Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
17’22
8’23
37’24
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35’26
124 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 21, 2026 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Aug 13, 2026 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Aug 13, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Aug 13, 2026 | F · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Jul 9, 2026 | C · minimal | Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Complaint |
| Apr 22, 2026 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 9, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Apr 9, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Apr 9, 2026 | D · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Complaint |
| Apr 9, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Apr 9, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Apr 9, 2026 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Apr 9, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 9, 2026 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Apr 9, 2026 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Apr 9, 2026 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Apr 9, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 9, 2026 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Apr 9, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 9, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Apr 9, 2026 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Apr 9, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 9, 2026 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Apr 9, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 9, 2026 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Apr 9, 2026 | D · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Mar 11, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 11, 2026 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Mar 4, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 20, 2026 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 11, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Feb 11, 2026 | D · potential | Provide appropriate foot care. | Complaint |
| Feb 11, 2026 | F · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Complaint |
| Jan 16, 2026 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| Jan 16, 2026 | F · potential | Dispose of garbage and refuse properly. | Complaint |
| Dec 12, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 12, 2025 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Dec 8, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 3, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 3, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Dec 2, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Nov 26, 2025 | D · potential | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Complaint |
| Nov 26, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Nov 26, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 20, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 20, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Aug 21, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Aug 21, 2025 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Complaint |
| Aug 15, 2025 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| Aug 15, 2025 | D · potential | 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. | Complaint |
| Aug 1, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 22, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 16, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jun 24, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 22, 2025 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 19, 2025 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 14, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 13, 2025 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 13, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Feb 13, 2025 | D · potential | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Complaint |
| Jan 6, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Jan 6, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 12, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Dec 12, 2024 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Dec 12, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Dec 12, 2024 | E · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| Dec 12, 2024 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 12, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Dec 12, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 12, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Dec 12, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 12, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Dec 12, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Dec 12, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Dec 12, 2024 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Dec 12, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Dec 12, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Dec 12, 2024 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Routine |
| Dec 12, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 12, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Dec 12, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Dec 12, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Dec 12, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 12, 2024 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Dec 12, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 12, 2024 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Dec 12, 2024 | E · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Dec 12, 2024 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Dec 12, 2024 | E · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Dec 2, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Nov 22, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Oct 23, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 23, 2024 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 14, 2024 | E · potential | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Complaint |
| Jul 21, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jul 21, 2024 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Complaint |
| Jul 2, 2024 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| Jun 10, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| Jan 29, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Dec 28, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Dec 19, 2023 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Dec 19, 2023 | D · potential | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Complaint |
| Dec 19, 2023 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Nov 18, 2023 | D · potential | Keep all essential equipment working safely. | Complaint |
| Nov 16, 2023 | F · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Complaint |
| Nov 15, 2023 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| Nov 15, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Dec 9, 2022 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Dec 9, 2022 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Dec 9, 2022 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Dec 9, 2022 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 9, 2022 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Dec 9, 2022 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Dec 9, 2022 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Dec 9, 2022 | E · potential | 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. | Routine |
| Dec 9, 2022 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Dec 9, 2022 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 9, 2022 | E · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Dec 9, 2022 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Dec 9, 2022 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 9, 2022 | C · minimal | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Routine |
| Dec 9, 2022 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 9, 2022 | F · potential | Implement a program that monitors antibiotic use. | Routine |
| Dec 9, 2022 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Oak Grove Post Acute
4545 Shelley Court, Stockton, CA 95207 · (209) 477-0271
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055201
- Certified beds
- 119
- Legal owner
- 4545 Shelley Court Opco, LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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