Live Oak Rehab: Hip Dislocation Investigation Skipped - CA
The resident, identified only as Resident 1 in inspection records, was admitted to Live Oak Rehab Center on January 3, 2025, for recovery following right hip surgery. The 83-year-old had already fractured their right thighbone and undergone surgical repair before arriving at the facility.
By January 9, a physical therapist noticed the resident was experiencing pain and discomfort in the hip area. The therapist immediately notified the charge nurse, who ordered bilateral hip x-rays.
The x-ray results revealed a right hip dislocation. Staff transferred the resident to a general acute care hospital for further evaluation that same day.
Nobody at Live Oak investigated what caused the dislocation.
During a federal inspection in August, the facility's Director of Nursing told inspectors that staff "did not know how Resident 1 sustained a hip dislocation injury." When pressed about why no investigation occurred, the director explained she "thought it was an injury that happened before Resident 1 was admitted to the facility."
The director later acknowledged the assumption was wrong. "Resident 1's injury was not but should have been investigated," she told inspectors.
Hip dislocations in nursing home residents with cognitive impairment and movement disorders like Parkinson's disease can result from falls, improper transfers, or inadequate assistance with mobility. The resident's medical assessment from January 9 showed they had short-term memory problems and were "moderately impaired in cognitive skills for daily decision making," making them unable to explain what happened.
The facility's own policies required an investigation. Live Oak's written procedure on "Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating," revised in March 2023, explicitly states that "injuries of unknown origin are to be reported and thoroughly investigated."
The policy designates the administrator as responsible for initiating such investigations.
When inspectors interviewed the facility's administrator during their August visit, the administrator confirmed that "injuries of unknown origin is considered an abuse and it should have but was not investigated."
Federal nursing home regulations classify unexplained injuries as potential indicators of abuse or neglect, requiring immediate investigation to determine the cause and prevent future incidents. The failure to investigate leaves both the specific resident and other patients potentially vulnerable to similar harm.
The resident's medical complexity made the oversight particularly concerning. Admitted with a recent hip fracture and surgical repair, they also lived with Parkinson's disease, which causes progressive movement problems including stiffness and uncontrollable movements that increase fall risk. The combination of cognitive impairment from dementia and physical instability from Parkinson's created multiple scenarios where injury could occur without witnesses.
Live Oak's investigation policy outlines specific steps that should have been taken immediately after discovering the hip dislocation. The procedure requires staff to secure the scene, interview witnesses, review relevant medical records, and document all findings. None of these steps occurred.
The timing of the injury raised additional questions that remain unanswered. The resident had been at the facility for six days when the physical therapist noticed hip pain. The original hip surgery and fracture had occurred before admission, but the dislocation represented a new injury that developed while under the facility's care.
Physical therapy sessions typically involve careful movement and positioning of residents recovering from hip surgery. The therapist who discovered the resident's pain would have been among the staff members most likely to notice changes in the patient's condition or mobility.
Federal inspectors found that Live Oak's failure to investigate affected not just Resident 1, but potentially other vulnerable patients at the 120-bed facility. The inspection report noted that the violation "had the potential to affect the health and safety of the resident" and classified it as causing "minimal harm or potential for actual harm."
The inspection occurred following a complaint filed against the facility. Federal investigators reviewed admission records, nursing progress notes, and the facility's minimum data set assessment for the resident, along with interviewing key staff members including the director of nursing and administrator.
Live Oak Rehab Center has operated in San Gabriel since the 1980s, providing short-term rehabilitation and long-term care services. The facility accepts patients recovering from surgeries, strokes, and other medical conditions requiring intensive therapy and nursing care.
The August inspection revealed that Live Oak's leadership understood their obligations under federal regulations but failed to follow their own written policies. Both the director of nursing and administrator acknowledged during interviews that the injury should have been investigated according to facility procedures.
The case highlights ongoing challenges in nursing home oversight, particularly regarding residents with cognitive impairment who cannot advocate for themselves or explain how injuries occur. Federal regulations require facilities to protect vulnerable residents through systematic investigation of unexplained injuries, regardless of assumptions about when or where the harm might have occurred.
Resident 1's outcome following the hospital transfer remains unclear from available records. Hip dislocations in elderly patients, particularly those with underlying bone and joint problems, can lead to prolonged recovery periods and increased risk of future complications.
The facility's assumption that the injury predated admission meant that no corrective measures were implemented to prevent similar incidents. Staff received no additional training on proper transfer techniques, fall prevention protocols were not reviewed, and no environmental hazards were identified or addressed.
The director of nursing's admission that the investigation "should have been" conducted came eight months after the injury occurred, during a federal inspection prompted by an outside complaint about the facility's practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Live Oak Rehab Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LIVE OAK REHAB CENTER in SAN GABRIEL, CA was cited for violations during a health inspection on August 29, 2025.
The 83-year-old had already fractured their right thighbone and undergone surgical repair before arriving at the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.