F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on interview and record review, the facility failed to ensure the preservation of dignity for one of two
sampled residents (Resident 1), when Resident 1 was left on a soiled bedpan (a medical device used to
collect urine or feces for individuals who are unable to leave their bed to use a regular toilet) for hours
without any response to his multiple call light (typically a light or bell used in healthcare setting to notify staff
that a resident requires assistance) activation attempts to get assistance from facility staff.
These failures resulted in Resident 1 being made to endure an undignified experience being left for hours,
on a soiled bedpan, feeling helpless and embarrassed with an increased potential for skin breakdown.
Findings:
A review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information
about the resident) indicated Resident 1 was admitted to the facility in April 2025, for surgery aftercare
following a right lower leg fracture, with a history of falling, and difficulty walking.
During an interview on 5/8/25 at 3:34 p.m. Resident 1 stated he was left on a bedpan for hours in the
middle of the night and no one responded to his call light even though he pushed it multiple times. Resident
1 stated he felt helpless and embarrassed being left like that on a dirty bedpan, and he notified a nurse
immediately the next morning.
During an interview on 5/8/25, at 1:13 p.m. with the facility Administrator (ADM), the ADM confirmed
Resident 1 had been left on a bedpan for a prolonged period. The ADM stated he thought this incident
occurred due to a communication breakdown between CNA 1 and CNA 2 that night, when they changed
assignments in the middle of the shift. The ADM stated the facility used to have a process they used to
assign residents to CNAs for all shifts including the night shift, but the facility was not using that process
when this incident occurred. The ADM stated going forward, the old process of assigning residents to
specific CNAs would be brought back into practice. The ADM stated the two CNAs involved, CNA 1 and
CNA 2, were placed on suspension from 4/27/25 through 5/1/25, and were counseled about resident
dignity and communication.
During an interview on 5/8/25 at 1:56 p.m. with CNA 3, CNA 3 stated the normal process after leaving a
resident on a bedpan, is to provide privacy, leave the call light within reach so that the CNAs know when to
go back and assist the resident with being taken off the bedpan. CNA 3 acknowledged leaving a resident on
a bedpan for hours could potentially cause the resident ' s skin to break down,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056090
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056090
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blue Oak Post-Acute
850 Sonoma Ave
Santa Rosa, CA 95404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
causing injury.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/8/25 at 4:00 p.m. Licensed Nurse 1 (LN 1) stated the normal process, when a
resident needs assistance for anything, is to push the call light for assistance, and then staff, a certified
nurse assistant (CNA) or a nurse, should respond to the resident ' s call within a few minutes.
Residents Affected - Few
During an interview on 5/8/25 at 4:13 p.m. with the DON, the DON confirmed when Resident 1 was left on a
soiled bedpan for hours without any response to his multiple attempts for assistance from facility staff, was
a dignity issue. The DON added, the associated risk for Resident 1 in the facility ' s failure to ensure
Resident 1 ' s preservation of dignity, she thinks would be, possible embarrassment experienced by
Resident 1. The DON stated that her expectation is that staff provide residents with dignity, respond to call
lights timely, and not leave residents on bedpans for extended periods of time, per facility policy.
During a review of the facility policy and procedure titled, Dignity, revised February 2021, indicated, .Each
resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of
satisfaction with life, and feelings of self-worth and self-esteem . Residents are treated with dignity and
respect at all times . The facility culture supports dignity and respect for residents . standards of care that
compromise dignity are prohibited . Staff are expected to promote dignity and assist residents; for example:
. b. promptly responding to a resident ' s request for toileting assistance .
During a review of facility policy and procedure titled, Bedpan/Urinal, Offering/Removing, revised February
2018, indicated, The purpose of this procedure is to provide the resident with bedpan and/or urinal
assistance . Do not allow the resident to sit on a bedpan for extended periods. This is not only
uncomfortable to the resident, it also causes skin breakdown . Put the toilet tissue and call light within easy
reach of the resident . Allow the resident as much privacy as possible . Tell the resident to call you when he
or she has finished leave the room to give the resident privacy . When the resident calls that he or she has
finished, return to the room . Remove the bedpan
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056090
If continuation sheet
Page 2 of 2
