Live Oak Rehab Center: Fall Unreported for 7 Days - CA
The resident, identified in inspection records only as Resident 1, had a documented history of falling. She had dementia, muscle weakness, and an abnormal gait. Her care plan explicitly called for notifying her physician if she fell. A fall risk assessment completed three weeks earlier flagged her as high risk. According to her most recent functional assessment, she required two or more helpers for most daily activities and was severely impaired in her ability to make decisions for herself.
None of that changed what Licensed Vocational Nurse 1 did when she found the woman on the floor.
At approximately 9:30 PM on December 23, LVN 1 came upon Resident 1 sitting between her own bed and her roommate's bed, half on the floor mat and half on the bare floor, her left arm gripping her roommate's bedside rail. The resident had fallen sometime that morning, around 8:30 AM, without anyone witnessing it. By the time LVN 1 found her that evening, more than twelve hours had passed.
LVN 1 told inspectors she did not report the fall to the physician or the Director of Nursing because, in her words, she "thought nothing of it."
The physician was not notified. The Director of Nursing was not notified. The resident's family was not notified.
Seven days passed.
Progress notes dated December 29 recorded the fall and indicated that both the physician and the responsible party had been notified on December 30. But when inspectors interviewed the resident's family member on January 2, 2026, he told them he had not been notified about the fall on December 23. The notification the facility's own records described had not happened, at least not to him.
The Director of Nursing confirmed to inspectors that LVN 1 had been suspended specifically because she failed to report the fall to the physician, to the family, and to the DON herself. The suspension came after the inspection was already underway.
For a patient with dementia and documented muscle weakness, a fall carries real consequences that don't always show up immediately. Fractures, internal bleeding, and other complications can develop or worsen over hours and days without medical evaluation. The reason a care plan calls for immediate physician notification after a fall is precisely because the window for catching those complications closes quickly. Seven days is not a window. It is the window nailed shut.
Resident 1's care plan, dated December 5, said to notify the physician "as indicated" following a fall. Her fall risk assessment, also from December, confirmed she was at risk. Her functional assessment showed she was dependent on staff for nearly every aspect of daily care, from bathing and dressing to transferring from a chair to a bed. She was not a resident who could advocate for herself or summon help on her own.
LVN 1 found her on the floor, holding onto a stranger's bed rail, and walked away.
The facility's own written policy on changes in a resident's condition, last revised in March 2023, lists accidents and incidents of unknown origin among the events requiring immediate physician notification. The fall on December 23 was unwitnessed. Its cause was unknown. It met that standard exactly.
Federal inspectors cited the facility for failing to immediately notify the physician following the fall, a deficiency classified as causing minimal harm or potential for actual harm. The inspection was conducted January 2, 2026, in response to a complaint.
What Resident 1's family member was told, and when, remains unclear. What is clear is that on the morning after Christmas, and the morning after that, and the morning after that, he did not know his family member had been found on the floor, alone, gripping the wrong bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Live Oak Rehab Center from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LIVE OAK REHAB CENTER in SAN GABRIEL, CA was cited for violations during a health inspection on January 2, 2026.
The resident, identified in inspection records only as Resident 1, had a documented history of falling.
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.