Health inspection·December 8, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to protect the rights of two of 4 sampled residents (Resident 3 and Resident 6) to be free from physical abuse when:1. Resident 1 with a history of multiple resident-to-resident altercations, made racial slurs and pushed Resident 6 on 9/18/25; and,2. Resident 4 hit Resident 3 in the face on 8/30/25. These failures resulted in Resident 3 sustaining an injury to her mouth and Resident 6 falling from his wheelchair. Findings:1. A review of Resident 1' s medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including paranoid schizophrenia (a mental health condition that is characterized hearing and seeing things that are not real), insomnia (persistent problems falling and staying asleep), major depression disorder ( a mental health disorder characterized by depressed mood or loss of interest in activities), and anxiety disorder (a mental health conditions characterized by excessive and persistent worry, fear, and nervousness).A review of Resident 1's medical record titled, Order Summary Report, dated 9/24/25, indicated there was an active physician's order for one-on-one supervision (one staff member monitors one resident) 24 hours a day that was initiated on 6/8/25. There was also an active physician's order for monitoring episodes of aggressive behavior as evidenced by (AEB) striking out at others and was initiated on 9/10/25.A review of Resident 1's medical record titled, Interdisciplinary Care Conference - V5, dated 9/19/25 indicated, .On 9/18/25, it was reported that this resident [Resident 1] was involved in an altercation. [Resident 1] struck at [Resident 6]. [Resident 6] attempted striking back. Residents were separated immediately and assessed for injuries.Recommendations.72 hour monitoring - Q [every] 30 min safety checks.A review of Resident 1's medical record titled, Progress Notes, dated 9/18/2025 at 11:30 AM, indicated, .per observer or witnesses [Resident 1] was verbally aggressive to [Resident 6] and contact was made but was separated by staff.A review of Resident 1's medical record titled, Care Plan Report, indicated the following:-6/28/22, .Interventions.Monitor for mood and/or behavior changes or symptoms, assist in finding alternative interventions to aid resident's [Resident 1] adjustment and understanding of need.maintain a safe environment with minimal stimulation.-11/02/24, Goal.Promote respectful interactions with peers and staff.Interventions.Educate the resident on the importance of non-violent communication and conflict resolution.Implement regular observations to assess behavior and provide immediate feedback.-6/9/25, .Focus.Resident [Resident 1] with potential/risk to exhibit psycho-social distress related to the following: 1. Resident served in Vietnam war. 2. Hx [history] of Homelessness.4. Dx [diagnosis] of schizophrenia and hx of stroke [a brain injury related to an event where oxygen to the brain is blocked]. 5. Physical Aggression triggered by paranoia r/t [related to] name calling, staring, being within close proximity with another person. (Res [resident]-to-Res Altercations:) - 1/24/2025 - 1/29/2025 - 2/26/2025 - 3/5/2025 - 3/10/2025 - 3/19/2025 - 3/24/25 - 4/17/2025 - 4/23/2025 - 5/9/2025 - 6/7/2025.Goal.Resident [Resident 1] will reduce or decrease episodes of PTSD [Post-traumatic stress disorder, a mental health condition that's caused by an extremely Page 1 of 4 055201 055201 12/08/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stressful or terrifying event] triggered by altercations.Interventions.Resident to have 1:1 [one staff supervised one resident] staff support as indicated. Resident [Resident 1] will be supported in participating in restorative conversations, as appropriate. -8/21/25, .Goal.Resident [Resident 1] will have no decline in psychosocial well-being.resident [Resident 1] will have no episodes of resident-to-resident altercations.Interventions. continue 1:1 supervision.A review of Resident 6' s medical record titled, admission RECORD, indicated Resident 6 was admitted to the facility with diagnoses including schizophrenia (a chronic mental health condition characterized by a combination of symptoms that significantly impair a person's thoughts, perceptions, and behaviors), muscle weakness, major depression disorder, and anxiety disorder.A review of Resident 6's medical record titled, Interdisciplinary Care Conference - V5, dated 9/19/25, indicated, .On 9/18/25, Resident to resident altercation contributed to witnessed fall.A review of Resident 6's medical record titled, SBAR Communication Form, dated 9/18/2025 at 12:45 PM, indicated, .APPEARANCE . [Resident 1] began making racial slurs to [Resident 6] [Resident 6] then grabbed [Resident 1] by the collar of his shirt and began cursing. [Resident 1] was able to wheel self backwards with the help of his nurses aid. [Resident 6] then fell forward onto his hands and knees.A review of Resident 6's medical record titled, Care Plan Report, indicated the following:-4/24/25, .Goal.Resident will demonstrate a reduction in episodes of aggression/restlessness.Interventions.Monitor and document behaviors .maintain consistent routines to minimize confusion and anxiety.-9/08/25, Goals.resident will have no falls .During a concurrent observation and interview on 9/24/25 at 11:00 AM, Resident 1 was observed in his bed and stated he did not like Resident 6 and Resident 6 made him mad. Resident 1 stated he pushed Resident 6 and Resident 6 fell. Resident 1 stated he did not like loud sounds and Resident 6 was too loud when Resident 6 talked to God. Resident 1 stated Resident 6 slapped his chest and said derogatory (bad) words to Resident 1. Resident 1 stated at the time of the incident there was no staff providing one-on -one care (a personalized care model where a single caregiver provides their full and undivided attention to one individual) to him.During an observation and concurrent interview on 9/24/25 at 11:22 AM, Certified Nursing Assistant (CNA) 1 stated she was providing one-on-one care to Resident 1 because he was aggressive towards other residents. CNA 1 stated in the beginning of 9/25, she saw Resident 1 get agitated and speak to himself when Resident 1 saw other residents pass by his room. CNA 1 stated when she was sitting with Resident 1 outside his room, she heard Resident 1 say derogatory words to himself and she had redirected Resident 1 back to his room. During an interview on 9/24/25 at 11:36 AM, Licensed Nurse (LN) 1 stated Resident 6 had yelled at other residents in the past. LN 1 stated Resident 6 was sent to the hospital on 9/23/25 for yelling and having aggressive behavior towards a CNA and other residents.During an interview on 9/24/25 at 11:47 AM, Resident 2 stated he had heard Resident 1 yell and Resident 1 said derogatory words to Resident 6. Resident 2 stated that in the past Resident 1 had come into his room and punched him and, on 9/2/25, Resident 1 had yelled and used derogatory words towards him. Resident 2 stated he was worried Resident 1 would hurt him again. Resident 2 stated he would not like anyone to hurt his face because the injury would cause him to be in pain.During an interview on 9/24/25 at 12:36 PM, CNA 2 stated Resident 1 had told her that he did not like black people. CNA 2 stated when she provided one-on-one care to Resident 1, she witnessed Resident 1 show his middle finger and say derogatory words to other residents. During an interview and concurrent record review on 9/24/25 at 1:19 PM, LN 2 stated Resident 1 had been on one-on-one care since 6/8/25. LN 2 stated Resident 6 did not yell at anyone unless he was provoked.During an interview on 9/25/25 at 11:16 AM, Admissions Assistant (AA) stated the incident between Resident 1 and Resident 6 happened in the facility's lobby on 9/18/25, around noon time. AA stated as Resident 6 backed his 055201 Page 2 of 4 055201 12/08/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair up and started to leave the lobby she saw Resident 1 wheel himself towards Resident 6. AA stated Resident 1 was by himself when he wheeled himself into the lobby. AA stated she heard Resident 6 saying I am not done talking to her, and she saw Resident 1 got agitated and pointed his finger towards Resident 6. AA stated Resident 1 yelled and said something to Resident 6 which she could not understand. AA stated Resident 1 wheeled his wheelchair close to Resident 6 and both residents had a fist fight. AA stated she saw Resident 6 fall from his wheelchair during the altercation. AA stated Resident 1 was on one-on-one care on the day of the altercation and she did not see any staff around Resident 1 in the lobby at the time of the incident.During an interview on 9/25/25 at 11:51 AM, CNA 3 stated she was assigned to provide one-on-one care to Resident 1 at the time of the incident. CNA 3 stated Resident 1 was placed on one-to-one care because Resident 1 was aggressive towards other residents. CNA 3 stated she pushed Resident 1 in his wheelchair to the lobby. CNA 3 stated as soon as she took her hands off from Resident 1's wheelchair Resident 1 quickly wheeled his wheelchair close to Resident 6. CNA 3 stated Resident 1 said you black people, to Resident 6 and Resident 6 said derogatory words to Resident 1. CNA 3 stated Resident 6 grabbed Resident 1's shirt, Resident 1 pushed Resident 6's wheelchair, and then Resident 6 fell from his wheelchair. CNA 3 stated Resident 1 was the first one to say things to Resident 6. CNA 3 stated Resident 1 had told her in the past that he did not like black people because they were so loud. CNA 3 stated when she was providing one-to-one care to Resident 1, she should have kept her eyes on Resident 1 at all times. CNA 3 stated to prevent the altercation from happening she should have stood in the middle of both residents instead of standing behind Resident 1. CNA 3 stated if Resident 1 and Resident 6 did not get close to each other the incident would not have happened.During an interview on 9/25/25 at 12:31 PM, Resident 6 stated at the time of the incident he was sitting in his wheelchair in the lobby. Resident 6 stated Resident 1 showed him the middle finger then yelled and punched him. Resident 6 stated Resident 1 had shown his middle finger in the past and Resident 6 did not like that. Resident 6 stated Resident 1 pushed him and he fell from his wheelchair. Resident 6 stated he did not want any trouble.2. A review of Resident 3' s medical record titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning) with other behavioral disturbance.A review of Resident 3's medical record titled, Interdisciplinary Care Conference - V5, dated 9/2/25 indicated, .[Resident 3] was propelling herself in her wheelchair and got her wheel stuck in the male resident's wheelchair.The male resident [Resident 4] backhanded [Resident 3], striking her in the face. [Resident 3] was noted to have some bleeding in the mouth.A review of Resident 3's medical record titled, Body Check, dated 8/30/25 indicated, . [Resident 3] was hit in mouth resulting in bleeding.A review of Resident 3's medical record titled, Care Plan Report, dated 4/29/25, indicated, .Goal.resident will have no episodes of resident-to-resident altercations.observe for change in mood, behavior and psychosocial well-being.A review of Resident 4' s medical record titled, admission RECORD, indicated Resident 4 was admitted to the facility with diagnoses including schizophrenia.A review of Resident 4's medical record titled, Interdisciplinary Care Conference - V5, dated 9/2/25, indicated, .resident-to-resident altercation occurred between [Resident 4] and [Resident 3].the residents were outside the activities room in the hallway when [Resident 3] was propelling herself in her wheelchair and got her wheel stuck in [Resident 4's] wheelchair.[Resident 4] backhanded [Resident 3] striking her in the face.A review of Resident 4's medical record titled, Care Plan Report, indicated the following:-8/4/23, .Interventions.Monitor for target behaviors/symptoms of striking out behavior.-5/1/205, .Goal.resident will have no episodes of resident-to-resident altercations.Interventions.Observations for any change in mood, behavior and 055201 Page 3 of 4 055201 12/08/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few psychosocial well-being.During an interview on 9/24/25 at 11:22 AM, CNA 1 stated Resident 3 was confused, and Resident 3 had stated that she was looking for her son, and she wanted to go to the behavioral center (a center that treats mental illness).During an interview on 9/24/25 at 12:36 PM, CNA 2 stated Resident 3 was confused when she took care of her, and Resident 3 was looking for her mother.During an interview on 9/24/25 at 12:51 PM, Nursing Assistant (NA) stated he was providing one-to-one care to Resident 4 because Resident 4 was combative.During an interview on 9/24/25 at 12:51 PM, NA stated Resident 3 had been confused when he tried talking to her.During an interview on 9/24/25 at 12:53 AM, Resident 4 stated he heard Resident 3 say something about his mother in the dining room and at that time Resident 3 was not sitting close to Resident 4. Resident 4 stated Resident 3 then wheeled her wheelchair close behind his wheelchair and made another statement about his mother. Resident 4 stated that was when he pushed Resident 3 away.During an interview on 9/24/25 at 1:07 PM, Resident 5 stated he saw Resident 3 in her wheelchair go behind Resident 4's wheelchair and push Resident 4. Resident 5 stated he heard Resident 3 say a derogatory word to Resident 4. Resident 5 further stated he heard Resident 4 say if you do it again, I will slap you. Resident 5 stated he saw Resident 3 push Resident 4's wheelchair again.During an interview on 9/24/25 at 1:19 PM, LN 2 stated Resident 3 was confused. LN 2 further stated Resident 4 was on one-on-one care since 9/2/25, because he had got into a fight. LN 2 stated Resident 1 and Resident 4 were on one-to-one care because they had repeated negative interactions with other residents. LN 2 stated an altercation could happen when a resident cussed at another resident. LN 2 stated altercations could affect a resident's safety and living situation where a resident might have to change rooms. LN 2 stated if two residents who had an altercation before shared the same space there was a chance of another altercation happening.During an interview and concurrent record review on 9/25/25 at 1:30 PM, LN 3 stated Resident 3 was confused, and she talked about going to get food with her mother. LN 3 stated Resident 6 talked about God and Resident 6 got agitated when someone tried to interrupt him. LN 3 stated when a resident was on one-on -one care there had to be a visual of the resident at all times. LN 3 stated to prevent a resident from getting agitated and getting into altercations he would keep the resident away from another resident that provoked him. During a phone interview on 9/25/25 at 1:51 PM, Resident 3's Responsible Party (RP) 1 stated he did not like that Resident 3 had bloody lips after being punched by another resident. RP 1 stated Resident 3 was confused most of the time and the incident should not have happened.During an interview on 9/25/25 at 4:51 PM the Administrator (ADMN) stated Resident 1 had been into altercations with other residents of the facility in the past and the facility staff had tried their best to prevent further altercations from happening. The ADMN confirmed Resident 1 was on one-on-one care at the time of the incident. The ADMN confirmed the altercation between Resident 3 and Resident 4 had happened on 8/30/25 and this was the second altercation between both residents. The ADMN stated both altercations should not have happened. Review of the facility's policy and procedure titled Abuse Prohibition, revised on 10/25/24, indicated, .Policy; .Prevention of occurrences.Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse.for all patients.Process: 6.b. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting.i. The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected.ii. The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in altercation. 055201 Page 4 of 4