Live Oak Rehab Center
LIVE OAK REHAB CENTER in SAN GABRIEL, CA — inspection on January 2, 2026.
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
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
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