Live Oak Rehab Center
Inspection Findings
F-Tag F0558
F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
get very upset. I will just blow up. I get so much anxiety when I cannot find my call light. During an interview
on 8/19/2025 at 2:02 PM with Resident 1, Resident 1 stated that during lunch on 8/19/2025, CNA 1 and another staff (hospice [compassionate care for people who are near the end of life] staff) were talking so loudly, while CNA 1 was assisting one of her roommates. Resident 1 stated, I told them to keep it down because they were talking too loudly, but they did not stop. I got upset. Resident 1 also stated the night shift staff still wear strong perfume when they come in to work, despite being requested not to. Resident 1 stated, I can smell the night shift staff in the hallway even just standing by my door. During a concurrent
interview and record review on 8/19/2025 at 2:24 PM with SSD, the Social Services Notes, dated 4/1/2025 to 8/19/2025 were reviewed. There was no documentation that SSD followed up with Resident 1 from 4/2025 to 8/19/2025 to discuss Resident 1's preferences. SSD stated, I visit and talk to Resident 1, but she brings up personal stories. SSD stated she did not document every visit to Resident 1. 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.
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LIVE OAK REHAB CENTER in SAN GABRIEL, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.