Health inspection·December 3, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) when:1. Resident 1 was readmitted on [DATE] to the facility with new skin issues; and, 2. Resident 1 had known skin scratching behavior. These failures placed Resident 1 at risk for further skin breakdown and potential worsening of the existing skin issues due to the skin scratching behavior. Findings:1. Review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses that included type 2 diabetes mellitus (a condition when the body cannot control blood sugar levels), end stage renal disease (when they kidneys are no longer able to function on their own to filter waste and excess fluid from the body) and dependence on renal dialysis (a treatment to filter waste and excess fluid from the blood).Review of Resident 1's medical record titled, Body Check. dated 10/30/25, indicated .Body Check completed with Skin Issues. 31) Right buttock [butt cheek] - 0.5 cm x 0.5 cm [centimeter-a unit of measure] scattered skin scrape. 32) Left buttock - 0.5 cm x 0.5 cm scattered skin scrape.Other (specify). 0.5 cm x 0.5 cm right scrotum [part of a males reproductive organs-a thick sac (pouch) of skin] skin scrape.Additional Comments: MD order to monitor for now. During a concurrent interview and record review on 12/2/25, at 3:45 p.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 1 had scratches on his buttocks area and had an MD order for staff to just monitor the areas. LN 1 reviewed Resident 1's medical record and verified on 10/30/25 Resident 1 was readmitted to the facility and had a Body Check assessment completed which indicated he had scrotum and bilateral (both left and right side) buttock skin scrapes. LN 1 reviewed Resident 1's care plans and confirmed there were no care plans initiated for the new skin issues found during Resident 1's readmission on [DATE]. LN 1 stated the nurse who did Resident 1's skin assessment on his readmission on [DATE] should have created a care plan for the new skin issues. LN 1 stated it was important to have a care plan to track wound healing and should have been done every time a new skin issue was found. LN 1 stated the risk of not having a care plan in place would be risk of infection and worsening of skin issues. During an interview on 12/2/25, at 4:40 p.m., with LN 2, LN 2 stated if a resident had a change in a current skin issue or was found to have new skin issues, a care plan should be initiated. During an interview on 12/3/25, at 12:00 p.m., with LN 4, LN 4 stated Resident 1 was readmitted to the facility on [DATE] and had skin issues on his buttocks and right scrotum area. LN 4 stated he could not recall if he created Resident 1's care plan for the skin issues found on 10/30/25. LN 4 stated Resident 1 needed a care plan and monitoring orders to be in place for the skin issues found when he was readmitted to the facility on [DATE]. During a concurrent interview and record review on 12/3/25, at 2:01 p.m., with the Director of Nursing (DON), the DON stated it was expected for the nurses to treat a re-admission like a new admission, which would include a full skin assessment. The DON stated it was important for a resident to have a care plan for new skin issues to know the Page 1 of 6 055201 055201 12/03/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions on how to take care of the problem for a positive outcome. The DON stated it was expected for the nurse to have created a care plan for any new skin issue. The DON stated the risk of not having a care plan in place would be poor outcome for the residents, not preventing worsening of issues and not planning to make it better. Review of facility's policy titled, Readmission, dated 3/22/22, indicated .III.PROCEDURE.B. A Licensed Nurse will do the following upon the readmission: Complete an admission Assessment.Update Care plan.Review of facility's policy titled, CARE PLAN COMPREHENSIVE, dated 8/25/21, indicated .I. PURPOSE.An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.III. PROCEDURE.7. Assessments of residents are ongoing and reviewed and revised as information about the resident and the resident's condition change.8. The Interdisciplinary Team is responsible for evaluation and updating of care plans:.c. When the resident has been readmitted to the facility from a hospital stay.2. During a concurrent observation and interview on 12/2/25, at 11:16 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 had no known skin issues that she knew of. CNA 1 stated Resident 1 used adult briefs (used for a lack of bowel and bladder control) and would sometimes use the toilet with assistance. CNA 1 checked Resident 1's skin under his adult brief and stated she saw some redness, with some scabbing, and pink areas on his buttocks area.During a concurrent interview and record review on 12/2/25, at 3:58 p.m., with LN 1, LN 1 reviewed Resident 1's orders and stated Resident 1 had scratches on his buttocks area with an MD order to monitor them. LN 1 stated Resident 1 had a habit of self-scratching based on other staff reporting. During a concurrent observation and interview on 12/2/25, at 4:11 p.m., with CNA 1, LN 1 and LN 2, CNA 1 assisted Resident 1 with changing his adult brief while LN 1 and LN 2 were present to assess his skin. LN 1 stated Resident 1 had scattered scabs around the buttocks area from scratching himself. Both LN 1 and LN 2 confirmed Resident 1's buttocks area had scattered scabbing with some open areas that used to be scabbed areas and have now reopened. LN 1 stated Resident 1's reopened scabbing on the buttocks area and some scabs with a pink base were observed. LN 1 stated Resident 1's current order for his buttocks area was for monitoring only and thinks there should at least be a skin treatment to be applied as a skin barrier to prevent skin issues from worsening. During the observation, Resident 1 was observed scratching on his buttocks area and LN 1 confirmed Resident 1 had a known behavior of scratching. Review of Resident 1's Order Summary Report and Care Plan Report did not indicate any behavior monitoring orders or care plans initiated for Resident 1's scratching behavior. During a concurrent interview and record review on 12/2/25, at 4:48 p.m., with LN 1, LN 1 stated he recalled a CNA staff who asked him about Resident 1's scratching of his bottom area. LN 1 stated he could not recall when the CNA staff asked him about Resident 1's scratching behavior but it was recent. LN 1 stated Resident 1 was prone to having dry skin due to having a long-term kidney condition and was getting dialysis treatments. LN 1 reviewed Resident 1's chart and verified there was no care plan initiated for his scratching behavior and stated there should have been a care plan initiated since Resident 1 was observed with this behavior. LN 1 further stated he should have initiated a care plan and behavior monitoring when the CNA staff told him about Resident 1's scratching behavior. During an interview on 12/2/25, at 4:54 p.m., with CNA 2, CNA 2 stated he was aware of Resident 1's behavior of scratching on his bottom area and that he had dry scabs or scratches on the buttocks area. CNA 2 stated he noticed Resident 1 was always scratching his bottom lately and had asked the nurse about it. During an interview on 12/3/25, at 11:07 a.m., with LN 3, LN 3 stated if a resident had behaviors of skin scratching, there should be a care plan in place especially if it was a new observed behavior that could affect ongoing skin issues. During an interview on 055201 Page 2 of 6 055201 12/03/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/3/25, at 12:00 p.m., with LN 4, LN 4 stated he was aware of Resident 1's scratching behavior. LN 4 stated due to Resident 1's kidney disease and having dialysis treatments, he would be prone to having dry skin and at risk of having open wounds. LN 4 stated a care plan should have been done for Resident 1's scratching behavior since it was a known issue. LN 4 stated it was important to have a care plan in place to know what to do since Resident 1 had scratching behavior and to show he was being taken care of. LN 4 stated the risk to Resident 1 would be worsening skin issues or complications. During an interview on 12/3/25, at 2:01 p.m., with the DON, the DON stated it was her expectation for the nursing staff to have created a care plan for Resident 1 since they knew about his scratching behavior. The DON stated the risk of not having a care plan would be poor outcome for Resident 1. Review of facility's policy titled, Skin Integrity Management, dated 5/26/21, indicated .PURPOSE: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and Promote healing of all wounds.II. POLICY: The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continuously observes and monitors patients for changes and implements revisions to the plan of care as needed.III. PROCEDURE.4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated.9. Review care plan and revise as indicated. 055201 Page 3 of 6 055201 12/03/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's Treatment Administration Record (TAR) report for 11/2025 had missing documentation from a licensed nurse on multiple treatment orders; and, 2. Resident 2's TAR report for 11/2025 had missing documentation from a licensed nurse for the stage 3 pressure ulcer treatment to her coccyx (a deep wound on the tailbone area). These failures had the potential for both Resident 1 and Resident 2's medical records to have insufficient information to determine if treatment orders were being carried out as ordered and could place both residents at risk of complications. Findings:1. Review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses that included type 2 diabetes mellitus (a condition when the body is unable to regulate blood sugar levels), end stage renal disease (a condition when they kidneys are no longer able to function on their own to filter waste and excess fluid from the body) and dependence on renal dialysis (a treatment to filter waste and excess fluid from the blood). Review of Resident 1's medical record titled, TREATMENT ADMINISTRATION RECORD, for the month of 11/2025, indicated the following MD orders with missing documentation: a.0.5cm x 0.5cm [centimeter, a unit of measure] left buttock [butt cheek] scattered skin scrape. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Notify MD for worsening every shift. - order started on 10/30/25 with missing documentation on the morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 11/10/25 and 11/27/25. b.0.5cm x 0.5cm right buttock scattered skin scrape. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Notify MD for worsening every shift. - order started on 10/30/25 with missing documentation on morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 11/10/25 and 11/27/25. c.0.5cm x 0.5cm right scrotum [part of a male's reproductive organs-a thick sac (pouch) of skin] scattered skin scrape. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Notify MD for worsening every shift. - order started on 10/30/25 with missing documentation on morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 11/10/25 and 11/27/25. d.L [left] hand swelling: Monitor for worsening of symptoms. Notify MD. D/C [Discontinue] order when resolved every shift. - order started on 9/21/25 with missing documentation on morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 11/10/25 and 11/27/25.e.LEFT GREAT TOE BLACK DISCOLORATION: Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings. Notify MD for worsening. Every shift. - order started on 11/25/25 with missing documentation on morning shift for dates 11/26/25 to 11/28/25; and evening shift for date 11/27/25. f.Monitor for +4 pitting edema [severe fluid accumulation under the skin] to LUE [left upper extremity] Q shift [every shift]. Call MD for worsening, d/c when resolved. Every shift. started on 7/9/25 with missing documentation on morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 11/10/25 and 11/27/25. g.Monitor R [right] eye: watch for s/s [signs and symptoms] of infection or worsening such as redness, warmth, drainage, swelling or odor. Notify MD of significant findings. D/C when resolved every shift. -started on 7/9/25 with missing documentation on morning shift for dates 11/3/25, 11/9/25, 11/14/25 to 11/15/25, 11/26/25 to 11/28/25; and, evening shift for dates 055201 Page 4 of 6 055201 12/03/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/10/25 and 11/27/25.h.REDNESS TO RIGHT GREAT TOE: Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings. Notify MD for worsening every shift. - started on 11/25/25 with missing documentation on morning shift for dates 11/26/25 to 11/28/25; and evening shift for date 11/27/25.i.Terbinafine HCL External Cream 1% [antifungal medication].Apply to bilateral feet and toenail topically every evening shift for tine pedis [fungal infection]. started on 11/26/25 with missing documentation for evening shift on 11/27/25. j.TX-R [treatment-right] GREAT TOE - BETADINE [yellow liquid used for wound healing] SOAK, COVER W [WITH] DRY DRESSING. SOAK 4X4 GAUZE W BETADINE, COVER W DRY DRESSING. Every evening shift. - started on 11/26/25 with missing documentation on evening shift for dates 11/27/25 and 11/29/25. During a concurrent interview and record review on 12/2/25, at 4:58 p.m., with the Treatment Nurse (TN), the TN reviewed Resident 1's TAR monthly report for 11/2025 and confirmed the dates listed above lacked documentation from a nurse that the treatment was completed for Resident 1's treatment orders. The TN further stated missing or blank items on the TAR report meant that the treatment orders were not done or carried out. The TN stated the nurses should have documented if the order was carried out and should not have been left blank. The TN stated incomplete resident treatment documentation was an ongoing issue in the facility.During a concurrent interview and record review on 12/3/25, at 11:07 a.m., LN 3 stated the nurse should have documented if orders were completed but, if documentation was missing on the TAR report, then there should have been a progress note entered into the resident's medical record as to why the treatment was missed. LN 3 stated it was important to document on the TAR report to monitor Resident 1's skin issues to see if it was getting worse or better. LN 3 further stated not documenting on the TAR would place Resident 1 at risk of being neglected, worsening of the skin issues, and worst case could be infection or becoming septic (a serious condition when the body's immune system has an extreme response to an infection). During a concurrent interview and record review on 12/3/25, at 2:01 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's TAR monthly report for 11/2025 and verified missing documentation on multiple dates on multiple treatment orders. The DON stated it was her expectation for the nurses to have carried out the treatment orders with complete documentation. The DON stated the risk of not providing or carrying out treatment orders could be new or worsening of existing skin issues. 2. Review of Resident 2's medical record titled, admission RECORD, indicated Resident 2 was admitted to the facility in 2022 with diagnoses that included cellulitis of back (a bacterial infection that causes redness) and pressure ulcer of sacral region (located at the lower back on the tailbone area) stage 3. Review of Resident 2's medical record titled, TREATMENT ADMINISTRATION RECORD, indicated the following treatment orders: a.P/U [pressure ulcer] coccyx, cleanse with normal saline [mild salt water], dry, apply collagen powder [wound healing powder] and cover with a dry dressing daily and as needed until resolved one time a day., started on 11/12/25 with the following dates: - 11/15/25 (Saturday) documented with NN; and 11/29/25 (Saturday) and 11/30/25 (Sunday) with missing documentation.b.P/U [pressure ulcer] coccyx, cleanse with normal saline, dry, apply collagen powder and cover with a dry dressing daily and as needed until resolved as needed., started on 11/11/25 with no documented entries for the timeframe of 11/11/25 to 11/30/25. During a concurrent interview and record review on 12/3/25, at 11:07 a.m., with LN 3, LN 3 stated Resident 2 had a pressure ulcer on her coccyx area that needed treatment to be done daily and as needed if soiled. LN 3 stated Resident 2's treatment was done by the TN during the weekdays and whoever the assigned nurse would be during the weekends. LN 3 reviewed Resident 2's TAR report for 11/2025 and verified on 11/15/25, the LN documented NN which meant to check the resident's progress notes. LN 3 reviewed Resident 2's progress notes on 11/15/25 and stated LN documented 055201 Page 5 of 6 055201 12/03/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few endorsed to PM (evening schedule) shift. LN 3 further reviewed Resident 2's notes and TAR report and confirmed there was no documentation of the PM shift completing the treatment order. LN 3 stated she was the nurse who worked during that PM shift and stated she carried out Resident 2's pressure ulcer treatment order but did not document on the as needed TAR order. LN 3 stated she should have clicked on Resident 2's pressure ulcer on the coccyx as needed order on the TAR since she did the treatment during the PM shift. LN 3 verified Resident 2's TAR report on dates 11/29/25 and 11/30/25 were both missing documentation which meant it was not done by the nurse. LN 3 stated it was important to have both carried out and documented the treatment orders to ensure that it was done. LN 3 stated Resident 2's pressure ulcer on her coccyx could get worse if the treatment order was not being done and documented. During a concurrent interview and record review on 12/3/25, at 2:01 p.m., with the DON, the DON reviewed Resident 2's TAR report for 11/2025 and verified Resident 2's pressure ulcer order indicated daily changing and as needed if soiled. The DON stated the nurses were expected to document in the resident's chart whether an order was carried out, not carried out or if there was a resident refusal of the order. The DON stated the risk of not documenting orders carried out could result in a poor outcome for the resident. Review of facility's policy titled, Nursing Documentation, dated 6/27/22, indicated .I. PURPOSE.To communicate patient's status and provide complete, comprehensive and accessible accounting of care and monitoring provided.II. POLICY.Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation and complexity.Nursing documentation will follow Genesis HealthCare policy and procedure and federal and state regulations.III. PROCEDURE. c. The patient's record specifies what nursing interventions were performed by whom, when, and where. 055201 Page 6 of 6