Oak Grove Post Acute
4545 Shelley Court · Stockton, CA · 95207 · 2094770271
119 certified beds For profit - Limited Liability company Chain: Windsor
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.41 | 0.55–0.75 |
| Weekend hours / resident-day | 3.77 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 5 · $83,719 |
Inspection citations (136 in the current record)
-
Potential for harm · E April 22, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D April 9, 2026
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected April 28, 2026 · Resident Rights
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Potential for harm · D April 9, 2026
Reasonably accommodate the needs and preferences of each resident.
Corrected April 28, 2026 · Resident Rights
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Potential for harm · D April 9, 2026
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.
Corrected April 28, 2026 · Resident Rights
-
Potential for harm · D April 9, 2026
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 28, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 9, 2026
Assess the resident when there is a significant change in condition
Corrected April 28, 2026 · Resident Assessment and Care Planning
-
Potential for harm · E April 9, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 28, 2026 · Resident Assessment and Care Planning
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Potential for harm · E April 9, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 28, 2026 · Resident Assessment and Care Planning
-
Potential for harm · E April 9, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 28, 2026 · Quality of Life and Care
-
Potential for harm · D April 9, 2026
Provide activities to meet all resident's needs.
Corrected April 28, 2026 · Quality of Life and Care
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Potential for harm · D April 9, 2026
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 28, 2026 · Quality of Life and Care
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Potential for harm · D April 9, 2026
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected April 28, 2026 · Quality of Life and Care
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Potential for harm · D April 9, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 28, 2026 · Pharmacy Service
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Potential for harm · D April 9, 2026
Ensure that residents are free from significant medication errors.
Corrected April 28, 2026 · Pharmacy Service
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Potential for harm · E April 9, 2026
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.
Corrected April 28, 2026 · Pharmacy Service
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Potential for harm · F April 9, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 28, 2026 · Nutrition and Dietary
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Potential for harm · F April 9, 2026
Dispose of garbage and refuse properly.
Corrected April 28, 2026 · Nutrition and Dietary
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Potential for harm · E April 9, 2026
Provide and implement an infection prevention and control program.
Corrected April 28, 2026 · Infection Control
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Potential for harm · D April 9, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected April 28, 2026 · Infection Control
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Potential for harm · D April 9, 2026
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.
Corrected April 28, 2026 · Infection Control
-
Potential for harm · D April 9, 2026 · found via complaint
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected April 28, 2026 · Resident Rights
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Potential for harm · D March 11, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 13, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 11, 2026 · found via complaint
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.
Corrected March 13, 2026 · Nursing and Physician Services
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Potential for harm · D March 4, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 6, 2026 · Infection Control
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Potential for harm · E February 20, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 23, 2026 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 20, 2024 | Fine | $4,938 |
| February 12, 2024 | Fine | $7,527 |
| January 22, 2024 | Fine | $19,107 |
| December 26, 2023 | Fine | $8,711 |
| June 28, 2023 | Fine | $43,436 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055201 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.