Live Oak Rehab Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the light cord and wrap it on her finger back in December 2025 and took it away from the resident. CNA 2 also stated to ensure safety for Resident 1, the staff should put away things that could possibly be used by
the resident to wrap her fingers with. 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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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.