Oak Grove Post Acute: Behavioral Health Failures - CA
Inspectors cited the facility under F0742, the federal standard governing behavioral health services in nursing homes. The deficiency affected a small number of residents, but inspectors determined there was potential for actual harm.
The facility's own written policy described what was supposed to happen. Behavioral symptoms would be identified using approved screening tools. Qualified staff with the necessary competencies would provide services. Residents with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder would be flagged during initial assessment by nursing staff and the attending physician. Every resident was to receive a Level I PASARR screen before admission.
PASARR, the Preadmission Screening and Resident Review process, exists specifically to identify nursing home residents who may have serious mental illness, intellectual disability, or related conditions, and to make sure those residents get appropriate services. If a Level I screen suggests someone might meet the criteria, they are supposed to be referred to the state for a Level II evaluation. That evaluation is then supposed to shape the resident's care plan.
The facility's policy also addressed what should happen after admission. New or changed behaviors suggesting a serious mental disorder were to trigger a Level II referral. Residents already identified as Level II were to be referred again if their condition changed significantly.
What inspectors found was that this process, as written, was not being carried out as required for at least a few residents.
The inspection was a complaint survey, meaning someone, a resident, a family member, a staff member, or another party, raised a concern serious enough to prompt investigators to come in and look. Complaint inspections are targeted. They do not cover everything. What they find is what the complaint pointed them toward, and in this case, what they found was a failure in one of the more consequential areas of nursing home care.
Behavioral health needs in nursing homes are easy to overlook and easy to minimize. A resident who is agitated, withdrawn, confused, or acting in ways that seem disruptive can be managed with redirection, with medication, or simply with avoidance. The PASARR process exists in part because those responses are not always appropriate, and because residents with genuine psychiatric conditions or intellectual disabilities are entitled to specialized services, not just management.
When a facility skips or shortcuts that process, residents who need more than the facility can provide may never get referred out. Residents who need specific therapeutic interventions may receive none. Care plans built without proper evaluation may address symptoms while missing the underlying condition entirely.
Oak Grove Post Acute's own policy acknowledged all of this in detail. The language about qualified staff, competencies, minimal complications, regulatory compliance, it was all there on paper. The gap was between the policy and what actually happened for the residents inspectors reviewed.
The deficiency was rated at the lower end of the harm scale. Minimal harm or potential for actual harm, affecting few residents. In the hierarchy of federal nursing home violations, that places it below the most severe findings. It does not place it below concern.
For a resident with an unrecognized mental health condition living in a facility that has not completed the evaluations required to understand that condition, the practical consequence is a care plan that does not fully account for who they are or what they need. That gap can persist for weeks or months before anyone notices, if anyone notices at all.
The inspection covered ten pages. This deficiency appeared on the last one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Post Acute from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 18, 2026 · Our methodology
OAK GROVE POST ACUTE in STOCKTON, CA was cited for violations during a health inspection on August 21, 2025.
Inspectors cited the facility under F0742, the federal standard governing behavioral health services in nursing homes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.