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Complaint Investigation

Oak Grove Post Acute

August 15, 2025 · Stockton, CA · 4545 Shelley Court
Citations 2
CMS Rating 1/5
Beds 119
Provider ID 055201
Healthcare Facility
Oak Grove Post Acute
Stockton, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

OAK GROVE POST ACUTE in STOCKTON, CA — inspection on August 15, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0583
Resident Rights Deficiencies

During an interview and concurrent record review of facility in-service education on 8/14/25 at 2:50 p.m. with the Director of Staff Development (DSD), the DSD stated that staff were not supposed to be on cell phones while providing resident care.

The DSD stated that upon hire, staff received in-service education on cell phone use in the facility, and cell phone use by employees was also discussed in the employee handbook provided to each employee upon hire.

During an interview with the ADM and the ADON on 8/15/25 at 12:20 p.m., the ADM stated that Resident 4's Responsible Party was notified regarding the incident, and the CNAs involved in the Tik Tok incident were terminated.A review of a facility policy and procedure (P&P) titled, Personal Electronic Devices, dated 11/01/23, the P&P indicated, .The Facility recognizes that cellphones and other personal communication devices have become valuable tools in managing our personal lives.

However, workplace use of these devices can raise a number of issues involving safety, security, privacy, and productivity.

Therefore, the Facility has adopted the following rules regarding the use of personal communication devices in the workplace during working hours.Employees should conduct personal business during meal breaks or other rest periods.

This includes the use of personal communication devices (including cell phones) for personal business (including personal phone conversations and.internet use for personal reasons) .Due to the availability of sensitive resident/client information, no cameras are to be allowed without prior approval from your Administrator.

Phones and other devices with cameras or recording capabilities are strictly prohibited in all work areas.Camera phones and other devices with photographic or recording capabilities may not be used in restrooms, locker rooms, or other private areas in the workplace.Unless properly authorized, employees must refrain from the use of any form of personal electronic communication devices during normal work hours.

Violation of this policy may result in discipline, up to and including termination.A review of a facility P&P titled, Social Media Guidelines, dated 11/1/23, the P&P indicated, .The guidelines apply to all Facility employees who participate in any form of personal social networking.Except when expressly authorized in writing for use for business purposes, social media activities are not permitted at work or while on Facility time.You may not disclose confidential.information.Employees may not personally attack, nor post any personal information about.residents.or make any statement or posting that violates the privacy of publicity rights of any other person.Failure to comply with these policies could lead to discipline, up to and including termination.

055201 08/15/2025

Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

During an interview on 8/15/25 at 11:15 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that it was her expectation that LNs checked the residents' orders for the type of enteral feeding formula and any flushes ordered before preparing the residents' tube feedings for administration.

The ADON stated that when the LNs prepared the enteral feedings, her expectation was that the enteral feeding bags were labeled with the date and time hung, that the LNs checked the resident's identifiers before starting the feeding, and reset the feeding pump with the correct feeding rate of infusion.

The ADON stated that the enteral feeding bags should be changed every 24 hours.

The ADON stated that the risk of not labeling the enteral feeding bags was that staff would not know when the feeding was started and when the feeding bag needed to be changed.

The ADON acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Enteral Tube Feeding via Syringe (Bolus), revised 11/18, the P&P indicated, .Purpose.The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally.General Guidelines.3.

Check the enteral nutrition label against the order before administration.

Check the following information.a.

Resident's name, ID, and room number; b.

Type of formula; c.

Date and time formula was prepared.g.

Rate of administration (mL/hour) .

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STOCKTON, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAK GROVE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.