Delta Oaks Post Acute

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reviewed. The DSAS verified Resident 3's enteral feeding care plan indicated interventions to change Resident 3's dressing at the stoma site (an artificial opening created through surgery on the stomach) per doctor's orders and to clean the stoma site as ordered/per facility protocol. The DSAS also verified Resident 3 did not have an order to change the dressing at the G-tube site or an order to clean the site. The DSAS stated care plans provide interventions to situations that were resident specific. The DSAS further stated it was important to follow the care plan to prevent infection.During an interview on 9/25/25, at 5:05 p.m., with

the Administrator (ADM), the ADM stated it was her expectation that care plans would be followed. The ADM further stated it was important to follow the care plan to stay consistent with resident care.During a

review of the facility's policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, dated 8/25/21,

the P&P indicated, .Each resident's comprehensive care plan is designed to. incorporate identified problem areas.aid in preventing or reducing declines in the resident's functional status and/or functional levels.reflect currently recognized professional standards of practice for problem areas and conditions .

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Delta Oaks Post Acute

6940 Pacific Avenue Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688

(P&P) titled, Restorative Nursing Services, dated 7/17, the P&P indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Delta Oaks Post Acute

6940 Pacific Avenue Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on interview and record review, the facility failed to ensure a physician order was in place to indicate

the appropriate care of a gastrostomy tube feeding (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) for 2 of the 3 sampled residents (Resident 1 and Resident 3) to prevent potential complications of the feeding tube when, Resident 1 and Resident 2 did not have a physician treatment order to indicate the care needed for the G-tube site.This failure had the potential for Resident 1 and Resident 3 to experience skin breakdown and infection at the G-tube site.Findings:1. Review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis including but not limited to .ENCOUNTER FOR ATTENTION TO GASTROSTOMY [this diagnosis applies to routine tasks like cleansing, dressing changes, and managing the g-tube].During a concurrent interview and record review on 9/24/25, at 3:43 p.m., with Licensed Nurse (LN) 1, Resident 1's Order Summary Report, printed on 10/24/25, was reviewed.

LN 1 confirmed there was no treatment order for Resident 1's G-tube site. LN 1 stated the order should have been there, and it was part of the facility policy to provide treatment to Resident 1's G-tube site every day. LN 1 further stated if the G-tube site does not receive treatment there was a risk of infection and skin breakdown at the site.During an interview on 9/24/25, at 4:05 p.m., with the Director of Sub-Acute Services (DSAS; provides more intensive medical services and therapy than a traditional nursing home but is less intensive than acute (hospital) care), the DSAS stated it was her expectation for Resident 1 to have a physician treatment order that included g-tube treatment instructions.A review of Resident 1's, Treatment Administration Record, dated 8/24, indicated there was no documented evidence that Resident 1 received treatment to the G-tube site upon readmission to the facility on 8/9/24.2. Review of Resident 3's clinical

record titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnosis including but not limited to .ENCOUNTER FOR ATTENTION TO GASTROSTOMY.During a concurrent interview and

record review on 9/25/25, at 3:07 p.m., with Licensed Nurse (LN) 2, Resident 1's, Order Summary Report, with a printed date of 10/25/25, was reviewed. LN 2 verified Resident 3 had no active order for treatment for Resident 3's G-tube site from 8/20/25, until today, 9/25/25. LN 2 stated that without a treatment order for the g-tube, Resident 3 was at risk for skin breakdown and infection of the G-tube site.During a concurrent

interview and record review on 9/25/25, at 4 p.m., with the DSAS, Resident 3's Order Summary Report, with a printed date of 10/25/25, was reviewed. The DSAS verified Resident 3 did not have an order to change the dressing at the G-tube site or an order to clean the site. The DSAS stated if Resident 3's G-tube site did not have a treatment order Resident 3 was at risk for infection and skin breakdown at the G-tube site.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings [a method of providing nutrition directly into the gastrointestinal (GI; includes stomach and intestines) tract through a tube] - Safety Precautions, dated 11/18, the P&P indicated, .The facility will remain current in and follow accepted best practices in enteral nutrition.Keep the skin around exit site clean, dry and lubricated.

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If continuation sheet