Health inspection·February 5, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and maintain an effective infection prevention and control program, including an infection surveillance system (an ongoing, systematic, and active monitoring of infections, as well as the practices used to prevent them) to prevent transmission of communicable disease (an infectious illness that can spread from one person to another), during an Respiratory Syncytial Virus (RSV, a respiratory infection that infects the lungs and breathing passages) infection for two of six sampled residents (Resident 1 and Resident 2) when:1. Resident 1 who had RSV infection was cohorted (grouping of residents) with other residents during the RSV isolation period without implementation of appropriate transmission-based precautions (also called Isolation Precautions, are actions implemented in addition to standard precautions that are based upon the means of transmission for the infectious agent in order to prevent or control infections)2. Resident 1 and Resident 2's RSV infection were not assessed and monitored during the isolation period. 3. The facility did not maintain records showing the RSV outbreak (6 residents) was reported to local and state health authorities as required.These failures had the potential to result in increased transmission of RSV among residents and staff, delayed nursing evaluation of Residents 1 and 2's progression of RSV symptoms such as worsening of respiratory illness, and serious complications such as pneumonia (an infection that causes inflammation in the air sacs of one or both lungs), hospitalization, or death. During a record review of Resident 1's admission Record (AR) printed on 2/5/26, the AR indicated Resident 1 was admitted to the facility in November 2025 with diagnoses of pneumonia and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems).During a record review of Resident 1's record, titled, Inter-Facility Transfer Report (IFTR), dated 1/22/26, the IFTR indicated Resident 1 was admitted to hospital due to acute hypoxic (a critical, sudden drop in blood oxygen levels) and hypercapnic failure (a condition where the respiratory system fails to properly remove carbon dioxide from the blood) due to COPD exacerbation (a sudden worsening) triggered by RSV infection. The IFTR indicated Resident 1 tested positive of RSV on 1/19/26.During a record review of undated facility-provided record, titled, RSV, the record indicated five residents tested positive of RSV within the previous 30 days (1/5/26 through 2/5/26). However, Resident 1, who was identified as RSV positive on 1/19/26, was not included on the facility's RSV line list.During a record review of Resident 2's AR printed on 2/5/26, the AR indicated Resident 2 was admitted to the facility in December 2025 with diagnoses of cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain) and Alzheimer's disease (a progressive, irreversible neurodegenerative brain disorder that destroys memory, thinking skills, and eventually the ability to perform daily tasks).During a record review of Resident 2's record of laboratory results, dated 1/29/26, the result showed Resident 2 tested positive of RSV infection. During a record review of Resident 2's Electronic Health Record (EHR), Residents Affected - Some Page 1 of 3 056381 056381 02/05/2026 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 did not have documentations including a change in condition assessments, monitoring, progress notes, or care plan interventions to RSV management.During an interview on 2/5/26 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had multiple recent hospitalizations and confirmed Resident 1 was not placed in isolation precaution upon the last two re-admissions to the facility.During an interview on 2/5/26 at 11:27 a.m. with the Infection Preventionist (IP) nurse, IP stated Resident 1 tested positive of RSV at the hospital on 1/19/26. IP stated Resident 1 was re-admitted to the facility on [DATE]. IP stated Resident 1 was not placed in isolation upon re-admission because they were not aware of the RSV diagnosis. IP stated she only became aware of the positive RSV result when Resident 1 returned from the hospital on 2/1/26.During a follow-up interview on 2/5/26 at 12:06 p.m. with IP, IP stated the isolation period for RSV was seven days, indicating Resident 1 should have been placed on isolation precautions upon re-admission on [DATE]. IP stated she was unaware Resident 1 was RSV-positive because the hospital discharge documents were not uploaded into Resident 1's EHR until 2/2/26 and she had not been notified. IP stated Admitting Nurse (AN) 1 should have reviewed the hospital discharge documentation thoroughly. IP further stated Resident 1 was not placed on isolation and was not monitored for RSV, created the potential for transmission of infection to other residents. IP stated more than two confirmed RSV cases should have been reported to appropriate public health authorities for recommendations related to RSV outbreak. IP further stated there was no formal or verifiable documented communication between the facility and the public health department authorities regarding outbreak notification, recommendations, or guidance for management of the RSV outbreak.During a record review and interview on 2/5/26 at 12:16 p.m. with IP, Resident 2's EHR was reviewed. IP confirmed there was no documentation showing Resident 1 was assessed or monitored, and no documentation the physician and responsible party were notified after Resident 2 tested positive for RSV on 1/29/26. IP stated Resident 2 should have been assessed and monitored to evaluate the progression of symptoms and response to RSV infection. IP stated failure to assess and monitor Resident 2 for RSV infection could have resulted in worsening respiratory condition requiring hospitalization and increased risk for transmission of RSV to other residents due to lack of monitoring and infection surveillance. During a phone interview on 2/5/26 at 2:13 p.m. with AN 1, AN 1 stated she completed Resident 1's re-admission on [DATE] and did not identify that Resident 1 tested positive for RSV in the hospital discharge documentation. AN 1 stated she relied primarily on the hospital discharging nurse's report and focused on physician orders for the facility rather than reviewing the complete discharge hospital discharge summary. AN 1 further stated Resident 1 resided in a shared bedroom with two other residents, placing other residents at risk for exposure and transmission of RSV.During an interview on 2/5/26 at 2:43 p.m. with the Director of Nursing (DON), DON confirmed the facility was unaware that Resident 1 tested positive for RSV when Resident 1 returned from the hospital on 1/22/26. DON stated awareness of the RSV diagnosis did not occur until 2/1/26, following a notification from nursing staff regarding the need for isolation precautions. DON stated there was a miscommunication between the charge nurses and the case manager when Resident 2 subsequently tested positive for RSV. DON further confirmed nursing staff did not document Resident 2's RSV status in the medical record. DON stated the facility should have implemented appropriate infection prevention and control measures including timely assessment, monitoring, initiation of transmission-based precautions, and reporting and documentation of the outbreak to the public health authorities. During a record review of the facility's policy and procedure (P&P), titled, Respiratory Syncytial Virus (RSV) Prevention, revised in August 2025, the P&P indicated, Residents are monitored for clinical signs and symptoms of RSV .1. The clinical staff monitor residents for signs and symptoms of severe 056381 Page 2 of 3 056381 02/05/2026 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RSV disease .5. Residents diagnosed with RSV are placed on contact precautions (prevent the spread of infectious diseases transmitted through direct or indirect contact) for the duration of their illness .6. The IP is responsible for surveillance and reporting of infectious diseases .During a record review of the facility's P&P, titled, Outbreak of Communicable Diseases, revised in April 2025, the P&P indicated, Outbreaks of communicable diseases within the facility are promptly identified and managed .1. An outbreak is defined as one of the following .a. One case of an infection that is highly communicable or has serious health implications .c. Occurrence of three or more cases of the same infection over a specified period of time and in defined area .6. The IP and DON services are responsible for .b. communicating with local and state health authorities .d. monitoring ill residents and staff .initiating transmission-based precautions, as appropriate .f. communicating with the medical director and the attending physicians .During a record review of the facility's P&P, titled, Infection Prevention and Control Program, revised in August 2019, the P&P indicated, 6. Outbreak Management .a. Outbreak management is a process that consists of .2. managing the affected resident .3. preventing spread to other residents .documenting information about the outbreak .5. reporting the information to appropriate public health authorities . 056381 Page 3 of 3