Oak Grove Post Acute
4545 Shelley Court, Stockton, CA 95207Map
Medicare/Medicaid certified119 certified beds~113 residents/dayFor profit - Limited Liability company
What the abuse icon means moreless
CMS flags a facility with its abuse icon when inspectors cited it for abuse that harmed a resident within the past year, or for abuse that could have harmed a resident in each of the last two years. CMS shows this same icon on its own Care Compare site, and caps the facility's ratings while it's flagged. The icon is removed when newer inspections come back clean. The deficiency list below will contain the underlying citations — read them.
What to do with this: read the abuse-related citations below, and ask the facility directly what happened and what changed. Verify the current status at medicare.gov/care-compare.
What Special Focus status means moreless
CMS keeps a short national list of nursing homes with the most persistent serious problems — the Special Focus Facility (SFF) program. SFF homes get inspected about twice as often and must improve or face termination from Medicare/Medicaid. 'SFF candidate' means the home qualifies for the list but isn't on it yet (the list has limited slots per state). Some SFF homes do graduate and improve; the designation means CMS is watching closely right now.
What to do with this: ask the administrator where the home is in the SFF process and what the improvement plan is. Verify status at medicare.gov/care-compare.
Last standard health inspection: April 9, 2026
Oak Grove Post Acute is a 119-bed for-profit, LLC-owned nursing home in Stockton, San Joaquin County, California, serving an average of 113 residents per day. As of CMS data processed June 1, 2026, its overall rating is 1 of 5 stars.
CMS star ratings
CMS scores every nursing home 1–5 stars overall, built from three sub-ratings. moreless
Medicare inspects and measures every certified nursing home, then rolls the results into a 1–5 star overall rating. It combines three parts: health inspections, staffing, and quality measures. Five stars means much better than average — it does not mean perfect. One star means much worse than average — it does not mean every shift is bad. Stars are a screening tool, not a verdict. They can lag reality by months, and they can't see things like how kind the aides are or how the building smells at 7am.
What to do with this: use stars to build a shortlist, then visit in person. Nothing on this site replaces walking the halls.
Health-inspection stars are graded on a curve within each state — never compare stars across state lines. moreless
CMS sets health-inspection star cutoffs separately for each state: roughly the top 10% of homes in a state get 5 stars, the bottom 20% get 1 star, no matter how the state compares to others. That means a 4-star home in one state and a 4-star home in another state may have very different inspection records. The stars tell you how a home compares to its neighbors, not to the whole country. That's why this site shows your state's median next to each star rating — and never a national star comparison.
What to do with this: compare stars only between homes in the same state. To compare across states, use staffing hours — those are real numbers, not curves.
Not all three sub-ratings are equally hard to game: inspections are the most objective, quality measures the least. moreless
The three sub-ratings come from different sources. Health inspections are done on-site by trained state surveyors who show up mostly unannounced — the most objective signal. Staffing comes from payroll records that facilities must submit and CMS audits — quite reliable. Quality measures are partly self-reported by the facility from its own resident assessments — useful, but the facility grades some of its own homework.
What to do with this: when sub-ratings disagree, weigh the inspection star most and the quality-measure star least.
Staffing
Reported hours per resident per day, from payroll records. Hours, unlike stars, can be compared across states.
Hours per resident per day: total staff hours worked, divided by the number of residents. moreless
If a home reports 3.5 total nursing hours per resident per day, that's all nursing staff time across 24 hours — roughly one caregiver-hour every 7 hours per resident, spread across day, evening, and night shifts. On a real floor it decides whether call lights get answered in 5 minutes or 25, whether someone has time to help with dinner, and whether night shift is one aide for a hall or two. Unlike star ratings, hours are actual numbers, so they CAN be compared across state lines.
What to do with this: compare a home's hours to the state and national medians shown, and ask the facility how the hours split across day, evening, and night shifts.
RN (registered nurse) hours
LPN (licensed practical nurse) hours
Nurse aide hours
Total nursing hours
CMS also adjusts these numbers for how sick each home’s residents are — a home with sicker residents needs more staff for the same star. This home’s case-mix-adjusted total: 4.67 (US median, adjusted: 3.78).
CMS also adjusts staffing numbers for how sick each home's residents are. moreless
A home full of short-term rehab patients needs different staffing than a home caring for people with advanced dementia or ventilators. Case-mix adjustment estimates how many hours a home's particular residents need, then scales the reported hours so homes can be compared fairly. A home with sicker residents needs more staff for the same star. This page shows reported (raw payroll) numbers and compares them only to other reported numbers — like with like.
What to do with this: if a home's reported hours look low, check whether its residents may simply need less care — and ask the facility directly.
Staff turnover
Total nursing staff turnover: 46.6% · CA median: 36.5% · RN turnover: 64.3% (CA median: 40%)
The share of nursing staff who left within the year. Lower is steadier. moreless
Total nursing staff turnover is the percentage of the home's nurses and aides who stopped working there during the year. Around half of nursing-home staff leaving annually is sadly common in this industry. High turnover means residents are cared for by people who don't know them — which matters enormously for dementia care, pain management, and noticing the small changes that catch problems early. Low turnover usually means staff are treated well enough to stay.
What to do with this: when you visit, ask aides how long they've worked there. Long-tenured aides are the best sign a building has.
Inspections & deficiencies
The last 3 inspection cycles, from CMS’s federal health-survey file. State-only citations and fire-safety surveys are not included — an empty list means nothing federal is in this file, not that nothing ever happened.
Each deficiency gets a letter A–L: how severe it was × how widespread it was. moreless
Surveyors grade every deficiency on a grid. Severity runs from 'potential for minimal harm' up to 'immediate jeopardy to resident health or safety.' Scope runs from isolated (one or a few residents) to pattern to widespread. A and B are paperwork-level; D–F caused no actual harm but had the potential; G–I caused actual harm; J, K, and L mean immediate jeopardy — the most serious finding a surveyor can make. Most citations nationally are D–E.
What to do with this: scan for G or higher. One J/K/L tells you more than ten D's.
Standard surveys are routine; complaint surveys happen because someone reported a problem. moreless
A standard survey is the routine top-to-bottom inspection every home gets on a recurring cycle. A complaint survey happens because a resident, family member, or staff member reported something to the state — surveyors come specifically to investigate it. Infection-control surveys focus on practices like hand hygiene and isolation procedures. A deficiency found during a complaint survey means someone cared enough to report it and a surveyor confirmed enough to cite it.
What to do with this: note which deficiencies came from complaints — they show you what residents and families actually experienced.
The F-number on each deficiency is CMS's code for which federal requirement was violated. moreless
Every federal nursing-home requirement has a tag number. F0686, for example, is the pressure-ulcer requirement; F0600 is freedom from abuse. The tag tells you exactly which rule was broken, and the description next to it is CMS's own plain-language summary of that rule. The same tag appearing across multiple inspections is a pattern worth noticing.
What to do with this: if the same tag repeats across surveys, ask the facility what changed since the last citation.
This data shows federal health surveys only — state-only citations and fire-safety surveys aren't included. moreless
CMS's public deficiency file contains federal health-survey citations. It does not include citations issued under state-only rules, fire-safety (Life Safety Code) surveys, or anything older than three inspection cycles. A facility with no rows here may still have state citations or fire-safety findings. 'No deficiencies in this file' never means 'no violations ever.'
What to do with this: for the full picture, check your state health department's site and medicare.gov/care-compare, which shows fire-safety results separately.
136 deficiencies across the last 3 inspection cycles, in CMS’s federal health-survey file:
- Quality of Life and Care: 46
- Resident Rights: 19
- Freedom from Abuse, Neglect, and Exploitation: 14
- Infection Control: 14
- Resident Assessment and Care Planning: 13
- Pharmacy Service: 12
- Nutrition and Dietary: 7
- Environmental: 6
- Administration: 3
- Nursing and Physician Services: 2
April 22, 2026Complaint surveyTag F0689E — no actual harm, potential for more than minimal harm, pattern
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
April 9, 2026Standard surveyTag F0552D — no actual harm, potential for more than minimal harm, isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0558D — no actual harm, potential for more than minimal harm, isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard + Complaint surveyTag F0561D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0600D — no actual harm, potential for more than minimal harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0637D — no actual harm, potential for more than minimal harm, isolated
Assess the resident when there is a significant change in condition
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0656E — no actual harm, potential for more than minimal harm, pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0658E — no actual harm, potential for more than minimal harm, pattern
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0677E — no actual harm, potential for more than minimal harm, pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 28, 2026
Show 126 more deficiencies
April 9, 2026Standard surveyTag F0679D — no actual harm, potential for more than minimal harm, isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0695D — no actual harm, potential for more than minimal harm, isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0698D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0755D — no actual harm, potential for more than minimal harm, isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0760D — no actual harm, potential for more than minimal harm, isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0761E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0812F — no actual harm, potential for more than minimal harm, widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0814F — no actual harm, potential for more than minimal harm, widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0880E — no actual harm, potential for more than minimal harm, pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0883D — no actual harm, potential for more than minimal harm, isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected April 28, 2026
April 9, 2026Standard surveyTag F0887D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected April 28, 2026
March 11, 2026Complaint surveyTag F0609D — no actual harm, potential for more than minimal harm, isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 13, 2026
March 11, 2026Complaint surveyTag F0726D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected March 13, 2026
March 4, 2026Complaint surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 6, 2026
February 20, 2026Complaint surveyTag F0684E — no actual harm, potential for more than minimal harm, pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected February 23, 2026
February 11, 2026Complaint surveyTag F0677D — no actual harm, potential for more than minimal harm, isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected February 12, 2026
February 11, 2026Complaint surveyTag F0687D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate foot care.
Deficient, Provider has date of correction · corrected February 12, 2026
February 11, 2026Complaint surveyTag F0925F — no actual harm, potential for more than minimal harm, widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected February 12, 2026
January 16, 2026Complaint surveyTag F0761D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 19, 2026
January 16, 2026Complaint surveyTag F0814F — no actual harm, potential for more than minimal harm, widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected January 19, 2026
December 12, 2025Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected December 16, 2025
December 12, 2025Complaint surveyTag F0686E — no actual harm, potential for more than minimal harm, pattern
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected December 16, 2025
December 8, 2025Complaint surveyTag F0600D — no actual harm, potential for more than minimal harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected December 12, 2025
December 3, 2025Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected December 5, 2025
December 3, 2025Complaint surveyTag F0842D — no actual harm, potential for more than minimal harm, isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected December 5, 2025
December 2, 2025Complaint surveyTag F0697D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected December 5, 2025
November 26, 2025Complaint surveyTag F0603D — no actual harm, potential for more than minimal harm, isolated
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Deficient, Provider has date of correction · corrected December 2, 2025
November 26, 2025Complaint surveyTag F0609D — no actual harm, potential for more than minimal harm, isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected December 2, 2025
November 26, 2025Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected December 2, 2025
November 20, 2025Complaint surveyTag F0600D — no actual harm, potential for more than minimal harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected November 23, 2025
November 20, 2025Complaint surveyTag F0842D — no actual harm, potential for more than minimal harm, isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected November 23, 2025
August 21, 2025Complaint surveyTag F0686D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 22, 2025
August 21, 2025Complaint surveyTag F0742D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected August 22, 2025
August 15, 2025Complaint surveyTag F0583D — no actual harm, potential for more than minimal harm, isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected August 18, 2025
August 15, 2025Complaint surveyTag F0693D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected August 18, 2025
August 1, 2025Complaint surveyTag F0600G — actual harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 4, 2025
July 22, 2025Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 24, 2025
July 16, 2025Complaint surveyTag F0692D — no actual harm, potential for more than minimal harm, isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected August 27, 2025
June 24, 2025Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected June 24, 2025
May 22, 2025Complaint surveyTag F0600E — no actual harm, potential for more than minimal harm, pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected June 14, 2025
May 19, 2025Complaint surveyTag F0600E — no actual harm, potential for more than minimal harm, pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected May 20, 2025
April 14, 2025Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 24, 2025
March 13, 2025Complaint surveyTag F0600E — no actual harm, potential for more than minimal harm, pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected March 17, 2025
March 13, 2025Complaint surveyTag F0610D — no actual harm, potential for more than minimal harm, isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected March 17, 2025
February 13, 2025Complaint surveyTag F0603D — no actual harm, potential for more than minimal harm, isolated
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Deficient, Provider has date of correction · corrected March 7, 2025
January 6, 2025Complaint surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 8, 2025
January 6, 2025Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected January 8, 2025
December 12, 2024Standard surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0583D — no actual harm, potential for more than minimal harm, isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0585E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Complaint surveyTag F0600E — no actual harm, potential for more than minimal harm, pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0609D — no actual harm, potential for more than minimal harm, isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard + Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0677D — no actual harm, potential for more than minimal harm, isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0686D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0688D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0692E — no actual harm, potential for more than minimal harm, pattern
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0695D — no actual harm, potential for more than minimal harm, isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0697D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0742D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0755E — no actual harm, potential for more than minimal harm, pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0758D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0759E — no actual harm, potential for more than minimal harm, pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0761E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0812F — no actual harm, potential for more than minimal harm, widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0849D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0880E — no actual harm, potential for more than minimal harm, pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0883D — no actual harm, potential for more than minimal harm, isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0887E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0919E — no actual harm, potential for more than minimal harm, pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected January 3, 2025
December 12, 2024Standard surveyTag F0925E — no actual harm, potential for more than minimal harm, pattern
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected January 3, 2025
December 2, 2024Complaint surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 20, 2024
November 22, 2024Complaint surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected December 10, 2024
October 23, 2024Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected November 8, 2024
October 23, 2024Complaint surveyTag F0880E — no actual harm, potential for more than minimal harm, pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 8, 2024
August 14, 2024Complaint surveyTag F0559E — no actual harm, potential for more than minimal harm, pattern
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Deficient, Provider has date of correction · corrected September 13, 2024
July 21, 2024Complaint surveyTag F0755D — no actual harm, potential for more than minimal harm, isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected September 12, 2024
July 21, 2024Complaint surveyTag F0825D — no actual harm, potential for more than minimal harm, isolated
Provide or get specialized rehabilitative services as required for a resident.
Deficient, Provider has date of correction · corrected September 12, 2024
July 2, 2024Complaint surveyTag F0688E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected August 16, 2024
June 10, 2024Complaint surveyTag F0688D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected July 11, 2024
January 29, 2024Complaint surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected February 2, 2024
December 28, 2023Complaint surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected February 14, 2024
December 19, 2023Complaint surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 14, 2024
December 19, 2023Complaint surveyTag F0882D — no actual harm, potential for more than minimal harm, isolated
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected December 20, 2023
December 19, 2023Complaint surveyTag F0921D — no actual harm, potential for more than minimal harm, isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected January 11, 2024
November 18, 2023Complaint surveyTag F0908D — no actual harm, potential for more than minimal harm, isolated
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected December 5, 2023
November 16, 2023Complaint surveyTag F0727F — no actual harm, potential for more than minimal harm, widespread
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.
Deficient, Provider has date of correction · corrected February 14, 2024
November 15, 2023Complaint surveyTag F0573D — no actual harm, potential for more than minimal harm, isolated
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Deficient, Provider has date of correction · corrected November 27, 2023
November 15, 2023Complaint surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected November 27, 2023
September 25, 2023Complaint surveyTag F0641D — no actual harm, potential for more than minimal harm, isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected October 13, 2023
September 25, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 13, 2023
September 18, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 25, 2023
August 22, 2023Complaint surveyTag F0677E — no actual harm, potential for more than minimal harm, pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected September 24, 2023
August 22, 2023Complaint surveyTag F0836E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected September 24, 2023
August 9, 2023Complaint surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected September 1, 2023
August 2, 2023Complaint surveyTag F0803D — no actual harm, potential for more than minimal harm, isolated
Ensure 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.
Deficient, Provider has date of correction · corrected August 17, 2023
August 2, 2023Complaint surveyTag F0806D — no actual harm, potential for more than minimal harm, isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected August 17, 2023
August 1, 2023Complaint surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected August 10, 2023
July 25, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 10, 2023
July 20, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 27, 2023
July 17, 2023Complaint surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected August 5, 2023
July 12, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 7, 2023
July 11, 2023Complaint surveyTag F0622D — no actual harm, potential for more than minimal harm, isolated
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Deficient, Provider has date of correction · corrected August 17, 2023
July 11, 2023Complaint surveyTag F0623D — no actual harm, potential for more than minimal harm, isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected August 17, 2023
July 6, 2023Complaint surveyTag F0686G — actual harm, isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected July 19, 2023
June 28, 2023Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 20, 2023
December 9, 2022Standard surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0657E — no actual harm, potential for more than minimal harm, pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0658D — no actual harm, potential for more than minimal harm, isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0688E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0689E — no actual harm, potential for more than minimal harm, pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0692E — no actual harm, potential for more than minimal harm, pattern
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0693E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0695E — no actual harm, potential for more than minimal harm, pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0755D — no actual harm, potential for more than minimal harm, isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0758E — no actual harm, potential for more than minimal harm, pattern
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.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0761D — no actual harm, potential for more than minimal harm, isolated
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.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0812E — no actual harm, potential for more than minimal harm, pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0838C — no actual harm, potential for minimal harm, widespread
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.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0880F — no actual harm, potential for more than minimal harm, widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0881F — no actual harm, potential for more than minimal harm, widespread
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected January 9, 2023
December 9, 2022Standard surveyTag F0919E — no actual harm, potential for more than minimal harm, pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected January 9, 2023
Fines & penalties
CMS can fine a home or stop paying for new admissions. Shown per CMS's current data window (~3 years) — not all-time. moreless
When deficiencies are serious or aren't fixed, CMS can impose a fine (a civil money penalty) or a payment denial — refusing to pay for new Medicare/Medicaid admissions until the home fixes the problem. Payment denials hit harder than most fines because they stop revenue. CMS's public dataset covers a rolling window of roughly the last three years, so the totals here are recent history, not an all-time record. Many facilities have no penalties in the window — that's common, not remarkable.
What to do with this: a recent large fine deserves a direct question on your visit — what happened, and what changed?
Fines: 5 totaling $83,719 — per CMS data (rolling ~3-year window).
| 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 |
Ownership & chain
Who actually owns and controls the facility — individuals, companies, and their stakes. moreless
Nursing homes are often owned through layers: an operating company, a property company, management companies, and individual investors with percentage stakes. CMS publishes who holds 5%-or-greater interests and who has operational control. Ownership matters because it sets the budget: research has linked some ownership structures, especially certain chains and investment vehicles, to lower staffing. That's a pattern across the industry, not a verdict on any one building.
What to do with this: know who owns the home before you sign anything, and ask the administrator who actually sets the staffing budget.
Part of Windsor (23 facilities). Chain average overall rating: 2.4★ — this facility: 1★.
Most US nursing homes belong to a chain. The chain's average rating is context for this home's rating. moreless
A chain is a group of facilities sharing an owner or operator. Chains share budgets, policies, and management practices, so a chain's average rating tells you something about the company behind the building. A home rating well above its chain's average may have an unusually strong local team; one below it may be the chain's neglected building. Either way, the chain sets the constraints the local staff work within.
What to do with this: if the chain average is low, ask the administrator what this building does differently.
| Owner / manager | Role | Stake | Since |
|---|---|---|---|
| Sapphire Operations, LLC (Organization) | 5% or greater direct ownership interest | 100% | 09/01/2024 |
| 9560 Pico LLC (Organization) | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 09/01/2024 |
| Newgen LLC (Organization) | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 09/01/2024 |
| Pico Ar LLC (Organization) | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 09/01/2024 |
| Robin, Aaron (Individual) | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 09/01/2024 |
| Tress, Avrohom (Individual) | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 09/01/2024 |
| Glavan-Martinez, Martha (Individual) | Adp of the snf | NOT APPLICABLE | 10/21/2013 |
| Jimenez, Rafileiry (Individual) | Adp of the snf | NOT APPLICABLE | 01/13/2025 |
| Newgen Administrative Services, LLC (Organization) | Adp of the snf | NOT APPLICABLE | 09/01/2024 |
| Verma, Atul (Individual) | Adp of the snf | NOT APPLICABLE | 10/14/2024 |
| Glavan-Martinez, Martha (Individual) | Operational/managerial control | NOT APPLICABLE | 10/21/2013 |
| Jimenez, Rafileiry (Individual) | Operational/managerial control | NOT APPLICABLE | 01/13/2025 |
| Verma, Atul (Individual) | Operational/managerial control | NOT APPLICABLE | 10/14/2024 |
Nearby facilities in San Joaquin County
Most families compare 2–3 homes. Same county, sorted by overall rating:
Visiting? Go in with questions.
Built from this facility’s own CMS data — bring them on the tour.
- CMS has applied its abuse icon to this facility — ask what happened, what the corrective plan was, and how staff are trained now.
- CMS lists this facility as a Special Focus Facility candidate — ask where the home is in the program and what the improvement plan is.
- Their reported RN hours (0.41/resident/day) are below the CA median (0.50) — ask how nights and weekends are staffed.
- Their total nursing staff turnover (46.6%) is above the CA median (36.5%) — ask how long the aides on your person's unit have worked there.
- CMS data shows 5 fines totaling $83,719 in its current data window — ask what the citations were for and what changed afterward.
- Their weekend total nurse staffing (3.77/resident/day) is lower than their overall figure (4.19) — ask who covers weekends and how shifts are filled when someone calls out.
- Their last standard health inspection was April 9, 2026 — ask what's improved since then.
Data: Centers for Medicare & Medicaid Services (data.cms.gov), processing date June 1, 2026. This site is not affiliated with CMS or any government agency.