Oak Grove Post Acute
4545 Shelley Court, Stockton, CA 95207
Oak Grove Post Acute is a nursing home in Stockton, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (209) 477-0271
- Last standard health inspection
- April 9, 2026 (7 months ago)
- Certified beds
- 119
- Residents per day, on average
- 108.8
- Ownership type
- For profit - Limited Liability company
- Legal business name
- 4545 Shelley Court Opco, LLC
- Chain
- Windsor
- Takes part in
- Medicare and Medicaid
More health citations than the California average (124 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of October 8, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
1 citation
Health inspection on August 21, 2026
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS has cited this home for F0686 4 times since 2024.
3 citations
Health inspection on August 13, 2026
CMS lists this as a complaint inspection.
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on September 3, 2026.
CMS has cited this home for F0921 2 times since 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on September 3, 2026.
CMS has cited this home for F0698 2 times since 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 3, 2026.
CMS has cited this home for F0842 3 times since 2025.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
1 citation
Health inspection on July 9, 2026
CMS lists this as a complaint inspection.
Citation F0844. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
1 citation
Health inspection on April 22, 2026
CMS lists this as a complaint inspection.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 23, 2026.
CMS has cited this home for F0689 7 times since 2022.
20 citations
Health inspection on April 9, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0812 3 times since 2022.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0814 2 times since 2026.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0656 6 times since 2024.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0658 2 times since 2022.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0677 3 times since 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0761 4 times since 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0880 7 times since 2022.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on April 28, 2026.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 28, 2026.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on April 28, 2026.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0584 3 times since 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0600 8 times since 2024.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on April 28, 2026.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 28, 2026.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0695 3 times since 2022.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on April 28, 2026.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0755 4 times since 2022.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 28, 2026.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0883 2 times since 2024.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0887 2 times since 2024.
18 citations
Fire safety inspection on April 9, 2026
CMS lists this as a standard inspection.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0918 3 times since 2022.
Citation K0919. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on April 20, 2026.
CMS has cited this home for K0919 2 times since 2024.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 17, 2026.
CMS has cited this home for K0293 3 times since 2022.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on April 16, 2026.
Citation K0342. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on April 15, 2026.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 16, 2026.
CMS has cited this home for K0363 2 times since 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on April 20, 2026.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 15, 2026.
CMS has cited this home for K0920 3 times since 2024.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on April 17, 2026.
CMS has cited this home for K0211 2 times since 2024.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on April 17, 2026.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 20, 2026.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 22, 2026.
CMS has cited this home for K0324 2 times since 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0353 3 times since 2022.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 20, 2026.
CMS has cited this home for K0355 3 times since 2022.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0521 3 times since 2024.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on April 15, 2026.
CMS has cited this home for K0711 2 times since 2025.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 20, 2026.
CMS has cited this home for K0741 2 times since 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 15, 2026.
1 citation
Fire safety inspection on March 26, 2026
CMS lists this as a complaint inspection.
Citation K0521. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 27, 2026.
CMS update of March 25, 2026
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
2 citations
Health inspection on March 11, 2026
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on March 13, 2026.
CMS has cited this home for F0609 3 times since 2024.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 13, 2026.
1 citation
Health inspection on March 4, 2026
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 6, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Name
CMS lists a new name for this home. It was STOCKTON NURSING CENTER.
1 citation
Health inspection on February 20, 2026
CMS lists this as a complaint inspection.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 23, 2026.
CMS has cited this home for F0684 5 times since 2022.
3 citations
Health inspection on February 11, 2026
CMS lists this as a complaint inspection.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on February 12, 2026.
CMS has cited this home for F0925 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on February 12, 2026.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on February 12, 2026.
2 citations
Health inspection on January 16, 2026
CMS lists this as a complaint inspection.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on January 19, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 19, 2026.
2 citations
Health inspection on December 12, 2025
CMS lists this as a complaint inspection.
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 16, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 16, 2025.
1 citation
Health inspection on December 8, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 12, 2025.
2 citations
Health inspection on December 3, 2025
CMS lists this as a complaint inspection.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 5, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 5, 2025.
1 citation
Health inspection on December 2, 2025
CMS lists this as a complaint inspection.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on December 5, 2025.
CMS has cited this home for F0697 2 times since 2024.
3 citations
Health inspection on November 26, 2025
CMS lists this as a complaint inspection.
Citation F0603. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS lists it as corrected on December 2, 2025.
CMS has cited this home for F0603 2 times since 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 2, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 2, 2025.
2 citations
Health inspection on November 20, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on November 23, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on November 23, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
1 citation
Fire safety inspection on November 19, 2025
CMS lists this as a complaint inspection.
Citation K0711. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on November 20, 2025.
2 citations
Health inspection on August 21, 2025
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 22, 2025.
Citation F0742. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 22, 2025.
CMS has cited this home for F0742 2 times since 2024.
2 citations
Health inspection on August 15, 2025
CMS lists this as a complaint inspection.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on August 18, 2025.
CMS has cited this home for F0583 2 times since 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 18, 2025.
CMS has cited this home for F0693 2 times since 2022.
1 citation
Health inspection on August 1, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 4, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.7 to 3.3 hours per resident per day.
1 citation
Health inspection on July 22, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 24, 2025.
1 citation
Health inspection on July 16, 2025
CMS lists this as a complaint inspection.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on August 27, 2025.
CMS has cited this home for F0692 3 times since 2022.
1 citation
Health inspection on June 24, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 24, 2025.
1 citation
Health inspection on May 22, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 14, 2025.
1 citation
Health inspection on May 19, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 20, 2025.
1 citation
Health inspection on April 14, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 24, 2025.
2 citations
Health inspection on March 13, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on March 17, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on March 17, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on February 13, 2025
CMS lists this as a complaint inspection.
Citation F0603. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS lists it as corrected on March 7, 2025.
2 citations
Health inspection on January 6, 2025
CMS lists this as a complaint inspection.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 8, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 8, 2025.
27 citations
Health inspection on December 12, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 3, 2025.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 3, 2025.
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on January 3, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 3, 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on January 3, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 3, 2025.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on January 3, 2025.
CMS has cited this home for F0919 2 times since 2022.
Citation F0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on January 3, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 3, 2025.
CMS has cited this home for F0550 4 times since 2022.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on January 3, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on January 3, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 3, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on January 3, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 3, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 3, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
CMS has cited this home for F0688 4 times since 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 3, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on January 3, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on January 3, 2025.
Citation F0742. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
CMS has cited this home for F0758 2 times since 2022.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 3, 2025.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on January 3, 2025.
12 citations
Fire safety inspection on December 12, 2024
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 24, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 24, 2024.
CMS has cited this home for K0712 2 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 24, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 24, 2024.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on December 24, 2024.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on December 24, 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 24, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 24, 2024.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on December 24, 2024.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on December 27, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 27, 2024.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 24, 2024.
1 citation
Health inspection on December 2, 2024
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 20, 2024.
1 citation
Health inspection on November 22, 2024
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 10, 2024.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
2 citations
Health inspection on October 23, 2024
CMS lists this as a complaint inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 8, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 8, 2024.
CMS update of September 26, 2024
Fine
CMS changed the fine from February 20, 2024 from $4,893 to $4,938.
CMS update of August 29, 2024
Fine
CMS changed the fine from December 26, 2023 from $8,631 to $8,711.
1 citation
Health inspection on August 14, 2024
CMS lists this as a complaint inspection.
Citation F0559. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on September 13, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
2 citations
Health inspection on July 21, 2024
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 12, 2024.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on September 12, 2024.
4 citations
Fire safety inspection on July 18, 2024
CMS lists this as a complaint inspection.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 5, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on August 5, 2024.
Citation E0015. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on August 5, 2024.
Citation K0211. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on August 5, 2024.
1 citation
Health inspection on July 2, 2024
CMS lists this as a complaint inspection.
Citation F0688. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 16, 2024.
1 citation
Health inspection on June 10, 2024
CMS lists this as a complaint inspection.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 11, 2024.
Fine
February 20, 2024 (2 years ago)
CMS fine of $4,938 on February 20, 2024.
Fine
February 12, 2024 (2 years ago)
CMS fine of $7,527 on February 12, 2024.
CMS update of January 31, 2024
Fine
CMS changed the fine from June 28, 2023 from $66,825 to $43,436.
1 citation
Health inspection on January 29, 2024
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on February 2, 2024.
Fine
January 22, 2024 (2 years ago)
CMS fine of $19,107 on January 22, 2024.
1 citation
Health inspection on December 28, 2023
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on February 14, 2024.
Fine
December 26, 2023 (2 years ago)
CMS fine of $8,711 on December 26, 2023.
CMS update of December 21, 2023
CMS abuse icon
CMS removed its abuse icon from this home.
3 citations
Health inspection on December 19, 2023
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 14, 2024.
Citation F0882. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on December 20, 2023.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on January 11, 2024.
1 citation
Health inspection on November 18, 2023
CMS lists this as a complaint inspection.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on December 5, 2023.
1 citation
Health inspection on November 16, 2023
CMS lists this as a complaint inspection.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on February 14, 2024.
2 citations
Health inspection on November 15, 2023
CMS lists this as a complaint inspection.
Citation F0573. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
CMS lists it as corrected on November 27, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 27, 2023.
17 citations
Health inspection on December 9, 2022
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 9, 2023.
Citation F0881. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on January 9, 2023.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on January 9, 2023.
Citation F0688. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 9, 2023.
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on January 9, 2023.
Citation F0693. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2023.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on January 9, 2023.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 9, 2023.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on January 9, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 9, 2023.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on January 9, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 9, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 9, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2023.
Citation F0838. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2023.
11 citations
Fire safety inspection on December 9, 2022
CMS lists this as a standard inspection.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on January 9, 2023.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 9, 2023.
Citation E0006. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on January 9, 2023.
Citation E0037. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on January 9, 2023.
Citation E0039. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on January 9, 2023.
Citation E0041. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on January 9, 2023.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 9, 2023.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on January 9, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 9, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on January 9, 2023.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 9, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SAPPHIRE OPERATIONS, LLC5% or greater direct ownership interest · 100% · since 09/01/2024
- GLAVAN-MARTINEZ, MARTHAOperational/managerial control · not applicable · since 10/21/2013
- JIMENEZ, RAFILEIRYOperational/managerial control · not applicable · since 01/13/2025
- VERMA, ATULOperational/managerial control · not applicable · since 10/14/2024
Questions
When was Oak Grove Post Acute last inspected?
CMS lists April 9, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Oak Grove Post Acute have?
CMS lists 124 health citations since December 9, 2022. CMS also calls these deficiencies.
Has Oak Grove Post Acute been fined?
CMS lists 4 fines in the past three years, $40,283 in total.
What is the CMS star rating of Oak Grove Post Acute?
Its CMS overall star rating is 1 of 5.
Is Oak Grove Post Acute a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.