OAK GROVE POST ACUTE

CMS abuse icon · CCN 055201 · 4545 SHELLEY COURT OPCO, LLC · For profit - Limited Liability company · WINDSOR chain · 119 certified beds · San Joaquin · CA


OAK GROVE POST ACUTE is a 119-bed nursing home in STOCKTON, California. CMS has certified it for Medicare and Medicaid since 1967-01-01. It averages 113.8 residents a day.

What harm was found in the violations cited at OAK GROVE POST ACUTE?

CMS lists 128 health-inspection deficiencies for OAK GROVE POST ACUTE since 2022-12-09, 111 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-04-22.

Survey dateTagDeficiencySeverity
2026-04-22F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E
2026-04-09F0812, F0814Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Dispose of garbage and refuse properly.F
2026-04-09F0656, F0658, F0677, F0761, F0880Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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. / Provide and implement an infection prevention and control program.E
2026-04-09F0552, F0558, F0561, F0584, F0600, F0637, F0679, F0695, F0698, F0755, F0760, F0883, F0887Ensure that residents are fully informed and understand their health status, care and treatments. / Reasonably accommodate the needs and preferences of each resident. / Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Assess the resident when there is a significant change in condition / Provide activities to meet all resident's needs. / Provide safe and appropriate respiratory care for a resident when needed. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure that residents are free from significant medication errors. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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.D
2026-03-11F0609, F0726Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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.D
2026-03-04F0880Provide and implement an infection prevention and control program.D
2026-02-20F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.E
2026-02-11F0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.F
2026-02-11F0677, F0687Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate foot care.D
2026-01-16F0814Dispose of garbage and refuse properly.F
2026-01-16F0761Ensure 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.D
2025-12-12F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.E
2025-12-12F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D
2025-12-08F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2025-12-03F0656, F0842Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2025-12-02F0697Provide safe, appropriate pain management for a resident who requires such services.D
2025-11-26F0603, F0609, F0689Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-11-20F0600, F0842Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2025-08-21F0686, F0742Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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.D
2025-08-15F0583, F0693Keep residents' personal and medical records private and confidential. / 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.D
2025-08-01F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G
2025-07-22F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-07-16F0692Provide enough food/fluids to maintain a resident's health.D
2025-06-24F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-05-22F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E
2025-05-19F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E
2025-04-14F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-03-13F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E
2025-03-13F0610Respond appropriately to all alleged violations.D
2025-02-13F0603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).D
2025-01-06F0584, F0656Honor 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. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D
2024-12-12F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2024-12-12F0585, F0600, F0692, F0755, F0759, F0761, F0880, F0887, F0919, F0925Honor 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide enough food/fluids to maintain a resident's health. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure medication error rates are not 5 percent or greater. / 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. / Provide and implement an infection prevention and control program. / 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. / Make sure that a working call system is available in each resident's bathroom and bathing area. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.E
2024-12-12F0550, F0583, F0584, F0609, F0656, F0677, F0684, F0686, F0688, F0689, F0695, F0697, F0742, F0758, F0849, F0883Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Keep residents' personal and medical records private and confidential. / 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide safe and appropriate respiratory care for a resident when needed. / Provide safe, appropriate pain management for a resident who requires such services. / 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. / 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. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations.D
2024-12-02F0880Provide and implement an infection prevention and control program.D
2024-11-22F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2024-10-23F0880Provide and implement an infection prevention and control program.E
2024-10-23F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D
2024-08-14F0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.E
2024-07-21F0755, F0825Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Provide or get specialized rehabilitative services as required for a resident.D
2024-07-02F0688Provide 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.E
2024-06-10F0688Provide 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.D
2024-01-29F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D
2023-12-28F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D
2023-12-19F0880, F0882, F0921Provide and implement an infection prevention and control program. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.D
2023-11-18F0908Keep all essential equipment working safely.D
2023-11-16F0727Have 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.F
2023-11-15F0573, F0684Let each resident or the resident's legal representative access or purchase copies of all the resident's records. / Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2023-09-25F0641, F0689Ensure each resident receives an accurate assessment. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2023-09-18F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2023-08-22F0677, F0836Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.E
2023-08-09F0880Provide and implement an infection prevention and control program.D
2023-08-02F0803, F0806Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.D
2023-08-01F0584Honor 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.D
2022-12-09F0880, F0881Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use.F
2022-12-09F0657, F0688, F0689, F0692, F0693, F0695, F0758, F0812, F0919Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / 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. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Make sure that a working call system is available in each resident's bathroom and bathing area.E
2022-12-09F0550, F0658, F0684, F0755, F0761Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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.D
2022-12-09F0838Conduct 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.C

Why was OAK GROVE POST ACUTE fined 4 times?

DateTypeAmount
2024-02-20Fine$4,938
2024-02-12Fine$7,527
2024-01-22Fine$19,107
2023-12-26Fine$8,711

How is OAK GROVE POST ACUTE staffed relative to the CA average?

MeasureThis facilityCA average
Total nurse staffing hours per resident per day3.930584.51570
Total nursing staff turnover (%)48.436.7
Average number of residents per day113.887.9

Who owns OAK GROVE POST ACUTE, and what chain is it in?

OAK GROVE POST ACUTE is registered with CMS as For profit - Limited Liability company, operates under the legal business name 4545 SHELLEY COURT OPCO, LLC and belongs to the WINDSOR chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTSAPPHIRE OPERATIONS, LLCsince 09/01/2024
5% OR GREATER INDIRECT OWNERSHIP INTERESTNEWGEN LLC, ROBIN, AARON, TRESS, AVROHOMsince 09/01/2024
OPERATIONAL/MANAGERIAL CONTROLGLAVAN-MARTINEZ, MARTHA, JIMENEZ, RAFILEIRY, VERMA, ATULsince 01/13/2025
ADP OF THE SNFNEWGEN ADMINISTRATIVE SERVICES, LLC, GLAVAN-MARTINEZ, MARTHA, JIMENEZ, RAFILEIRY, VERMA, ATULsince 01/13/2025

Were you or a family member harmed at OAK GROVE POST ACUTE?