Live Oak Rehab Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to report an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) to the Department within 24 hours for one of the sampled residents (Resident 1) by failing to:a. Ensure the facility reported to the Department when the facility was made aware on 1/9/2025 of Resident 1's sustained further injury and dislocation (a disruption of the normal position of the ends of two or more bones where they meet at a joint) of the right hip in accordance with the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting.This failure had the potential to affect the health, safety, and well-being of the residents. Findings:During a

review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with the diagnoses including, but not limited to, a right upper thigh fracture, recent right hip joint replacement surgery, encephalopathy (a condition affecting brain function), difficulty walking, and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS), dated [DATE REDACTED], the MDS indicated the resident had moderate cognitive impairment affecting daily decision-making. The MDS indicated a short-term memory problem, with difficulty recalling information after 5 minutes. The MDS indicated Resident 1 required substantial to maximal assistance with activities of daily living and mobility.During a

review of Resident 1's nursing progress notes, dated 1/9/2025, the progress notes indicated an x-ray was conducted at the facility. The x-ray report indicated Resident 1 had a right hip dislocation.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition [COC] to the resident) form, dated 1/9/2025, the form indicated Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation due to a possible right hip dislocation after complaining of pain and discomfort.During an interview on 8/29/2025 at 11:52 AM, Administrator (ADM) stated the injury was not and should have been reported to

the state agency. 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Live Oak Rehab Center

537 W Live Oak San Gabriel, CA 91776

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet