Health inspection·February 10, 2026

Blue Oak Post-Acute (formerly Creekside Rehabilitation and Behavioral Health) Intake# 2673500 State Citation B was written. REGULATION VIOLATION(S) F600: §483.12(a)(1) (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 12/10/25 at 11:15 a.m., an unannounced visit was conducted at the facility to investigate an allegation of staff to resident abuse. The Department determined 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 1 (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 Set (MDS- a federally mandated assessment tool), dated 11/28/25 indicated Resident 1 had no memory impairment, no symptoms of depression, no hallucinations and no behavioral symptoms. A review of an SBAR (SBAR-Situation, background, assessment, recommendation) note dated 11/19 at 4:16 pm indicated Resident 1 reported to case manager and program director feelings of emotional distress after an interaction with staff. It further indicated Resident 1 had no prior incidents and reported feeling embarrassed and humiliated by the interaction. During an interview on 12/10/25 at 11:45 am with Resident 1, Resident 1 recalled the incident in detail. Resident 1 stated that CNA 1 came to the dining room and asked Resident 1 to come with CNA 1 to her room where Unlicensed Staff 1 was waiting with a bag. CNA 1 proceeded to instruct Resident 1 to remove the contents of the toilet, which contained urine and feces, with gloved hands because it wasn't fair to Unlicensed Staff 1. Resident 1 stated she was shocked and didn't know what to do so she complied. Resident 1 asked CNA 1 to please close the door and CNA 1 refused. Resident 1 stated, "I felt extremely embarrassed, humiliated and victimized. I felt CNA 1 was intentionally trying to humiliate and control me." During an interview on 12/10/25 at 3:36 pm with the Director of the Behavioral Health Program (DBH), DBH stated she was shocked by the accusation and CNA 1's behavior was inappropriate and wrong and would not be tolerated and that CNA 1 and Unlicensed Staff 1 were both terminated due to the incident. DBH stated the incident would make the resident feel fearful, concerned about retaliation, and humiliated. A review of the facility's 5-day summary report, dated 11/25/25, indicated CNA 1 admitted to her actions and stated she was trying to teach Resident 1 a lesson. The report further indicated Unlicensed Staff 1 confirmed the incident to be true. A review of the facility's policy titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021, stipulated, residents have the right to be free from abuse, including verbal abuse and mental abuse and the facility has a commitment to prevent resident abuse by anyone. Therefore, the department determined 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 1 ( 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. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.