Health inspection·August 15, 2025

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** These findings represent past non compliance with this regulatory requirement. There was significant evidence the facility corrected the non compliance as of 08/15/25 and there were no other occurrences of the same deficient practice at the time of the survey. The facility was in substantial compliance with this regulatory requirement and there for doesn't not require a plan of correction. Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella Disease (a type of pneumonia (lung infection) caused by the bacteria Legionella pneumophila) and other opportunistic waterborne pathogens (a microorganism (bacteria) that exists in water sources or plumbing (pipes required for the water supply, heating, and sanitation in a building) systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 71 when:a. The facility did not implement adequate water safety control measures; b. The facility did not establish sufficient water safety monitoring protocols; andc. The facility did not create an intervention plan for when control limits were not met.These failures put the residents and staff at risk of potential Legionella and other opportunistic waterborne pathogen exposure, threatening their health and well-being.Findings:During an interview on 8/14/25 at 9 AM, the local Public Health Officer (PHO) confirmed she discussed with the facility about improving their water management plan. The PHO stated the facility's plan and policy in place did not align with nationally accepted standards to minimize the risk of Legionella contamination. The PHO further stated when she reviewed the Water Safety Management Program (Legionella) policy and procedures, and stated the facility was missing important components such as the roles of each member of the water management program must be assigned and listed. The PHO further explained these roles once they were assigned, the staff should be aware and knowledgeable when they were needed. The PHO explained, during a meeting with the facility on 8/6/25, the facility was provided with the information needed to have a complete and compliant water management program. The PHO stated the information needed to be mapped out with an action plan, including who they would contact and work with to chlorinate and flush lines in case of a Legionella outbreak.During an interview with Licensed Nurse 1 (LN1) on 8/14/25 at 1:31 PM, LN1 stated since being employed at the facility for a little over a year she did not receive any training on water management during her employment at this facility. LN1 stated, on 7/22/25 staff received their first notification via text indicating the water would be off for some time for maintenance.During an interview with the Maintenance Director (MTD) on 8/14/25 at 3 PM, the MTD stated upon recommendation of his regional headquarters due to the recent legionella alert he recently completed replacing the showerheads and placing filters on all areas where water was used for consumption by the residents. A walk through in the kitchen and visualization of the specialized filters confirmed placement. The MTD stated preventative maintenance was important to prevent the residents from getting sick. The MTD explained the special filters on the showerheads Residents Affected - Many Page 1 of 3 555387 555387 08/15/2025 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and eye washing station help filter diseases like Legionella from the water. The MTD further stated it was important to test the water to prevent sicknesses which could harm the residents and cause death. The MTD could not explain the facilities process for decontaminating the facilities water systems if necessary. The MTD confirmed they did not have an outside source contracted to decontaminate the water system, prior to the notification of a positive Legionella resident and a company was scheduled to come on 8/15/25. The MTD stated it was important to have a contracted company to be aware if there were harmful things in the water.During an interview on 8/14/25 at 4:10 PM with the Administrator (ADM), the ADM stated the facility was notified by the Public Health Department (PHD) on 7/22/25 that a resident who was sent to the hospital from the facility tested positive for Legionella pneumophila (a severe form of pneumonia -a lung infection caused by Legionella bacteria). The ADM further stated the facility contacted the local Public Health Department after they initially contacted the facility to schedule a meeting to develop a better understanding of how to address this issue. This meeting was conducted on 8/6/25 for detailed guidance on how to handle the results. The ADM explained the PHD asked that the water samples be collected by a company certified to do so. The ADM explained the PHD also wanted the facility to be contracted with a company to provide certified testing and facility water maintenance in case of a positive result. The ADM stated they did not have a contracted provider at the time and requested a list of certified companies from the PHD. The ADM explained the facility contracted with a company who will be coming out to the facility on 8/15/25 to collect six samples to test the water. The ADM confirmed the facility did not have records of baseline testing for legionella or any comparative results that would inform the facility of the need for immediate corrective action.During an interview with the Director of Nursing and the Infection Preventionist (IP) on 8/14/25 at 4:30 PM, the DON explained the PHD told them to test the residents with respiratory symptoms (signs like runny nose, cough, and difficulty breathing that indicate a problem with your breathing or lungs) and to test their water for Legionella by a certified company. The DON stated they tested all the residents in the facility with respiratory symptoms and all results were negative. The DON and the IP confirm the facility did not have a risk management program (program is a proactive plan to find and fix any problems in a building's water system that could allow dangerous Legionella bacteria to grow and spread) in place and documentation of utilization of the program nor a protocol for testing the residents. The DON stated the staff have not had any water management training prior to the notification from the PHD about the positive legionella case.During a follow up interview and record review of the policy and procedures with the ADM, on 8/15/25 at 5 PM while reviewing the facilities water management program, the ADM confirm the facility did not have assigned duties to each member of the water management program team.During a follow-up interview on 8/15/25 at 3:46 PM, the DON stated the water management plan prior to the incident did not meet her expectations. The DON further stated although the facility did have water management in place all the components and requirements were not utilized to the standards of the PHD. The DON explained legionella can grow and spread in stagnant water and plumbing. The DON further explained it was important to have a detailed water safety management program and plan in place to prevent the residents from getting Legionella pneumonia. The DON stated the risk to the residents was respiratory distress and illness.A review of the facilities Policy and Procedures (P&P) titled, Water Safety Management Program (Legionella) dated, 7/21, the P&P indicated, .1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and 555387 Page 2 of 3 555387 08/15/2025 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] recommendations for developing a Legionella water management program . A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program.A review of the Centers for Disease Control's online guide titled Overview of Water Management Programs, published 3/15/24, the guide indicated, .Key Points.Many buildings need a water management program (WMP) for their building water system.WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens.Developing and maintaining a WMP is a multi-step process that requires continuous review.Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities.the principle of effective water management includes Ensuring adequate disinfection.Maintaining devices to prevent.Sediment, Scale, Corrosion, Biofilm.Maintaining water temperatures to limit Legionella growth, preventing water stagnation.Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met.Each program has to be tailored for each building at a particular point in time.In some settings, the entire building needs a WMP: Hospitals and long-term care facilities.(https://www.cdc.gov/control-legionella/php/wmp/index.html) 555387 Page 3 of 3