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).
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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)
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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
-
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
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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
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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
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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
-
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
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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.