritional value of the food.During an interview on 10/1/25, at 9:45 a.m., with the RD, the RD stated it was her expectation food stored in the reach in freezer should be tightly closed and not exposed to open air. The RD further stated food left open to air in the freezer could potentially affect palatability of the food stored.3. During the initial kitchen tour on 9/29/25, at 9 a.m., three bowls were worn, chipped, and without glaze on the ready to use shelves.During the initial kitchen tour on 9/29/25, at 9:05 a.m., a green cutting board stored ready for use was visibly worn with deep gouges.During an interview on 10/1/25, at 9:30 a.m., with CDM 2, CDM 2 stated bowls that were worn, chipped, and without glaze should have been thrown away because they cannot be cleaned properly. CDM 2 further stated the cutting board should have been thrown away and stated the bowls and cutting boards that were worn are at risk of bacterial growth potentially leading to food borne illness.During a review of the facility's policy and procedure (P&P) titled, Equipment, dated 9/2017, the P&P indicated, .All foodservice equipment will be clean, sanitary, and in proper working order.Review of the US Food and Drug Administration's (FDA) Food Code Section 4-501.12 of the 2022 Food Code on Cutting Surfaces indicated Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.4. During the initial kitchen tour on 9/29/25, at 9:13 a.m., the food cool down log was reviewed. The cool down log for egg salad dated 9/27/25, did not indicate when the egg salad reached 40 degrees Fahrenheit (F, a unit of measurement for temperature) or less.During an interview on 10/1/25, at 9:30 a.m., with CDM 2, CDM 2 stated it was important to follow the cool down log to ensure food that is being logged is safe for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 25 of 34 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 10/02/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete consumption. CDM 2 stated when the cool down log was not followed there is a risk the food that should have been logged could cause a food born illness.During an interview 10/1/25, at 9:45 a.m., with the RD, the RD stated following the cool down log process was important, not following the cool down log process risks bacteria growth on foods.Review of US FDA 2022 Food Code section 3-501.14 on Cooling indicated (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from.135 degrees Fahrenheit (F, a unit of measurement ) to.70 degrees F: and (2) Within a total of 6 hours from.135 degrees F to 41 degrees F or less. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. It further indicated that Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness.5. During the initial kitchen tour on 9/29/25, at 8:30 a.m., the two compartment sink did not have an air gap.During an interview on 9/29/25, at 3:15 p.m., with the DDM, the DDM verified the two compartment sink in the kitchen did not have an air gap. The DDM stated without an air gap there is risk of sewage backflow into the sink. During an interview on 10/1/25, at 9:30 a.m., with CDM 2, CDM 2 stated the two compartment sink was used to rinse pots and pans before going into the dishwasher, and in the event, dishwasher is down used for manual dishwashing. CDM further stated the two compartment sink should have an air gap, an air gap prevents back flow of contaminated water into the sink.Review of US FDA 2022 Section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. Event ID: Facility ID: 055735 If continuation sheet Page 26 of 34 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 10/02/2025 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 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 practice appropriate infection prevention and control measures for a census of 104, when:Urinals were found inside the trash can instead of being placed in the provided urinal receptacle and were not replaced with a clean urinal for Resident 62; and,Flying pests were found inside Resident 65's room; and,Licensed Nurse (LN) 4 did not clean, sanitize, and disinfect a glucometer (device used to measure blood sugar) per manufacturer guidelines.These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.1. Review of Resident 62's admission Record, indicated Resident 62 was admitted with multiple diagnoses which included but not limited to cerebral infarction (when part of the brain doesn't get enough blood causing brain cells in that area to die), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), and chronic kidney disease (kidneys are slowly losing their ability to clean your blood and remove waste from your body). Residents Affected - Some During a concurrent observation and interview on 9/29/25 at 9:15 AM, in Resident 62's room, there was three labeled urinals hooked by the urinal handle onto the inside of the trash can. The urinals, all marked with the resident's name and room number, all contained small amounts of yellow urine, and the urinal lids had dark stains. Only one urinal had a date written on the urinal and was dated 9/15/25. The trash can also contain used tissue paper, gloves, and an empty medicine cup, while the blue-colored urinal holder attached to Resident 62's bed frame remained empty. Resident 62 stated, I'm using a urinal. Staff don't have time to replace my urinal. Staff were not consistent in replacing my urinal. I need to press my call button for someone to come and replace it. I wish they would do it routinely. It's not my preference to put it inside the trash can. During a concurrent observation and interview on 9/29/25, at 9:30 AM, in Resident 62's room, Certified Nursing Assistant (CNA) 2 confirmed Resident 62 had three urinals located in the garbage can. CNA 2 stated Resident 62 required only one urinal at a time, and the urinal should not be placed in the garbage can as this was not acceptable and did not follow standard procedures. CNA 2 stated the urinal needed to be placed in the designated urinal holder located at the side of the bed that was within reach. CNA 2 stated urinals placed inside a trash can, posing an infection control risk that could impact Resident 62's safety and physical condition. During an interview on 10/1/25 at 12:48 PM with Infection Preventionist (IP), the IP stated that she expected the CNAs and nurses to store one urinal at the bedside using the designated blue-colored urinal holder attached to the bedframe. The IP stated staff should properly dump the contents into the toilet and return the urinal to the designated holder. The IP stated the urinals needed to label with the resident's name and room number. The IP stated if the urinal was dirty, the staff must replace the urinal. The IP stated each resident should have only one labeled urinal. The IP explained it was unacceptable to have urinals inside the garbage can. The IP stated that using a urinal placed inside the trash could result in germ contamination, which may pose a risk to Resident 62. The IP stated that proper storage of clean urinals was essential for preventing infection and maintaining cleanliness. During an interview on 10/1/25 at 1:17 PM with Director of Staff Development (DSD), the DSD stated CNAs needed to label the urinal with the resident's name and room number and place it in the blue-colored urinal holder. The DSD stated each resident should ideally have only one urinal unless they preferred more. The DSD stated nurses should not allow urinals to be placed inside the trash can. The DSD stated further that germs in the trash could spread and pose an infection risk to Resident 62. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 27 of 34 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 10/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/2/25 at 9:36 AM with Director of Nursing (DON), the DON stated CNAs must clean the urinal after each use and place it back in the designated urinal holder. The DON stated if the urinal was dirty, it should be thrown away and replaced with a new one. The DON stated throwing away dirty urinals and replacing the urinal with a new one would reduce the risk of infection and potential cross contamination. Residents Affected - Some Review of the facility's Policy and Procedure (P&P) titled Bedpan/Urinal, Offering/Removing dated 2/18, the P&P indicated, . Policy Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: 3. If the resident prefers to keep a urinal at his bedside, check it frequently. Empty and clean it as necessary. Note on the resident's care plan his request to keep the urinal at his bedside. After Assisting the Resident: 8. Clean the bedpan or urinal. Wipe dry with a clean paper towel. Store the bedpan or urinal per facility policy. 2. Review of Resident 65's admission Record, indicated Resident 65 was admitted with multiple diagnoses which included but not limited to chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems), adult failure to thrive (someone is not eating well, losing weight and feeling weak), and generalized muscle weakness. During a concurrent observation and interview on 9/29/25 at 11:53 AM with Licensed Nurse (LN) 2, LN 2 confirmed the presence of an uncollected empty fruit cup containing used tissue paper and a spoon, a dark blue plastic mug with a small amount of coffee, an empty glass, and another plastic cup with a small amount of water, all of which had insects present. LN 2 stated that this situation was unsanitary, unacceptable, and presented an infection control concern that required immediate cleaning. LN 2 stated that the presence of multiple gnats in Resident 65's room should prompt CNAs to report the unclean environment to licensed nurses, who would then inform housekeeping to ensure proper cleaning. During an interview on 10/1/25 at 8:08 AM, in Resident 65's room, Resident 65 stated that staff were not cleaning his room regularly, and it was dirty. Resident 65 stated that he was not receiving consistent assistance from the staff and noted that his meal tray was not being picked up once he had finished. Resident 65 confirmed the presence of multiple flying insects in his room on 9/29/25 and expressed concern that this could attract more gnats, which might affect his health, particularly his breathing. Resident 65 stated that he did not decline the staff's assistance in cleaning his room. During an interview on 10/1/25 at 8:21 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated that she prepared Resident 65 for meals, served the meal tray, and collected it once Resident 65 finished eating. CNA 2 stated Resident 65 occasionally asked to leave juice or coffee on the bedside table, and she later checked if it was suitable to pick it up. CNA 2 stated that leaving empty fruit cups or glasses of juice on the bedside table can attract insects and increase the risk of infection for Resident 65. During a concurrent interview and record review on 10/1/25 at 12:48 PM with Infection Preventionist (IP), the IP confirmed the absence of a non-compliance care plan in Resident 65's records pertaining to staff not being permitted to pick up empty cups and glasses, as well as the refusal to have his room cleaned. The IP stated the presence of gnats in the environment could increase the risk of infection. During an interview on 10/1/25 at 1:17 PM with the Director of Staff Development (DSD), the DSD stated that CNAs must remove the meal tray as soon as Resident 65 finishes eating and if Resident 65 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 28 of 34 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 10/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm prefers to keep food at the bedside, nurses need to provide education about the associated risks and benefits. The DSD stated leaving food at the bedside may attract bugs, which could present an infection control concern and potentially impact Resident 65's health and safety. The DSD stated that it was her expectation for Resident 65's refusal of meal tray removal or room cleaning to be care planned and communicated during shift reports however, she confirmed that this did not occur with Resident 65. Residents Affected - Some During an interview on 10/2/25 at 9:36 AM with the Director of Nursing (DON), the DON stated that old food remaining at the bedside can lead to bacterial growth and food poisoning. The DON stated there should be no old food or meal trays left at the bedside. The DON stated leaving moldy old food at the bedside posed risks, including gastrointestinal (includes the stomach and intestines) issues like diarrhea, nausea, and vomiting. Review of the facility's P&P titled Assistance with Meals dated 3/22, the P&P indicated, . Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Resident Confined to Bed: 3. The nursing staff . will take food trays into resident's rooms. 4. Nursing services . will pick up resident's food trays after each meal . Review of the facility's P&P titled Pest Control dated 5/08, the P&P indicated, . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 5. Garbage and trash are not permitted to accumulate and removed from the facility daily. 3. During a concurrent observation and interview on 10/1/25 at 9:23 AM, (LN) 7 was observed cleaning the glucometer after use. LN 7 took one (name brand pre-moistened disinfectant) towelette and cleansed the glucometer for 10 seconds and then placed the glucometer on top of the medication cart (a mobile unit used in healthcare settings to store and transport medications for patient delivery). LN 7 stated she cleansed the glucometer for about 10 seconds and did not realize she needed to cleanse it longer or with a second disinfectant towelette for a wet-contact time (how long a disinfectant needs to stay wet on a surface to be effective) of two minutes. A review of the side of the disinfectant towelette label with LN 7 indicated, .Disinfects in 2 minutes.Allow surface to remain visibly wet for contact time(s) listed on the label. LN 7 stated the risk to the residents for not cleaning the glucometer per instructions was the spread of infection. During an interview on 10/2/25 at 9:50 AM, the IP stated the expectation for glucometer cleaning was for it to be cleansed with one towelette first, and then a second towelette to disinfect, with the pre-moistened facility provided purple wipes for a total wet contact time of 2 minutes. The IP further stated the cleaning process was as directed on the glucometer manufacturer's instructions. The IP explained the risk to the residents if it was not cleansed properly was the spread of infection. During an interview on 10/2/24 at 11:24 AM, the Director of Nursing (DON) stated the glucometers should be cleansed with the, .purple wipes. with 2 separate disinfectant wipes for a set time of 2 minutes. The DON further stated it was important to prevent cross contamination (the process where bacteria or other microorganisms (undetectable to the eye organisms) that can cause disease are transferred from one substance or object to another, with harmful effect). A review of an undated facility provided document titled, GUIDELINES FOR CLEANING AND DISINFECTING THE ASSURE PLATINUM METER, the document indicated, .To minimize the risk of transmitting blood-borne (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 29 of 34 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 10/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below.The meter should be cleaned and disinfected after use on each patient.Clean and disinfect the meter following step-by-step instructions.CLEANING.Step 1 Wear appropriate protective gear.Step 2.pull out 1 towelette.Step 3 Wipe surface of the meter to clean blood and other body fluids.Step 4.Dispose of used towelette.The meter should be cleaned prior to each disinfection step.DISINFECTING.Step 5 Pull out 1 new towelette and wipe entire surface.Step 6 Treated surface must remain wet for recommended contact time. Event ID: Facility ID: 055735 If continuation sheet Page 30 of 34 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 10/02/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer, obtain informed consent and provide education to a resident or resident representative (RP) about influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for two out of five sampled residents (Resident 13 and Resident 65) when:1. Resident 13 was not offered the flu vaccine for 2 years.2. Resident 65 was not offered the pneumococcal vaccine within 30 days of admission.These failures had the potential for Resident 13, Resident 65, and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the pneumococcal vaccine and flu vaccine prior to receiving or declining the vaccination and it violated Resident's right to make an informed choice.1. During a concurrent interview and record review on 10/1/25, at 12:49 PM, with the Infection Preventionist (IP), the IP stated they have an upcoming influenza, COVID-19, and pneumococcal vaccination clinic on 10/14/25. The IP stated they offer the flu vaccine annually to residents during the flu season (typically begins in October and ends in May). The IP stated that either her or the Licensed Nurse (LN) will obtain signed consents from the resident or the RP. The IP explained that they inform the resident or the RP about the availability of the vaccine being offered and if they agree, they are asked to sign the consent form. The IP stated if the resident or the RP were not interested in getting the vaccine, the risks of not receiving the vaccine and the benefits of getting it would be explained to them and if they still refused, they were asked to sign the refusal form. The IP stated they still offer the flu vaccine after their scheduled vaccination clinic if it is still Flu season. The IP stated when a resident gets admitted to the facility during the off season of the flu, they wait until October for the next flu season and offer the vaccine to the residents. Resident 13's medical record was reviewed with the IP and the IP stated Resident 13's last flu vaccine was given on 9/20/22. The IP confirmed there was no refusal form signed for Resident 13's flu vaccine during the 23/14 and 24/25 flu season. The IP stated the flu vaccine should have been offered to Resident 13 during the 23/24 and 24/25 flu season. During an interview on 10/2/25, at 9:11 AM, with the Sub-acute Director (SAD), the SAD stated they always offer the flu vaccine upon admission. The SAD stated the flu vaccine was offered yearly and if they offered it, they should educate the RP or the resident if and it should be documented that education was provided and indicate if the vaccine was refused or accepted. During a concurrent interview and record review on 10/2/25, at 10:04 AM, with the Director of Nursing (DON), the DON stated they offered the flu vaccine every year and upon admission even if it was not the flu season. Resident 13's medical record was reviewed with the DON, and the DON stated Resident 13's last flu vaccine was in 2022. The DON stated Resident 13 is nonverbal, and Resident 13's mother was the RP and if the RP refused the vaccine, it should have been documented. The DON confirmed that there was no documentation that the flu vaccine was offered for Resident 13. The DON stated they usually have the consent form, and she expected the nurses to document that the resident or the RP was educated with the risk and benefits of the vaccine and put it on the consent form and progress notes. The DON stated if the flu vaccine was not offered annually, there would be a chance of getting a respiratory infection or flu and that would deteriorate the resident's condition.A review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, revision date 8/25, the P&P indicated, .Between October 1st and March 31st each year, the influenza vaccine is offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized.The Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 31 of 34 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 10/02/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident (or representative) has the right to refuse vaccines. If refused, the date of and state reason for the refusal of the vaccine are documented in the resident's medical record. 2. During a concurrent interview and record review on 10/1/25, at 12:49 PM, with the Infection Preventionist (IP), the IP stated they offer the pneumococcal vaccine upon admission, but they could still get it during flu season vaccination clinic. The IP stated they offered pneumococcal vaccine for residents [AGE] years old and above, and if the resident is below [AGE] years old, they do not offer the pneumococcal vaccine. The admitting nurse is the one responsible for offering the vaccine and getting consent upon admission. The IP reviewed Resident 65's medical record and confirmed Resident 65 was admitted to the facility on [DATE] and there was no vaccine administration record. The IP stated Resident 65 will be offered the COVID-19, flu, and pneumococcal vaccine next week. The IP stated she did not know what happen and why the pneumococcal vaccine was not offered. The IP stated Resident 65 was admitted with pneumonia, he was on an antibiotic (medication to treat infection) for 7 days and the last dose of antibiotic was on 8/25/25. The IP stated Resident 65 was put back on antibiotics on 9/14/25 due to pneumonia. The IP stated the pneumococcal vaccine should have been offered to Resident 65 during the 2-week span after his last dose of the antibiotic. During an interview on 10/2/25, at 9:11 AM, with the Sub-acute Director (SAD), the SAD stated they always offer the pneumococcal vaccine upon admission but still depends on the type of pneumococcal vaccine that they have and the one that was received by the resident before because there were pneumococcal vaccines that varied depending on the age of the receiver. During a concurrent interview and record review on 10/2/25, at 10:04 AM, with the Director of Nursing (DON), the DON stated they offered pneumococcal vaccines upon admission and if the resident had a preference when to get the vaccine, the resident could always reach out to the charge nurse. The DON stated the nurses should document if the vaccine was refused and if the resident wanted the vaccine to be administered later, there should be a note in the medical record regarding that. Resident 65's medical record was reviewed with the DON and the DON confirmed Resident 65 was above [AGE] years old and would be eligible to receive a pneumonia vaccine. The DON stated she did not see a consent form for the pneumococcal vaccine or a progress note that it was offered. The DON stated she was not sure if it was offered. The DON stated it should have been documented that the resident was educated and if the resident agreed or refused. The DON stated that the pneumococcal vaccine is provided for residents aged 65 and older who have low immunity and are at a higher risk of developing pneumonia. The DON stated if the pneumococcal vaccine was not offered to the resident, the resident might be at risk for pneumonia. The DON stated Resident 65 should have been offered the pneumococcal vaccine after he finished his antibiotic treatment and if he refused, there should have been documentation in the medical record. The DON stated there was a possibility that Resident 65 might get pneumonia again. A review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, revision date 12/25, the P&P indicated, .Policy Statement All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Event ID: Facility ID: 055735 If continuation sheet Page 32 of 34 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 10/02/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide COVID-19 vaccine, for one out of five sampled residents (Resident 65) when:1. Resident 65s' clinical record did not contain documented evidence that the COVID-19 vaccine was administered within 30 days upon admission.2. Resident 65's COVID-19 vaccine information history was not obtained and documented in the medical record.This deficient practice put Resident 65 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.During a concurrent interview and record review on 10/1/25, at 12:49 PM, with the Infection Preventionist (IP), the IP stated the facility offered a COVID-19 vaccine to all residents upon admission. The IP stated that the admitting nurse is the one responsible for offering the COVID-19 vaccine and obtaining consent upon admission. The IP stated that once the consent was signed, the nurse would put the order in for the pharmacy to deliver the vaccine. The IP stated when a resident had a COVID-19 vaccine prior to admission to the facility, the facility would obtain the administration record of the COVID-19 vaccine and if the resident or the resident's responsible party (RP) could not provide the documentation of the COVID-19 vaccine administration information, they would just take their word for it. Resident 65's medical record was reviewed with the IP and the IP confirmed Resident 65 was admitted on [DATE], and he would be offered the flu vaccine (protect against infection by influenza viruses), the COVID-19 vaccine, and the pneumococcal vaccine (to prevent certain types of infection) next week. The IP stated the COVID-19 vaccine was offered to Resident 65, and he agreed to have it administered during the flu season vaccination clinic. The IP confirmed that there is no documentation that Resident 65 agreed to get the COVID-19 vaccine during flu season and it should have been documented. The IP stated Resident 65 signed a consent form on the day of his admission to the facility on 8/20/25 to receive the COVID-19 vaccine, but the vaccine had not yet been given to Resident 65. During an interview on 10/2/25, at 9:11 AM, with the Sub-acute Director (SAD), the SAD stated the facility offers the COVID-19 vaccine upon admission, and they can also provide it upon request. The SAD stated if the staff offered the vaccine, they should educate the RP or the resident and document whether they refused or accepted the vaccine.During a concurrent interview and record review on 10/2/25, at 10:04 AM, with the Director of Nursing (DON), Resident 65's medical record was reviewed with the DON. The DON stated they have a signed consent form of Resident 65's COVID-19 vaccine dated 8/20/25. The DON stated she did not see Resident 65's previous COVID-19 vaccine information. The DON stated the COVID-19 vaccine information history should have been documented. The DON stated that the immunization record does not provide evidence of administration, thus it is unclear whether Resident 65 received the vaccine. The DON stated she did not see any completed or active or discontinued doctor orders of the COVID-19 vaccine from Resident 65's order list therefore, the COVID-19 vaccine was not given yet. The DON stated the potential outcome when residents were not provided with the COVID-19 vaccine would be risks of getting COVID-19, respiratory issues, and the possibility of spreading COVID-19 infection to other residents and staff too.A review of Resident 65's admission RECORD, dated October 1, 2025, indicated, Resident 65's COVID Booster Vaccine Status and COVID Vaccine Status was left blank.A review of the undated facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, indicated, .If a resident requests vaccination, but missed earlier opportunities for any reason, the vaccine will be offered to that resident as soon as possible. Efforts to help the resident obtain vaccination are documented .Documentation and Reporting 1. The resident's medical record includes documentation that indicated, at a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 33 of 34 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 10/02/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm minimum, the following: .c. Each dose of COVID-19 vaccine that was administered to the resident. 2. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 34 of 34