Health inspection·December 22, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents' right to be free of physical abuse by another resident for two of eight sampled residents (Resident 2 and Resident 3) when:1. Resident 2 was struck several times in the back of his head by Resident 1; and2. Resident 3 was struck in the head by Resident 4.These failures resulted in Resident 3 having mild facial pain and fear and had the potential to result in serious bodily harm to the residents.Findings:1. A review of Resident 1's admission record indicated he was last admitted to the facility in 3/2025 with the diagnosis of schizophrenia (a mental illness that makes it hard to tell what's real, as people with this illness may hear voices, see things that aren't there, or have unusual beliefs. It also affects thinking and emotions).A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/19/25, indicated Resident 1 had no memory impairment.A review of Resident 1's progress note, dated 12/12/25 indicated, Resident 1 stated Resident 2 was making weird noises and he hit Resident 2.A review of Resident 2's admission record indicated he was last admitted to the facility in 8/2023 with the diagnosis of schizophrenia.A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairment.A review of Resident 2's progress note, dated 12/12/25, indicated Resident 2 reported he was sitting on his bed when Resident 1 approached and began hitting him on the back of the head. Resident 2 denied pain on back of head or neck and no visible marks or bruising noted on head or neck.During an interview on 12/22/25 at 1:44 p.m. with the Case Manager (CM) 1, the CM 1 stated she had spoken with Resident 1 and Resident 1 admitted to hitting Resident 2 on the back of the head.During an interview on 12/22/25 at 3:10 p.m. with the Program Director (PD), the PD acknowledged Resident 2 was hit by Resident 1 on the back of the head and agreed what occurred on 12/12/25 to Resident 2 was physical abuse. Furthermore, the PD stated it was the facility's responsibility to protect the residents from such abuse.2. A review of Resident 3's admission record indicated she was last admitted to the facility in 10/2025 with the diagnosis of schizophrenia.A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had no memory impairment.A review of Resident 3's progress note, dated 12/13/25 and written by the PD, indicated Resident 3 reported she had been lying in bed when Resident 4 approached her and hit her in the head with her hand several times. The note further indicated Resident 3 had complained of mild pain to the right temple area.A review of Resident 4's admission record indicated she was last admitted to the facility in 12/2025 with the diagnosis of schizoaffective disorder (a mental illness blending symptoms of schizophrenia with those of a mood disorder).A review of Resident 4's progress note, dated 12/13/25 and written by the PD, indicated Resident 4 had hit Resident 3 several times in the head, unprovoked.During an interview on 12/22/25 at 12:53 p.m. with Resident 3, Resident 3 stated Resident 4 had hit her on the right side of her face. Resident 3 stated that it hurt and she had been fearful of Resident 4. During an interview on 12/22/25 at 3:10 p.m. with the PD, the PD acknowledged Resident 3 had (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 12/22/2025 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)