Live Oak Rehab Center
LIVE OAK REHAB CENTER in SAN GABRIEL, CA — inspection on January 29, 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 an interview on 1/29/2026 at 11:30 AM, the Director of Nursing (DON) stated before Resident 1 came to the facility the resident already had a history of gangrene on her left pointer finger from wrapping her finger which was resolved.
The DON also stated 1 of the CNAs noticed on Tuesday (1/27/2026) that Resident 1 was wrapping the string of her gown and gastrostomy tube (GT, a tube inserted directly through the abdominal wall into the stomach to provide nutrition, fluids, and medications) on her finger, CNA removed everything but did not tell anyone. DON further stated the CNA should have notified other staff to ensure Resident 1 was being monitored and the behavior was care planned.
The DON stated tangled call light cords and coiled cables of the bed control are safety hazards for Resident 1.
During a concurrent interview and review of Resident 1's care plan on 1/29/2026 at 12:15 PM with the DON.
The DON stated she could not find any care plan related to the resident's behavior of wrapping her fingers on things. DON also stated Resident 1's care plan that focused on risk for injury dated 7/21/2025 was not specific to the resident's behavior and interventions related to providing the resident with a safe environment were not implemented.
During an interview on 1/29/2026 at 1:03 PM, CNA 3 stated she had observed Resident 1 wrapped her fingers with the cord of her gown and the GT during her rounds on Tuesday night of 1/27/2026 but did not notify any of the staff.
During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated that the facility strives to make the environment as free from accidental hazards as possible.
The P&P also indicated that the residents' safety, supervision and assistance to prevent accidents are facility wide priorities.
The P&P further indicated that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.
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