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Complaint Investigation

Live Oak Rehab Center

August 19, 2025 · San Gabriel, CA · 537 W Live Oak
Citations 1
CMS Rating 1/5
Beds 99
Provider ID 056127
Healthcare Facility
Live Oak Rehab Center
San Gabriel, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

LIVE OAK REHAB CENTER in SAN GABRIEL, CA — inspection on August 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0558
Resident Rights Deficiencies

During an interview on 8/19/2025 at 3 PM with CNA 1, CNA 1 stated when she covers for lunch break, she only introduces herself to the resident if she answers the resident's call light. If the Resident did not press their call light, she does not introduce herself to them.

During a concurrent interview and record review on 8/19/2025 at 3:05 PM with Registered Nurse Supervisor 1 (RNS 1), the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 3/2021, the P&P indicated, in order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. RNS 1 stated, Resident 1 wants things done in a certain way or has preferences, the Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) will discuss and if it meets facility policy then it will be added to the resident's care plan and implemented by the facility. RNS1 stated the facility has to meet Resident 1's needs. RNS 1 stated, We have to listen to the resident and accommodate as much as possible.

During a concurrent Interview and record review on 8/19/2025 at 3:27 PM with RNS 1, Resident 1 Care Plans dated 3/2024 to 8/2025 were reviewed. RNS 1 stated there were no care plans developed to address Resident 1's preferences. RNS 1 stated, No care plan means it was not consistently done. RNS 1 stated the care plans were made unique to the Resident and an organized way to determine if the facility is managing or solving the problem of the Resident.

During an interview on 8/19/2025 at 3:35 PM with RNS 1, RNS 1 stated, We should always introduce ourselves to the Resident to let the Resident know who to call for if they need assistance. It was part of the Resident rights. We introduce ourselves to the Resident for dignity and respect. RNS1 stated this keeps the Resident aware if the staff were to leave and who will be covering.

During a concurrent interview and record review on 8/19/2025 at 3:41 PM with Administrator (ADM), the Concern Record dated 3/14/2025 was reviewed. ADM stated, The Concern Record was all of Resident 1's preferences. We always come and see Resident 1, but we did not have a documentation every time we visit her to ensure that her preferences are being followed by the staff.

During a review of the facility's Policy and Procedure (P&P) titled, Dignity revised 2/2021, the P&P 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.1.

Residents are treated with dignity and respect at all times.2.

The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs.

This begins with the initial admission and continues throughout the resident's facility stay.3.

Individual needs and preferences of the residents are identified through the assessment process.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN GABRIEL, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LIVE OAK REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.