Oak Grove Post Acute

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

episodes of PTSD [ Post-traumatic stress disorder is a mental health condition that's caused by an extremely stressful or terrifying event] triggered by altercations.Interventions.Resident [Resident 2] to have 1:1 [one staff member supervises one resident at a time] staff support as indicated. The review indicated that Resident [Resident 2] was involved in multiple (11 in total) Resident-to-Resident altercations according to the documentation of dates in Resident 2's care plan.Review of Resident 2's medical record titled, Care Plan Report, created on 8/21/25, indicated, .RESIDENT-TO-RESIDENT POSSIBLE ALTERCATION.Goal.resident will have no episodes of resident-to-resident altercation x 30 days.Continue 1:1 supervision.Review of the facility record titled, ONE-ON-ONE CARE ACKNOWLEDGEMENT FORM, dated 8/25, indicated, .purpose of this form is to ensure that all staff members understand the expectations and responsibilities of providing one-on-one [1:1] care to residents.Expectations for One-on-One Care.Confirm who will relieve you for lunch and breaks before starting your assignment. Never leave the resident unattended for any reason. If relief does not arrive on time, remain with the resident.Keep the resident within your direct line of sight at all times.Consistent adherence to these expectations is required to ensure the safety and well-being of all residents.Review of the facility's policy and procedure titled, Abuse Prohibition, revised on 10/25/24, indicated, .Policy; .Prevention of occurrences.Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse.for all patients.Process: 6.b. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting.The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected.

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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

11/20/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

9/18/25, at 3:51 PM, Licensed Nurse (LN) 1 stated Resident 2 had been on one-on-one supervision since June 2025 for being involved in multiple altercations with other residents in the facility. LN 1 stated staff who were assigned to provide one-on-one supervision were accountable for staying with Resident 2, not leaving him unattended, and documenting every 15 minutes about his status. LN 1 added consistency of documentation was crucial element to ensure Resident 2 was supervised properly. LN 1 further stated not consistently documenting as it was instructed in every 15-minute safety checks, might indicate Resident 2 was not always kept within a direct line of sight. During an interview on 9/18/25, at 4:24 PM, CNA 4 stated

she was assigned to provide one-on-one for Resident 2 several times. CNA 4 stated at the beginning of her shift prior to covering for the previous staff, she would review every 15-minute safety checks to ensure documentation was completed. CNA 4 stated staff who provided one-on-one supervision should document resident status every 15 minutes on the safety checks form. CNA 4 further stated if documentation was not filled out properly, it might state that Resident 2 was left unattended and not always supervised.During a concurrent interview and record review on 9/19/25, at 11:25 AM, in the conference room, with the Administrator (ADMN), Resident 2's record titled, Q 15 MINUTE SAFETY CHECKS for the dates of 8/18/25, 8/20/25, and 8/25/25 were reviewed. The ADMN confirmed that staff did not follow the facility provided document guidelines. Review of Resident 2's every 15-minute safety check for 8/18/25, 8/20/25, and 8/25/25 revealed that the records were not consistently documented. The ADMN stated her expectation from staff was to complete every 15-minute safety checks form consistently and properly. Review of the facility provided ONE-ON-ONE CARE ACKNOWLEDGEMENT FORM, dated 8/25, the record indicated, .Purpose.Proper supervision and adherence to these guidelines are critical in maintaining resident safety and preventing resident-to-resident altercations.Expectation for One-on-One Care.Observe and document changes in the resident's mood or behavior.Report changes immediately to the charge nurse.

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