Blue Oak Post-Acute

In the surveyor’s words

From the most serious findings on record at Blue Oak Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 11, 2025

  Based on interview and record review, the facility failed to protect one of five sampled resident's ( Resident 1) right to be free from psychological abuse by a Certified Nursing Assistant ( CNA 1) and Unlicensed Staff 1, when Resident 1 was forced to unclog her room's toilet , which contained urine and feces, with her own gloved hands while the door to room was purposely left open.This failure made Resident 1 feel embarrassed, humiliated and victimized and negatively impacted her psychological well-being.A review of Resident 1's admission record indicated she was admitted in 05/25, with the diagnosis of Paranoid Schizophrenia (a serious mental health condition where a person has a hard time telling the difference between what is real and what is not).A review of Resident 1's Minimum Data… […]

• Actual harm, isolatedF689Jan 7, 2025

  Based on interview and record review, the facility failed to ensure supervision for one of three sampled residents (Resident 1) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) fell and sustained injuries. This failure resulted in Resident 1 sustaining a fracture (broken bone) of the left distal phalanx (a small bone on the tip of the thumb located under the nail) and abrasions (a partial loss of skin, usually due to scraping) to his face and both knees. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to the brain). […]

• No harm, potential for more than minimal, widespreadF883Feb 2, 2023

  Based on interviews and records review, the facility failed to ensure eligible residents received the pneumococcal vaccine (protects against serious and potentially fatal pneumococcal infections), according to the recommendation of the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to the Director of the CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States), for 99 out of 106 sampled residents. […]

• No harm, potential for more than minimal, patternF600Apr 16, 2026

  F600 The facility failed to ensure residents were free from physical abuse, including resident to resident abuse, when it did not implement effective preventative resident abuse nursing care planned interventions to prevent three resident to resident altercations for three of five sampled residents (Residents 2, 3, and 5). As a result, Resident 2 sustained head trauma to the right side and back of his head, with pain, swelling and redness; Resident 3 sustained abrasion with bleeding to his right ear, and Resident 5 sustained skin injury resulting in redness on his jaw. […]

• No harm, potential for more than minimal, patternF609Jan 7, 2026

  Based on interview and record review, the facility failed to provide the State Survey Agency (California Department of Public Health [CDPH]) written investigation reports (an investigation conducted by the facility following the allegations of abuse) of two facility reported abuse allegations within five calendar days, for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4).This failure decreased the facility's potential to ensure relevant interventions were in place and implemented to prevent further abuse and psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm for Resident 1, Resident 2, Resident 3, and Resident… […]