Live Oak Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 13, 2021

  On 11/22/20, at 2:30 p.m., during a general observation, it was noticed that housekeeping staff (HS) 2 was coming down the corridor, through the exit door and out of the Red Zone. HS 2's personal protective equipment (PPE) only consisted of a face mask, which covered from his nose, mouth and chin. He did not wear a gown nor gloves, and he did not sanitize his hands with the hand sanitizer, which was on a table outside of the Red Zone. At 2:35 p.m., an interview was conducted with HS1. He stated that he was the only housekeeping staff assigned to the Red Zone. HS 2 mentioned that the only time he wears a gown and gloves is when he entered the residents' rooms and removes the PPEs before he lives the residents' rooms. […]

• Immediate jeopardy, patternF678Feb 17, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure proper and effective basic life support ( level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system) including cardiopulmonary resuscitation (CPR: an emergency lifesaving procedure performed when the heart stops beating) was continuously performed for 1 of 65 identified full code (full support which includes, if the resident has no heartbeat and was not breathing) residents (Resident 1) in the facility during a code blue (an unexpected cardiac or respiratory arrest requiring resuscitation) by: 1. […]

• Immediate jeopardy, patternF725Jan 13, 2021

  Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to provide care for 12 of 36 sampled residents (Resident 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 36) by failing to: 1. Ensure the facility designated Infection Preventionist Nurse (IPN) was able to perform the IP nurse duties due to multiple duties (giving patient care in the red zone). 2. Ensure Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 3 (LVN 3) assigned to the Red Zone (area for residents tested positive for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person)) were able to assess and monitor multiple areas with black color discoloration on Resident 1's right foot. 3. […]

• Immediate jeopardy, isolatedF600Oct 10, 2025

  Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) when Resident 2 was observed on video surveillance and by a family member (Visitor 1), pushing Resident 1 down the hallway in a wheelchair and started to touch, caress and squeeze Resident 1's right and left breast while Resident 1 repeatedly pushed Resident 2's hand away on 10/7/2025 at around 12:17 PM. This deficient practice resulted in Resident 1 being sexually abused by Resident 2 while Resident 1 repeatedly pushed Resident 2's hands away from touching her breasts. […]

• Actual harm, patternF580Jan 13, 2021

  Based on interview and record review, the facility failed to ensure the physicians were immediately consulted and notified when there were changes in the residents' conditions, in accordance with the facility's policy and plan of care for four of five sampled residents (Residents 5, 7, 8 and 36). The facility failed to: 1. Immediately inform the physician when Resident 5 had a change in respiratory condition and was identified to have a low blood pressure, increased in heart rate and low oxygen saturation (refers to the extent to which hemoglobin (an element in your blood that binds with oxygen to carry it through the bloodstream to the organs and tissues) is saturated with oxygen, measured with a pulse oximeter (a device that measures the oxygen saturation levels)) levels of 85% (normal… […]