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Complaint Investigation

Oak Grove Post Acute

Inspection Date: November 26, 2025
Total Violations 3
Facility ID 055201
Location STOCKTON, CA
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Inspection Findings

F-Tag F0603

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

at 5:10 p.m. with Licensed Nurse (LN) 1, LN 1 stated, if staff prohibited a resident from leaving their room

the problem would be seclusion, and that would be a form of abuse. LN 1 stated, if she was placed in a room and not allowed to leave, she would feel nervous, scared, and confused, and would wonder why she was not allowed to leave. LN 1 further stated, if a resident was not allowed to leave their room, it could escalate unwanted behaviors and could potentially lead to physical injury if the resident tried to get out.Review of the facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, dated 2/23/21, indicated, .HealthCare Centers prohibit abuse.This includes.Involuntary seclusion. Abuse is defined as the willful infliction of injury, unreasonable confinement.Abuse also includes the deprivation [the state of lacking or being denied something that is needed or desired by an individual] [by] a caretaker. that are necessary to attain or maintain physical, mental or psychosocial well-being.Review of a facility document titled, Stockton Nursing Center 5-Day Incident Summary Report, dated 9/22/25, indicated, .Investigation Findings.a fellow CNA confirmed [CNA 1] blocked the resident from leaving her room.[CNA 1] admitted to making the statement and acknowledged preventing the resident from leaving.Conclusion.The facility determined the incident constituted resident seclusion.

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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

11/26/2025

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)

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F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Services-a federal agency that provides health coverage to millions of people through programs like Medicare, Medicaid] Module 2), indicated, Reporting Procedures.All nursing home staff are legally mandated reporters and must report abuse or suspected abuse immediately to the administrator after ensuring the elder's safety.Immediate Reporting: Report at the time you notice something.Chain of command: While you can inform supervisors, your legal responsibility is to ensure the administrator is notified directly.

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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

11/26/2025

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)

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F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

of the facility's policy and procedure (P&P) titled, Wandering and Elopement. Indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.Review of an online article from California Advocates for Nursing Home Reform (CANHR-a statewide nonprofit advocacy organization) titled, NURSING HOME CARE STANDARDS, dated 10/24/22, indicated, .The federal Nursing Home Reform Act of 1987 requires them [nursing homes] to help each resident attain or maintain the highest practicable physical, mental and psychosocial well-being. Safety and Preventing Accidents.This section addresses standards related to prevention of accidents and to a nursing home's duty to provide adequate supervision to keep residents safe. https://canhr.org/nursing-home-care-standards/

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📋 Inspection Summary

OAK GROVE POST ACUTE in STOCKTON, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

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

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.
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