Oak Grove Post Acute
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 16 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (1/5 stars)
- Above-median deficiencies (52 vs median 13.0)
- High RN turnover (64%)
Bottom 25% in CA · Below recommended RN staffing · Above recommended total nurse staffing · Worst in WINDSOR chain · $83,719 in fines · Abuse citation
What this means for your family
While some patients find the nursing staff helpful for rehabilitation, the facility has significant, documented issues with climate control and medical neglect. Families should prioritize verifying the current status of the HVAC system and the facility's ability to maintain consistent communication with residents.
Google Reviews
Google Reviews
16 reviews on Google“Families should exercise extreme caution due to severe allegations of medical neglect, improper temperature control, and poor communication. While some rehab patients and visitors praise the nursing staff and the availability of religious activities, recent reviews highlight critical failures in patient safety and facility maintenance.”
Quality Themes
Tap a score for detailsStrengths
- Attentive nursing and physical therapy staff
- Availability of religious/Bible study programs
- Consistent medication administration
Concerns
- Severe neglect and medical mismanagement (mentioned by 2 reviewers)
- Failure of facility climate control/air conditioning (mentioned by 2 reviewers)
- Inability to communicate with residents via phone
Rating Trends
Tap a year to see what changed
Distribution · 18 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1I noticed some wonderful mentions of the Bible study programs and religious services; could you tell me more about the spiritual activities available for residents?
- 2We want to ensure our loved one stays connected with us; what is the best way for family members to call or video chat with residents during the day?
- 3With the recent focus on improving health inspections, what specific steps is the facility taking to address recent state violations and improve care quality?
- 4How does the nursing team manage medication administration and ensure there are no errors in the daily routine?
- 5In the event of a medical emergency or a sudden change in health, what is the specific protocol for contacting the family and coordinating with doctors?
- 6We've heard great things about the physical therapy staff; how closely do the therapists work with the nursing team to support a resident's mobility?
Personalized based on this facility's data
Key Review Excerpts
“They treat their patients like animals. The air conditioner has been off for weeks and these patients have to stay in 110 degrees weather. My mother Has been septic three times because of the neglect.”
“I was there for my Treatment to get well I was Disable left gun shot wound the Nurse always help me and physical nurse also help me”
“I had a great time teaching and preaching Bible study to the Residents, they were adamant, listening and very attuned to the message, of the gospel of Jesus Christ.”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
4
measures
7
measures
6
measures
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has serious, recurring problems that families filed numerous complaints about. The most concerning issues involve protection from abuse and neglect, pressure ulcer care, and safety hazards. Multiple recent complaints cite failures to protect residents from harm, with some deficiencies still lacking correction plans. While the facility reports correcting most violations, the persistent pattern of resident abuse protection failures and safety issues suggests ongoing care quality concerns that warrant careful consideration.
Mar 26, 2026Complaint1
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Mar 11, 2026Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Nursing and Physician Services Deficiencies
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.
Mar 4, 2026Complaint1
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Feb 20, 2026Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Feb 11, 2026Complaint3
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Jan 16, 2026Complaint2
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Pharmacy Service Deficiencies
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.
Federal Penalties
Fine
Feb 20, 2024
$4,938
Fine
Feb 12, 2024
$7,527
Fine
Jan 22, 2024
$19,107
Fine
Dec 26, 2023
$8,711
Fine
Jun 28, 2023
$43,436
Ownership & Operations
Who Operates This Facility
Oak Grove Post Acute
for profit
Chain Affiliation
Windsor
23 facilities nationwide
Chain avg rating: 2.3/5 · Rank 14 of 19 (Worst)
Ownership & Management
Owners
Sapphire Operations, LLC
Owner · Organization
Tress, Avrohom
Owner (parent company)
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
16 reviews from families & visitors
Official Website
Visit stocktonnursing.com
Medicare data downloads
Original nursing home datasets
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