Live Oak

In the surveyor’s words

From the most serious findings on record at Live Oak, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF609Jul 29, 2026

  Based on record reviews and interviews the facility failed to report alleged allegations of abuse and neglect in the required timeframe to the State Survey and Certification Agency for 2 (#19 and #70) of 3 residents reviewed for facility reported incidents. Findings:Resident #19Review of Resident #19's medical record revealed an admission date of 02/21/2020 and diagnoses including atherosclerosis native arteries of left leg with ulceration other foot, insomnia, glaucoma, muscle wasting and atrophy multiple sites, and difficulty in walking.Review of the facility's incident log for dates 03/27/2026 through 07/27/2026 revealed Resident #19 had a fall with injury 07/12/2026 at 5:15 a.m.Review of Resident #19's incident on 07/12/2026 at 5:15 a.m. […]

• No harm, potential for more than minimal, patternF656Jul 29, 2026

  Based on record review and interviews, the facility failed to implement the plan of care to meet the needs of 1 (#90) of 29 sampled residents. The facility failed to administer Resident #90's final dose of a diuretic regimen and order imaging for Resident #90 in a timely manner. Findings:Review of Resident #90's medical record revealed an admission date of 05/06/2024 with diagnoses including in part, Alzheimer's disease, hypertension and anxiety disorder. Review of Resident #90's physician orders revealed in part: 06/04/2026 Chest x-ray (Due: 06/04/2026) due to edema 06/04/2026 Lasix 20 mg give 1 po now then give 40 mg po x 3 days Review of Resident #90's June 2026 MAR failed to reveal Resident #90 received the final Lasix 40 mg dose of the ordered 3 day diuretic regimen on 06/08/2026. […]

• No harm, potential for more than minimal, patternF757Jul 29, 2026

  Based on record review and interview, the facility failed to ensure 1 (#56) out of 5 residents reviewed for unnecessary medications completed a consent for a psychotropic medication.Findings:Review of Resident #56's medical record revealed an admit date of 08/11/2025 with the following diagnoses, including in part: vascular dementia unspecified severity without behaviors/psych/mood/anxiety, pseudobulbar affect, and depression unspecified.Review of Resident #56's physician orders revealed an order dated 08/25/2025 for Zoloft tablet 25 mg give 1 by mouth daily for depression.Review of Resident #56's medical record failed to reveal a psychotropic consent for Zoloft.During an interview on 07/28/2026 at 2:35 p.m. S2 Unit Manager acknowledged Resident #56 did not have a consent for Zoloft.

• No harm, potential for more than minimal, patternF605Jun 25, 2025

  Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#61) of 5 (#29, #33, #43, #61 and #63) residents reviewed for unnecessary medications. The facility failed to ensure Resident #61's PRN order for psychotropic medication was limited to 14 days. Findings: Review of Resident #61's medical record revealed an admit date of 03/29/2022 with diagnoses of but not limited to chronic kidney disease and dementia. Review of Resident #61's June 2025 physician's orders revealed an order for Atarax/Hydroxyzine 25mg (milligrams) give one tablet three times a day PRN for anxiety for one year. […]

• No harm, potential for more than minimal, patternF755Jun 25, 2025

  Based on record review and interviews, the facility failed to ensure narcotic records were maintained and reconciled for 1 (Cart A) of 3 (Cart A, Cart B, Cart C) medication carts reviewed. This had the potential to affect any of the 11 residents receiving narcotics from Cart A. Findings: Review of the facility's Medication Narcotic Count policy dated 04/11/2011 revealed in part: Procedure: III. Each nurse who is going off duty, along with the nurse that is coming on duty, counts the narcotics together. […]