Live Oak Rehab Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately inform the physician for one of two sampled residents (Resident 1), who had diagnoses that included history of falling, muscle weaknesses, dementia (a progressive state of decline in mental abilities), and abnormality in gait and mobility when Resident 1 had
an unwitnessed fall on 12/23/2025. This deficient practice placed Resident 1 at risk for delayed intervention to ensure Resident 1 did not have complications from the fall such as fracture (break or crack in the bone).
Findings
During a review of Resident 1' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with the following but not limited to diagnoses of muscle weaknesses, dementia and abnormality in gait and mobility. During a review of Resident 1's Fall Risk Assessment, dated 12/3/2025, the assessment indicated Resident 1 is at risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/5/2025, the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated, the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to stand, chair/bed to chair transfer, and toilet transfer. During a review of Resident 1's Care Plan with focus risk for falls/injury, dated 12/5/2025, the Care Plan indicated to notify physician as indicated (of the fall). During a review of Resident 1's Progress Notes, dated 12/29/2025, the Progress Notes indicated the resident had an unwitnessed fall on 12/23/2025 at 8:30AM. The progress notes indicated, the Physician and Responsible Party (RP) was notified of the unwitnessed fall on 12/30/2025. During an interview on 1/2/2025 at 10:55 AM, Resident 1's Responsible Party (RP) stated he was not notified about Resident 1's fall on 12/23/2025.
During an interview on 1/2/2025 at 3:15 PM, the Director of Nursing (DON) stated LVN 1 was suspended because LVN 1 did not report Resident 1's unwitnessed fall to the DON, Resident 1's physician and RP.
During an interview on 1/2/2025 at 3:33 PM, Licensed Vocational Nurse (LVN) 1 stated, on 12/23/2025 around 9:30 PM, she observed Resident 1 on the floor with half her buttock on the floor mat and the other half on the floor. LVN 1 also stated Resident 1 was observed sitting between Resident 1's bed and the resident's roommate's bed and Resident 1 left arm was held on to her roommates' bedside rail. LVN 1 stated she did not report the fall to the physician or the DON because she thought nothing of it. During a
review of the facility's Policy and Procedure (P&P) titled Change in a Resident's Condition, revised 3/2023,
the P&P indicated the nurse will notify the resident's attending physician when there has been the following but not limited to accident or incident of an unknown source
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:
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.