Live Oak Rehab Center
LIVE OAK REHAB CENTER in SAN GABRIEL, CA — inspection on August 29, 2025.
Found 2 citations. 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
During a record review of the facility's P&P titled, Unusual Occurrence Reporting, revised in 12/2007, the P&P indicated that unusual occurrences must be reported to appropriate agencies within 24 hours as required by law.During a review of the facility's P&P titled, Abuse, Neglect, or Misappropriation-Reporting and Investigating, revised March 2023, the P&P indicated that all reports of resident abuse (including injuries of unknown origin) neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) immediately and thoroughly investigated by facility management within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Live Oak Rehab Center
537 W Live Oak San Gabriel, CA 91776
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to investigate an injury of an unknown source for one of four sampled residents (Resident 1) per the facility's policy and procedure (P&P).This failure had the potential to affect the health and safety of the resident.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/3/2025, with the diagnoses including but not limited to fracture of the right thighbone, aftercare following right hip surgery, Parkinson's disease (a progressive brain disorder that causes uncontrollable movements such as stiffness), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/9/2025, the MDS indicated resident had a short-term memory problem and is moderately impaired in cognitive skills for daily decision making.During a review of Resident 1's Change of Condition (COC, communicating significant changes in resident health) form, dated 1/9/2025, the COC form indicated the Physical Therapist notified the Charge Nurse, Resident 1 had pain and discomfort in the hip.During a review of Resident 1's nursing progress notes, dated 1/9/2025, the notes indicated a bilateral hip x-ray was ordered.
The x-ray report indicated Resident 1 had a right hip dislocation and was transferred to the general acute care hospital (GACH) for further evaluation.
During an interview on 8/29/2025 at 10:51 a.m. with Director of Nursing (DON), DON stated staff did not know how Resident 1 sustained a hip dislocation injury.
The DON stated they did not investigate it because she thought it was an injury that happened before Resident 1 was admitted to the facility.
The DON also stated Resident 1's injury was not but should have been investigated.
During a concurrent interview and record review on 8/29/2025 at 1:04 PM of the facility's policy and procedure titled Abuse, Neglect, Exploitation, or Misappropriation -Reporting and Investigating, revised 3/2023, was reviewed.
The Administrator (ADM) stated injuries of unknown origin is considered an abuse and it should have but was not investigated.
During a review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation, or Misappropriation -Reporting and Investigating, revised 3/2023, the P&P indicated injuries of unknown origin are to be reported and thoroughly investigated.
The P&P also indicated the administrator initiates the investigations.
Facility ID: