Blue Oak Post-acute

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 interview and record review, the facility failed to prevent abuse for one resident (Resident 1) of two sampled residents when Resident 2 threw water at Resident 1.This failure resulted in Resident 1 having had water thrown at him.Findings:A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) after a stroke, and major depressive disorder.A review of Resident 1's Minimum Data Set (an assessment tool) dated 6/18/25 indicated a Brief Interview for Mental Status (BIMS, an assessment of cognitive function (the mental processes the brain uses to perceive, learn, remember, reason)) score of 12 which meant Resident 1's cognition was moderately intact.A review of an admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included stroke, anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and aphasia (a disorder that makes it difficult to speak).A review of Resident 2's MDS dated [DATE] indicated a BIMS score of 15 which meant Resident 2's cognition was intact.A review of Resident 2's change of condition note dated 8/29/25 at 8:47 a.m. indicated, [Resident 2] agitated by his neighbor being noisy and threw a pitcher of water at the noisy resident [Resident 1].A review of Resident 1's change of condition note dated 8/29/25 at 9:26 a.m. indicated, [Resident 1] did not realize he was being 'noisy' and agitating his neighbor and was surprised when his neighbor threw a pitcher of water at him.In an interview on 9/8/25 at 3:16 p.m., Resident 1 acknowledged a man from down the hall entered his room and threw water at him.In an interview on 9/8/25 at 3:25 p.m., Resident 2 stated he threw water on Resident 1 because Resident 1 continuously yells, and no one has done anything about it.A review of the facility's policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Residents have the right to be free from abuse .Protect a facility-wide commitment .to support the following objectives .Protect residents from abuse .by anyone including .other residents .

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.

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