Oak Grove Post Acute

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

repositioning a resident, Resident 4, so that she could change his wound dressings. LN 1 stated that whenever she asked CNA 2 to help with resident care, her coworker, CNA 1, always came along to help. LN 1 stated that she needed additional supplies to change Resident 4's dressings, so she told the CNAs to reposition Resident 4 on his side and she would return to change the dressing. LN 1 stated that the CNAs were in the room with Resident 4 with the door closed while she went to get additional supplies. LN 1 stated that when she returned to the room, she began to change Resident 4's dressing on his coccyx (tailbone;

the last bone at the base of the spine). LN 1 stated that the CNAs were in the room while she changed the dressing. LN 1 stated that after she finished changing the dressing, she noticed that she had forgotten her scissors, so she went to get them, then she went back to Resident 4's room and saw that CNA 2's cellphone was propped up and on Tik Tok live. LN 1 stated that they all left the room together and she stated that she said to CNA 2, I assumed your phone was not on, right? LN 1 stated that CNA 2 did not answer her question. LN 1 stated that she continued to change other residents' dressings because she thought that she had 24 hours to report the incident. LN 1 stated that she reported the incident the next morning at 6 a.m. LN 1 stated that she received an in-service and discovered that she should have reported the incident sooner. 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.

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Grove Post Acute

4545 Shelley Court 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 observation, interview, and record review, the facility failed to provide appropriate care and services with the use of enteral feeding (tube feeding, TF - the delivery of nutrients through a tube inserted directly into the stomach) for one resident (Resident 4) when Resident 4's tube feeding bag and tubing (containing nutrients to be delivered by a mechanical pump delivery system at a prescribed rate of flow) did not indicate the date and time it was put into use.This failure had the potential to produce bacterial growth

in the tube feeding solution resulting in an infection.A review of Resident 4's admission Record indicated that Resident 4 was admitted to the facility in 2025 with diagnoses which included Cerebral Infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), End Stage Renal Disease (failure of the kidneys to function normally), and Aphasia (loss of ability to produce or understand language). A review of Resident 4's Physician Order Summary, dated 6/5/25, indicated, .every shift Nepro [enteral formula] 75/ml [milliliters] @ 16 hours [infusion rate of flow]; on 2100 [9 PM], off 1300 [1 PM].During an interview and concurrent observation in Resident 4's room on 8/15/25 at 11:10 a.m. with Licensed Nurse (LN) 2, observed Resident 4's tube feeding bag did not have a label with

the date the feeding was started. LN 2 stated that the tube feeding bag should be labeled with the date and time started, resident's name, and feeding solution. LN 2 confirmed that Resident 4's tube feeding bag was not labeled. LN 2 stated that the risk of not labeling the tube feeding bag was that staff would not know when the tube feeding was started, what type of tube feeding it was, and when to change the bag. 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) .

Event ID:

Facility ID:

If continuation sheet