Health inspection·December 12, 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. Based on observation, interview, and record review, the facility failed to develop a care plan to reduce the potential risk of pressure injury for one of three sampled residents (Resident 1) when a low air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not included in Resident 1's care plans. This failure had the potential to place Resident 1 at risk for possible skin complications and not receiving effective and person-centered care. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility originally in 2020 and re-admitted in the Summer of 2025 with multiple diagnoses including encounter for palliative care (a patient-centered care that provider focuses on improving quality of life for serious illnesses, managing symptoms such as pain, anxiety, fatigue, offering emotional/spiritual support, working alongside curative treatments), senile degeneration of brain (an age-related cognitive decline, a progressive loss of brain function due to damaged brain cells), vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels, restricting blood flow and oxygen to the brain), pressure ulcer of sacral region stage 3 (full-thickness skin loss where fat tissue is visible, but bone, tendon or muscle is not exposed yet on the tailbone, requiring urgent care like pressure relief and dressing change to prevent infections), and pressure ulcer of the left buttock stage 3 (a deep thickness skin loss showing visible fat but not bone, muscle, or tendon, requiring urgent care like pressure relief and dressing change to prevent infections).Review of Resident 1's Order Summary Report, indicated an active order for a LAL mattress for prophylactic (preventive) skin management due to a history of pressure injury as per manufacturer guidelines was ordered on 7/8/25.During an observation on 12/11/25, at 9:17 AM, in Resident 1's room, Resident 1 was observed lying on her right side on a LAL mattress.During a concurrent interview and record review on 12/11/25, at 3:25 PM, with License Nurse (LN) 3, Resident 1's order summary report and care plans were reviewed. LN 3 confirmed that Resident 1 had an active physician order for a LAL mattress, which was initiated on 7/8/25 for prophylactic skin management. LN 3 further confirmed that there was no active care plan addressing the use of a LAL mattress documented in Resident 1's care plans. LN 3 stated that a care plan served as a guiding tool and a communication method for nursing staff to follow specific interventions to provide person-centered care and meet Resident 1's medical and physical needs. LN 3 further stated that Resident 1 had a history of pressure injuries and that a LAL mattress was implemented to reduce the risk of recurrence. LN 3 stated that to coordinate care effectively, nurses needed to develop and maintain care plans to ensure appropriate interventions were implemented to meet the residents' needs. LN 3 further stated that the absence of an active care plan for a significant intervention such as a LAL mattress could result in a negative outcome and increased risk for decline in Resident 1's skin condition, as the LAL mattress was intended to prevent or reduce the incidence of pressure Page 1 of 5 055201 055201 12/12/2025 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 injuries for a resident who was immobile and unable to express her needs.During an interview on 12/12/25, at 8:34 AM, LN 2 stated that care plans had an important impact on residents' care and should be individualized to meet each resident's needs. LN 2 further stated that care plans served as a guide for providing care, managing symptoms, and function as a helpful reference and checklist for nursing staff to follow the established plan of care. LN 2 stated that without care plans, nurses would lack clear guidelines to follow, resulting in a lack of continuity of care and no point of reference. LN 2 further stated that all residents' concerns, physician orders, treatments, behaviors, and interventions should be included in the resident's care plan. LN 2 explained that nursing staff needed to routinely review and update care plans to ensure residents' safety and that their needs were appropriately met. During a concurrent interview and record review on 12/12/25, at 1:12 PM, with the Director of Nursing (DON), Resident 1's active care plans, and the facility policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, dated 8/25/21 were reviewed. The DON confirmed there was no care plan found that addressed the use of a LAL mattress in Resident 1's current care plans. The DON stated that a care plan for the LAL mattress should have been created and maintained to reflect Resident 1's current plan of care. The DON further stated that care plans served as a method of communication for staff regarding how to provide proper care to the residents, and the absence of a care plan addressing LAL mattress could have negatively affected Resident 1's health condition. The DON explained that her expectation was for nursing staff to develop a person-centered care plan for the LAL mattress and to implement interventions consistent with Resident 1's health condition for as long as there was an active order. The DON confirmed that this expectation was not met by the nursing staff. Review of the P&P indicated, .PURPOSE: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical.needs shall be developed for each resident.PROCEDURE 1. Each resident's comprehensive care plan is designed to.h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. The DON acknowledged that the facility's P&P was not followed.Review of the facility's P&P 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.POLICY The implementation of an individual patient's skin integrity management.Staff continually. implements revisions to the plan of care as needed.PROCEDURE.5. Develop the resident-centered care plan and interventions based on the risk factors.the condition of the skin.a. The interventions must be based on current, recognized standards of care. 055201 Page 2 of 5 055201 12/12/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly adjusted according to Resident 1 and Resident 2's individual weights.These failures had the potential to place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.Findings:a. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility originally in 2020 and re-admitted in the Summer of 2025 with multiple diagnoses including encounter for palliative care (a patient-centered care that provider focuses on improving quality of life for serious illnesses, managing symptoms such as pain, anxiety, fatigue, offering emotional/spiritual support, working alongside curative treatments), senile degeneration of brain (an age-related cognitive decline, a progressive loss of brain function due to damaged brain cells), vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels, restricting blood flow and oxygen to the brain), pressure ulcer of sacral region stage 3 (full-thickness skin loss where fat tissue is visible, but bone, tendon or muscle is not exposed yet on the tailbone, requiring urgent care like pressure relief and dressing change to prevent infections), and pressure ulcer of the left buttock stage 3 (a deep thickness skin loss showing visible fat but not bone, muscle, or tendon, requiring urgent care like pressure relief and dressing change to prevent infections).Review of Resident 1's Order Summary Report, indicated an active order for a LAL mattress for prophylactic (preventive) skin management due to a history of pressure injury as per manufacturer guidelines was ordered on 7/8/25.Review of Resident 1's medical record titled, Weight Summary, dated 12/4/25, indicated, .112.2 LBS [pounds] Hoyer Lift [a mechanical or electric device used to safely lift and transfer individuals with limited mobility between a bed, chair, or other surfaces].During an observation on 12/11/25, at 9:17 AM, in Resident 1's room, Resident 1 was observed lying on her right side on a LAL mattress, which was set at 265 pounds (lbs, a unit for measuring weight). During a concurrent observation, interview, and record review on 12/11/25, at 9:40 AM, with Licensed Nurse (LN) 1, in Resident 1's room, LN 1 confirmed Resident 1 was lying on a LAL mattress set at 265 LBS. LN 1 stated that Resident 1 had a healed pressure ulcer to the coccyx (tailbone) area and was placed on a LAL mattress for prophylactic skin management due to a history of pressure injuries. Review of Resident 1's electronic health record (EHR), Resident 1's most recent weight, dated 12/4/25, showed the resident weighed 112.2 LBS, indicating the LAL mattress was not set according to the resident's current weight. LN 1 stated that it was the nurses' responsibility to ensure the LAL mattress setting was adjusted according to Resident 1's current weight. LN 1 further stated that an incorrect setting posed a potential risk for Resident 1's healed pressure ulcers to reopen. LN 1 explained that the purpose of the LAL mattress was to provide preventative care, and that failure to set it correctly could lead to skin deterioration and a prolonged healing process.During an interview on 12/11/25, at 11:36 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was waiting for another staff member to assist with transferring Resident 1 from the bed to a wheelchair using a Hoyer lift in order to take the resident to the activity room to join other residents. CNA 1 further stated Resident 1 was totally dependent on nursing staff for activities of daily living (ADLs, essential self-care tasks like bathing, dressing, eating, using the toilet, and walking) and mobility.During a concurrent Residents Affected - Some 055201 Page 3 of 5 055201 12/12/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview and record review on 12/11/25, at 11:42 AM, with the Treatment (TX) nurse, the TX nurse stated when redness was noted over bony prominences to the coccyx and buttocks, a LAL mattress would be placed for preventive skin care. The TX nurse further stated that the nurse would contact the physician to obtain an order, after which maintenance staff would place the mattress on the bed frame. The TX nurse stated that nursing staff were responsible for adjusting the LAL mattress pressure to the resident's current weight. The TX nurse further stated that if the LAL mattress was not set correctly, proper airflow would not be achieved, increasing the risk for pressure injuries and/or delaying the wound-healing process. The TX nurse explained that nurses needed to verify the resident's weight to ensure accuracy prior to adjusting the air pressure. The TX nurse stated that nurses needed to readjust the setting whenever there was a change in the resident's weight and the setting must be checked daily to ensure the setup was correct and functioning properly.b. Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in 2024 with multiple diagnoses including cerebral palsy (a group of permanent neurological disorders affecting movement, posture, and balance, caused by abnormal development or damage to the developing brain), dysphagia (difficulty swallowing food or liquids), and obesity (a chronic disease characterized by abnormal or excessive fat accumulation that negatively impacts health which increases the risk for serious conditions like heart disease, diabetes, and etc.).Review of Resident 2's Order Summary Report, indicated, .May have LAL mattress. Monitor function per manufacturer specifications every shift for history of PI [pressure injury]. was ordered on 9/9/25.Review of Resident 2's care plan revised on 10/14/25, indicated, .Focus .Resident at risk for skin breakdown related to impaired Cognition [the mental process of knowing, including thinking, learning, remembering, perceiving, and problem-solving ], incontinence [the inability to control bodily waste], limited mobility, poor safety awareness, obesity, depression [mood disorder]; hx [history] of right AKA [above knee amputation], cerebral palsy; use of psychotropics [mind altering drugs]; hx of pressure ulcer; dry skin/itching.May have LAL mattress. Monitor function per manufacturer specifications .During a concurrent observation and interview on 12/11/25, at 9:56 AM, with Resident 2, in Resident 2's room, Resident 2 was observed lying on her back on a LAL mattress. Resident 2 stated she had a special mattress for preventative skin care and reported she did not have any wounds. Resident 2 further stated the mattress was intended to keep her free from pressure wounds.During a concurrent observation, interview, and record review on 12/11/25, at 10:02 AM, with LN 1, in Resident 2's room, LN 1 confirmed that Resident 2's LAL mattress was set at more than 350 LBS (maximum firmness). A review of Resident 2's EHR, Resident 2's most current documented weight, dated 11/13/25, indicated she weighed 153.4 LBS. LN 1 stated that Resident 2 was at risk for increased friction due to lying on a LAL mattress set at maximum firmness. LN 1 stated that Resident 2 had a history of pressure injuries and that an air pressure not adjusted according to Resident 2's current weight could contribute to friction and the development of pressure ulcers, placing her health at risk. LN 1 further stated that the LAL mattress should have been adjusted based on Resident 2's current weight to function as a preventative measure and not place her at risk for injury. During a concurrent interview and record review on 12/12/25, at 1:12 PM, with the Director of Nursing (DON), Resident 1 and Resident 2's EHR were reviewed. The DON confirmed that Resident 1 had an order for a pressure-relieving mattress for preventative skin management due to a history of pressure injuries. The order indicated the mattress was to be monitored for proper function in accordance with manufacturer guidelines and was initiated on 7/8/25. A review of Resident 1's weight record dated 12/4/25, indicated she weighed 112.2 lbs. A review of the LAL mattress user manual for the identified brand name Item # specified that the pressure adjustment knob must be set according to the resident's 055201 Page 4 of 5 055201 12/12/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some current weight, using the weight scale as a guide to achieve a comfortable and therapeutic pressure level. The DON confirmed Resident 1's LAL mattress was not set to the resident's current weight. The DON further confirmed Resident 2 had an order for a pressure-relieving mattress with instructions to monitor its function per manufacturer guidelines since 9/9/25. A review of Resident 2's weight summary indicated the resident weighed 153.4 LBS on 11/13/25. The DON confirmed Resident 2's LAL mattress was not set to the resident's current weight. The DON further confirmed that both Resident 1 and Resident 2 were lying on mattresses that were not adjusted correctly to their current weights, as required by manufacturer guidelines. The DON stated that the mattresses were intended as a preventative intervention to reduce the risk of pressure injury recurrence. The DON further stated that when not set correctly, it would not be effective for residents with a history of pressure injuries creating the potential for recurrence of skin breakdown. The DON stated her expectation was that nursing staff monitor LAL mattress settings every shift to ensure air pressure was correctly adjusted based on Resident 1 and Resident 2's current weights and that the mattresses were functioning properly. The DON acknowledged that nursing staff did not meet her expectations.Review of the facility provided user manual for the LAL mattress titled, [Brand Name], dated 3/22/21, indicated, .PRODUCT FUNCTIONS.INTENDED USE.[item #] control unit and mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort.Pressure Adjust Knob adjustable by patient's weight.Turn the Pressure Adjust Knob to set a comfortable pressure level by using the weight scale as a guide. 055201 Page 5 of 5