Health inspection·February 17, 2026

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide comprehensive pain management, for one of three sampled residents (Resident 1) when, Resident 1 had not been given the appropriate pain medication as per the pain assessment scale (a tool used to assess the level of pain) and provided pain medication as ordered by the physician.This failure resulted in Resident 1's pain not being effectively managed and Resident 1's pain not being treated per the physician's orders. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in mid-2024 with diagnoses which included polyneuropathy (a condition characterized by damage to multiple peripheral nerves, usually causing symmetrical numbness, tingling, weakness, and burning pain, often starting in the feet or hands) and gout (a common, painful form of inflammatory arthritis caused by high levels of uric acid in the blood (hyperuricemia) that form needle-like crystals in joints).A review of Resident 1's Order Summary Report, indicated a physician's order for .Acetaminophen Tablet 325MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Mild Pain. Resident 1's order summary report also indicated another physician's order which indicated, .[Hydrocodone/acetaminophen] Norco [pain relieving medication] Oral, Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube [A gastrostomy tube (G-tube) is a medical device inserted through the abdomen directly into the stomach to provide long-term nutrition, fluids, and medication] every 6 hours as needed for pain level 5-10.[Pain scales are standardized, subjective tools used by healthcare professionals to measure pain intensity, typically ranging from 0 (no pain) to 10 (worst pain imaginable)].During an interview, on 2/17/26, at 3:25 p.m. with Licensed Nurse (LN) 1, LN 1 stated when Resident 1 was in pain, his respirations and heart rate would go up, his eyes and mouth would open and there was grimacing noted on his face. LN 1 stated they use a PAINAD scale (pain assessment in advanced dementia is a validated, 5-item observational tool used by healthcare professionals to measure pain (0-10 score) in patients with severe dementia or communication deficits. It assesses breathing, negative vocalization, facial expression, body language, and consolability) to access Resident 1's pain, after which she would then administer 2 acetaminophen tablets to Resident 1. LN 1 stated it was nursing judgement to determine pain medication to give. LN 1 stated Resident 1 was non-verbal and had a lot of wounds which were painful. LN 1 further stated, she did not like giving hydrocodone/acetaminophen as Resident 1's body would get used to it and the medication would become less effective.A review of Resident 1's Medication Administration Record [MAR], dated for the month of 1/26, Resident 1's administration record for acetaminophen, indicated Resident 1 had a documented pain level of 8 on 1/6/26, 5 on 1/17/26, 6 on 1/21/26, and 7 on 1/30/26 and Resident 1 was given 2 acetaminophen tablets on these dates. Further review of Resident 1's MAR for the month of 1/26, indicated Resident 1's administration record for hydrocodone/acetaminophen, indicated Resident 1 had a documented pain level of 4 on 1/8/26, 0 on 1/26/26 and 0 on 1/31/26 and Resident 1 was given 1 hydrocodone/acetaminophen tablet on these dates. During a concurrent interview and record review, on 2/17/26, at 4 p.m. with the Director of Nursing (DON), Resident 1's MAR, dated for the month of 1/26, was reviewed. The DON confirmed that Resident 1 was given acetaminophen sometimes when his pain level was above 5, and Resident 1 should have received the hydrocodone/acetaminophen pain medication at those times. The DON confirmed that Resident 1 received hydrocodone/acetaminophen sometimes when his pain level was lower, and Resident 1 should have received acetaminophen as per the physician's orders. The DON further stated, staff failed to manage Resident 1's pain properly and put Resident 1 at risk of being overmedicated when his pain was less and undermedicated when he was in more pain. The DON further stated that it was very important to follow the physician's order properly so residents' pain can be managed effectively as it is Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055735 If continuation sheet Page 2 of 3 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 02/17/2026 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete also the residents' right to get the right medication. Review of Resident 1's record titled Care Plan Report for pain, created on 1/22/25, in the section Focus, the record indicated, [Resident 1] has (acute/chronic) pain r/t [related to] Chronic Physical Disability. Wound STAGE 4 PRESSURE WOUND SACRUM [the most severe form of pressure injury, involving full-thickness tissue loss with exposed fascia, muscle, tendon, and bone; sacrum - the part of the spinal column that is directly connected with or forms a part of the pelvis] . In the section Interventions, indicated, .Administer analgesia [medications designed to relieve pain] ([hydrocodone/acetaminophen]) as per orders.Review of a facility policy and procedure (P&P) titled Administering Medications, revised 4/19, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and write method (route) of administration before giving the medication . Event ID: Facility ID: 055735 If continuation sheet Page 3 of 3