Live Oak Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF760May 22, 2025

  Based on interview, observation, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 8 residents (Resident #100 and Resident #235) reviewed for pharmacy services. 1. The facility failed to ensure Resident #100 received the correct dose of phenytoin sodium (anticonvulsant medication) extended oral capsule during his stay from [DATE] - [DATE] at the facility. Resident #100 received 900 mg at bedtime instead of the ordered 300 mg at bedtime for all seven nights he was in the facility, leading to a phenytoin level of 37.1 ug/mL, indicating phenytoin toxicity (normal ,d+[DATE] ug/ml). 2. […]

• No harm, potential for more than minimal, widespreadF812Feb 3, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed in that: Hot food on the steam table was below the required temperature for serving The steam table was not clean The shelf on the steam table was not clean A component of the vent hood was not clean There was no cleaning checklist for the kitchen These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings were: Observations of the kitchen during the initial tour with the DM on 01/31/23 at 01:30 PM revealed: the steam table had a thick yellowish crust in each of the 4 compartments. […]

• No harm, potential for more than minimal, patternF812Jul 8, 2026

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.1.The facility failed to ensure the walk-in freezer did not have ice accumulation inside of it.2.The facility failed to ensure all items in the refrigerator were labeled and dated.3.The facility failed to ensure the resident's refrigerator in the 400 hall did not have staff items in it.4.The facility failed to ensure items in the resident's refrigerator in the 400 hall were labeled and dated.5. The facility failed to ensure dented food-holding pans were removed from service. […]

• No harm, potential for more than minimal, patternF867Jul 8, 2026

  Based on interview and record review the facility failed to develop a QAPI plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies for one of one laundry rooms, five of eighteen residents (Resident #1, Resident #49, Resident #8, Resident #10, and Resident #3), and one of one kitchens. The facility failed to implement an effective QAPI program that identified, monitored, and corrected systemic quality deficiencies, including infection prevention and control. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #1's wound care and performed hand hygiene after glove removal. […]

• No harm, potential for more than minimal, patternF880Jul 8, 2026

  Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for five of eighteen residents (Resident #1, Resident #49, Resident #8, Resident #10, and Resident #3), and one of one laundry rooms reviewed for infection control and transmission-based precautions policies and practices.1. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #1's wound care and performed hand hygiene after glove removal. […]