Oak Grove Post Acute
OAK GROVE POST ACUTE in STOCKTON, CA — inspection on November 20, 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
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Grove Post Acute
4545 Shelley Court Stockton, CA 95207
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: