The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Oak Grove Post Acute are:
F-0600 · August 1, 2025 · Grade G — Actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date August 4, 2025
F-0812 · April 9, 2026 · Grade F — Potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Status: Deficient, Provider has date of correction · correction date April 28, 2026
F-0814 · April 9, 2026 · Grade F — Potential for more than minimal harm
Dispose of garbage and refuse properly.
Status: Deficient, Provider has date of correction · correction date April 28, 2026
K-0918 · April 9, 2026 · Grade F — Potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Status: Deficient, Provider has date of correction · correction date April 24, 2026
K-0919 · April 9, 2026 · Grade F — Potential for more than minimal harm
Meet requirements for the use of electrical equipment.
Status: Deficient, Provider has date of correction · correction date April 20, 2026
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Oak Grove Post Acute, 17 subject areas appear across health and fire-safety inspections.
Freedom from abuse, neglect, and exploitation
14 citations between December 12, 2024 and April 9, 2026. The most serious was graded G — actual harm, affecting one or a very small number of residents. Surveyors found that a resident was actually harmed by the failure, though it was not classed as immediate jeopardy. 12 of these citations came out of complaint investigations. Correction record: 14 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0600 · August 1, 2025 · Grade G — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0600 · May 22, 2025 · Grade E — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0600 · May 19, 2025 · Grade E — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Fire, smoke, and emergency safety
15 citations between December 9, 2022 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 15 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0345 · December 12, 2024 · Grade F — Have approved installation, maintenance and testing program for fire alarm systems.
K-0341 · April 9, 2026 · Grade E — Install a fire alarm system that can be heard throughout the facility.
K-0342 · April 9, 2026 · Grade E — Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Infection prevention and control
13 citations between December 9, 2022 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). 5 of these citations came out of complaint investigations. Correction record: 13 citations show a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · December 9, 2022 · Grade F — Provide and implement an infection prevention and control program.
F-0881 · December 9, 2022 · Grade F — Implement a program that monitors antibiotic use.
F-0880 · April 9, 2026 · Grade E — Provide and implement an infection prevention and control program.
Gas, Vacuum, and Electrical Systems
9 citations between December 9, 2022 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 9 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0918 · April 9, 2026 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0919 · April 9, 2026 · Grade F — Meet requirements for the use of electrical equipment.
K-0918 · December 12, 2024 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
Miscellaneous
7 citations between December 9, 2022 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 7 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0712 · December 12, 2024 · Grade F — Have simulated fire drills held at unexpected times.
K-0712 · December 9, 2022 · Grade E — Have simulated fire drills held at unexpected times.
K-0711 · April 9, 2026 · Grade D — Provide a written emergency evacuation plan.
Physical environment and safety
6 citations between December 9, 2022 and February 11, 2026. The most serious was graded F (potential for more than minimal harm). 3 of these citations came out of complaint investigations. Correction record: 6 citations show a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0925 · February 11, 2026 · Grade F — Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F-0919 · December 12, 2024 · Grade E — Make sure that a working call system is available in each resident's bathroom and bathing area.
F-0925 · December 12, 2024 · Grade E — Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Food, nutrition, and hydration
5 citations between December 9, 2022 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 5 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0812 · April 9, 2026 · Grade F — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-0814 · April 9, 2026 · Grade F — Dispose of garbage and refuse properly.
F-0814 · January 16, 2026 · Grade F — Dispose of garbage and refuse properly.
Services
3 citations between July 18, 2024 and April 9, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · July 18, 2024 · Grade F — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K-0521 · April 9, 2026 · Grade D — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K-0521 · March 26, 2026 · Grade C — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Nursing and Physician Services
2 citations between November 16, 2023 and March 11, 2026. The most serious was graded F (potential for more than minimal harm). 2 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
F-0727 · November 16, 2023 · Grade F — 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.
F-0726 · March 11, 2026 · Grade D — 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.
Quality of life and daily care
40 citations between December 9, 2022 and April 22, 2026. The most serious was graded E (potential for more than minimal harm). 21 of these citations came out of complaint investigations. Correction record: 40 citations show a recorded correction date.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0689 · April 22, 2026 · Grade E — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0677 · April 9, 2026 · Grade E — Provide care and assistance to perform activities of daily living for any resident who is unable.
F-0684 · February 20, 2026 · Grade E — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident rights
15 citations between December 9, 2022 and April 9, 2026. The most serious was graded E (potential for more than minimal harm). 7 of these citations came out of complaint investigations. Correction record: 15 citations show a recorded correction date.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0585 · December 12, 2024 · Grade E — 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.
F-0559 · August 14, 2024 · Grade E — Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
F-0552 · April 9, 2026 · Grade D — Ensure that residents are fully informed and understand their health status, care and treatments.
Assessments and care planning
13 citations between December 9, 2022 and April 9, 2026. The most serious was graded E (potential for more than minimal harm). 8 of these citations came out of complaint investigations. Correction record: 13 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0656 · April 9, 2026 · Grade E — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-0658 · April 9, 2026 · Grade E — Ensure services provided by the nursing facility meet professional standards of quality.
F-0657 · December 9, 2022 · Grade E — Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Medication and pharmacy services
12 citations between December 9, 2022 and April 9, 2026. The most serious was graded E (potential for more than minimal harm). 2 of these citations came out of complaint investigations. Correction record: 12 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0761 · April 9, 2026 · Grade E — 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.
F-0755 · December 12, 2024 · Grade E — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F-0759 · December 12, 2024 · Grade E — Ensure medication error rates are not 5 percent or greater.
Egress
7 citations between December 9, 2022 and April 9, 2026. The most serious was graded E (potential for more than minimal harm). Correction record: 7 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0293 · April 9, 2026 · Grade E — Have properly located and lighted "Exit" signs.
K-0211 · April 9, 2026 · Grade D — Keep aisles, corridors, and exits free of obstruction in case of emergency.
K-0222 · April 9, 2026 · Grade D — 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.
Fire, smoke, and emergency safety
5 citations between December 9, 2022 and July 18, 2024. The most serious was graded D (potential for more than minimal harm). Correction record: 5 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
E-0006 · December 9, 2022 · Grade D — Conduct risk assessment and an All-Hazards approach.
E-0037 · December 9, 2022 · Grade D — Establish staff and initial training requirements.
E-0039 · December 9, 2022 · Grade D — Conduct testing and exercise requirements.
Administration and leadership
3 citations between December 9, 2022 and July 9, 2026. The most serious was graded D (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date; 1 had a plan of correction on file at the last data release.
Administrative citations suggest the problem sits with management systems, not one staff member. Ask who is responsible for quality oversight and what the home's own quality committee changed afterward.
F-0849 · December 12, 2024 · Grade D — 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.
F-0844 · July 9, 2026 · Grade C — Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
F-0838 · December 9, 2022 · Grade C — 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.
Construction
1 citation between December 12, 2024 and December 12, 2024. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0161 · December 12, 2024 · Grade D — Use approved construction type or materials.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Oak Grove Post Acute appears in CMS data on 49 survey dates between December 9, 2022 and July 9, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
July 9, 2026
Complaint health survey — 1 citation, worst grade C (minimal or no harm potential)
April 22, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
April 9, 2026
Health survey including complaint investigations — 20 citations, worst grade F (potential for more than minimal harm)
April 9, 2026
Fire-safety survey — 18 citations, worst grade F (potential for more than minimal harm)
March 26, 2026
Fire-safety survey — 1 citation, worst grade C (minimal or no harm potential)
March 11, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
March 4, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
February 20, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
February 11, 2026
Complaint health survey — 3 citations, worst grade F (potential for more than minimal harm)
January 16, 2026
Complaint health survey — 2 citations, worst grade F (potential for more than minimal harm)
December 12, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
December 8, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
December 3, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
December 2, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
November 26, 2025
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
November 20, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
November 19, 2025
Fire-safety survey — 1 citation, worst grade C (minimal or no harm potential)
August 21, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
August 15, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
August 1, 2025
Complaint health survey — 1 citation, worst grade G (actual harm)
July 22, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
July 16, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
June 24, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
May 22, 2025
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
May 19, 2025
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
April 14, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
March 13, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
February 13, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 6, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
December 12, 2024
Health survey including complaint investigations — 27 citations, worst grade F (potential for more than minimal harm)
December 12, 2024
Fire-safety survey — 12 citations, worst grade F (potential for more than minimal harm)
December 2, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
November 22, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
October 23, 2024
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
August 14, 2024
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
July 21, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
July 18, 2024
Fire-safety survey — 4 citations, worst grade F (potential for more than minimal harm)
July 2, 2024
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
June 10, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 29, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
December 28, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
December 19, 2023
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
November 18, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
November 16, 2023
Complaint health survey — 1 citation, worst grade F (potential for more than minimal harm)
November 15, 2023
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
September 25, 2023
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
September 18, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
December 9, 2022
Standard health survey — 17 citations, worst grade F (potential for more than minimal harm)
December 9, 2022
Fire-safety survey — 11 citations, worst grade E (potential for more than minimal harm)
Penalties imposed
February 20, 2024 — Fine of $4,938
February 12, 2024 — Fine of $7,527
January 22, 2024 — Fine of $19,107
December 26, 2023 — Fine of $8,711
How Oak Grove Post Acute compares with peer homes
Raw citation counts mean more in context. The table below compares Oak Grove Post Acute with the median reviewed facility in San Joaquin County (9 homes in this research set) and across California (350 homes), using the same CMS data. On health citations alone, Oak Grove Post Acute sits above 88% of its reviewed county peers — near the top of the county for citation volume.
Measure
Oak Grove Post Acute
San Joaquin Co. median
California median
Health citations on record
123
89
74
Citations from complaint investigations
62
40
27
Citations at actual-harm level or worse
1
1
2
Immediate-jeopardy citations
0
0
0
Total fines in CMS penalty records
$40,283
$0
$43,467
Penalty records (fines + payment denials)
4
0
2
What families should ask Oak Grove Post Acute
- Ask why CMS flags Oak Grove Post Acute with its abuse icon, which citations produced the flag, and what staffing or supervision changes followed.
- Ask for the plan of correction and follow-up monitoring for the freedom from abuse, neglect, and exploitation citations — most recently F-0600 on August 1, 2025 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the infection prevention and control citations — most recently F-0880 on December 9, 2022 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the physical environment and safety citations — most recently F-0925 on February 11, 2026 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the food, nutrition, and hydration citations — most recently F-0812 on December 12, 2024 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 4 totalling $40,283, the most recent dated February 20, 2024 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Oak Grove Post Acute first document the change?
- Were recent complaint-related citations at Oak Grove Post Acute connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
055201
Legal business name
4545 SHELLEY COURT OPCO, LLC
Ownership type
For profit - Limited Liability company
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
January 1, 1967
Chain name
WINDSOR
Certified beds
119
Average residents per day
112.9
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
3 star
Reported nurse staffing hours per resident day
4.19393
Total nursing staff turnover
46.6%
Public records are a starting point, not a conclusion
This profile of Oak Grove Post Acute uses official CMS provider data as a research starting point. It does not state that Oak Grove Post Acute abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Sources for Oak Grove Post Acute
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.