Health inspection·August 7, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete impaired noted on 6/18/2025 to severely impaired noted on 7/16/2025.b. Resident 1's functional eating ability declined from setup or clean-up assistance (helper helps only prior to or following the activity completion) noted on 6/18/2025 to supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) noted on 7/16/2025.c. Resident 1's oral hygiene ability declined from supervision or touching assistance noted on 6/18/2025 to partial/moderate assistance noted on 7/16/2025. d. Resident 1's toileting hygiene (the ability to maintain perineal hygiene [refers to the care and cleaning of the region between the genitals and the anus]) ability declined from partial/moderate assistance on 6/18/2025 to dependent (helper does all effort needed to complete activity) noted on 7/16/2025.e. Resident 1's ability to transfer from chair to bed/bed to chair and complete position change of sit to stand/ stand to sit, declined from supervision or touching assistance on 6/18/2025 to substantial/maximal assistance (helper does more than half the effort needed to complete the activity) noted on 7/16/2025.f. Resident 1's ability to complete toilet transfers (the ability to get on and off a toilet or commode) and walk (varied distances of 10 feet [ft- plural for foot, a unit of length equal to 12 inches], 50 ft and/or 150 ft) declined from supervision or touching assistance ted on 6/18/2025 to not attempted due to medical condition or safety concerns noted on 7/16/2025.Resident 1's medical chart did not indicate a developed care plan for Resident 1's decline in cognitive and functional abilities. The MDSN stated Resident 1's current care plan only reflected Resident 1 with moderately impaired cognitive skills and did not reflect her current condition of severely impaired cognitive skills. The MDSN also stated Resident 1's medical chart did not reflect any specific interventions for Resident 1's functional ability with ADLs, only bowel and bladder function, and it should have a care plan to address Resident 1 needs for ADLS because Resident 1's ADL abilities declined, and the changes are significant. The MDSN stated it was important to have a resident centered care plan for Resident 1 so that the health care providers are aware of Resident 1's actual current condition and so that the appropriate interventions can be implemented, because the new condition requires different interventions and level of care/ assistance. During an interview on 8/7/2025 at 3:46 PM with the Director of Nursing, the DON stated Resident 1 experienced a stroke (a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off) that caused a cognitive decline, becoming confused and forgetful. The DON also stated Resident 1 experienced a decline with ADLs, requiring more cues with feeding, and more help with transfers and toileting. The DON stated Resident 1 should have a care plan that reflects these declines because staff need to address the new problems and needs. The DON stated the care plan is what will outline how they meet Resident 1's needs. During a review of the facility's policy & Procedure (P&P) titled Care Plans, Comprehensive PersonCentered, revised 3/2023, the P&P indicated a comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident within seven (7) days of completion of the resident's MDS assessment. The P&P also indicated each resident's comprehensive care plan: a. Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being.b. Reflects currently recognized standards of practice for problem areas and conditions.c. Builds on the residents' strengths.d. Revised as information about the residents' condition changes.e. Reviewed and updated at least quarterly and when there has been a significant change in the residents' condition. Event ID: Facility ID: 056127 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Rehab Center 537 W Live Oak San Gabriel, CA 91776 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received adequate supervision and assistance to prevent accidents and injuries, by failing to provide the assistance needed to Resident 1who was assessed to be dependent (helper does all effort needed to complete activity) to facility staff while toileting on 7/21/2025. This deficient practice resulted in Resident 1 having an unwitnessed fall and being found sitting in front of the toilet in the resident's restroom after the resident was left unattended by facility staff on 7/21/2025. Resident 1 experienced left inner thigh pain with a rating of 7 out of 10 (a tool for assessing pain intensity using scale 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable). Resident 1 underwent x- ray (an imaging study that takes pictures of bones and soft tissues) of left upper leg (femur/ thigh bone) on 7/21/20245 and result showed a left acute minimally displaced intertrochanteric fracture (a break in the upper part of the thigh bone [femur], specifically in the area between the femoral neck and the lesser trochanter [a bony prominence or projection on the femur near the hip joint, serving as an attachment site for muscles], where the broken pieces have shifted out of alignment). Resident 1 was sent to General Acute Care Hospital (GACH) emergency room (ER) on 7/21/2025, admitted to the GACH's medical surgical unit (a specialized area where patients receive care for a wide range of medical and surgical conditions. These units handle patients recovering from surgery, managing chronic illnesses, or requiring treatment for acute medical issues) on 7/22/2025 and underwent left hip open reduction internal fixation (ORIF- a surgical procedure used to treat fractures or dislocations by realigning the broken bones and stabilizing them with screws, plates, or rods) on 7/25/2025. Resident 1 stayed in GACH from 7/22/2025 until 7/28/2025 (7 days). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included cerebral infarction (also known as a stroke, a condition where part of the brain tissue dies due to a lack of blood supply) and dementia (a progressive state of decline in mental abilities). The admission records also indicated diagnosis of history of falling with onset (the first date that a resident experiences the first symptoms of a medical condition) on 2/3/2025 and repeated falls with onset date of 4/16/2025. During a review of Resident 1's Fall Risk Evaluation, dated 7/14/2025, the Fall Risk Evaluation indicated Resident 1 is at a high risk of falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/16/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all effort needed to complete activity) with toileting hygiene (the ability to maintain perineal hygiene [refers to the care and cleaning of the region between the genitals and the anus]), shower/bathing and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with personal hygiene and upper body dressing. The MDS indicated Resident 1 had impairments on both lower extremities (hips, knees, ankles, feet), substantial/maximal assistance with sit to stand mobility (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode) were not evaluated due to medical condition or safety concerns. The MDS also indicated a bed and w/c alarm were used in Resident 1's care. During a review of Resident 1's Change of Condition (COC)/Situation, Background, Assessment, Recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Interact Assessment Form, dated 7/21/2025, the COC/ SBAR Assessment Form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056127 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Rehab Center 537 W Live Oak San Gabriel, CA 91776 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few indicated Resident 1 had an unwitnessed fall at 8:50 AM and was found sitting in front of the toilet in the resident's restroom. The COC/ SBAR Assessment Form indicated the assigned Certified Nursing Assistant (CNA) 2 assisted Resident 1 onto a shower chair and into the resident's restroom, then left [the restroom] to grab something from Resident 1's bed. The COC/SBAR indicated CNA 2 then found Resident 1 sitting on the restroom floor. The COC Assessment Form also indicated Resident 1 stated tried to stand up to grab the toilet paper in front of the resident when Resident 1 lost her balance and fell onto the floor. The COC/ SBAR Assessment Form indicated at 2:43 PM, Resident 1 complained of left inner thigh pain with a rating of 7 out of 10 and Norco (the brand name of a medication that combines two pain-relieving drugs: hydrocodone and acetaminophen) 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) was administered to Resident 1. During a review of Resident 1's Medication Administration Record (MAR), dated 7/21/2025, the MAR indicated Resident 1 received 1,000 mg of Tylenol (brand name for acetaminophen; a pain medication) for 6 out of 10 left thigh pain and Norco for 7 out of 10 left extremity (left leg) pain. During a review of Resident 1's Order Summary Report, dated 7/21/2025, the Order Summary Report indicated for a statim (stat- urgent, without delay) x-ray of left upper leg (femur) due to complaints of pain status post (s/p - after) fall. During a review of Resident 1's Radiology Results Report, dated 7/21/2025, the Radiology Results Report indicated findings of a left minimally displaced acute intertrochanteric fracture. During a review of Resident 1's Order Summary Report, dated 7/21/2025, the Order Summary Report indicated to transfer to GACH ER for further evaluation related to acute minimally displaced intertrochanteric fracture due to s/p fall 7/21/2025. During a review of Resident 1's GACH records titled History & Physical (H&P), dated 7/22/2025, the H&P indicated Resident 1 chief complaint of left hip fracture after a mechanical fall with a left minimally displaced acute intertrochanteric fracture and Resident 1 was complaining of significant pain with movement. The H&P also indicated, Resident 1 was admitted to GACH's medical surgical unit (a specialized area where patients receive care for a wide range of medical and surgical conditions. These units handle patients recovering from surgery, managing chronic illnesses, or requiring treatment for acute medical issues). During a review of Resident 1's GACH records titled Consultation: Orthopedic Surgery, dated 7/22/2025, the Consultation form indicated Resident 1 was scheduled for left hip open reduction internal fixation (ORIF- a surgical procedure used to treat fractures or dislocations by realigning the broken bones and stabilizing them with screws, plates, or rods) on Friday 7/25/2025 at 2:00 PM. During a review of Resident 1's GACH record titled Progress Note, dated 7/25/2025 and timed 10:00 AM, the Progress Note indicated Resident 1 was in the recovery room status post ORIF to treat acute left hip fracture. During a review of Resident 1's GACH Femur X-ray Radiology Report, dated 7/25/2025, the Radiology Report indicated Resident 1 was s/p left hip surgery (date not indicated) with a compression screw and nail now noted within the left femur. During a review of Resident 1's GACH Patient Discharge Summary, dated 7/28/2025, the Discharge Summary indicated Resident 1 had an ORIF on the left hip and will be discharged back to the facility. During a review of Resident 1's MAR, (from the facility) dated 7/28/2025, the MAR indicated Resident 1 was admitted at the facility on 7/28/2025. The MAR also indicated Resident 1 received Tylenol 650 mg for 3 out of 10 left femur fracture pain. During a review of Resident 1's Falling Star Program care plan, revised 7/29/2025, the care plan indicated Resident with falls [in the facility] on 6/8/2025, 7/14/2025 and 7/21/2025 with the goal to reduce risk of falls and/or injury through appropriate intervention(s) daily until the next assessment. The care plan also indicated Resident 1 overestimates her ability to perform tasks independently. During a review of Resident 1's MAR, dated 8/4/2025, the MAR indicated Resident 1 received Norco 5-325 mg for 10 out of 10 left toe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056127 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Rehab Center 537 W Live Oak San Gabriel, CA 91776 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few pain. During an interview on 8/6/2025 at 10:04 AM with Resident 1, Resident 1 stated she cannot remember what happened with her fall, but she was currently still having left leg pain. During an interview on 8/6/2025 at 1:32 PM with the CNA 2, CNA stated she was taking care of Resident 1 on 7/21/2025 when the fall occurred. CNA 2 stated she assisted Resident 1 onto a shower chair (assistive equipment designed to provide a safe and stable seating option in a shower or bathtub) and moved the shower chair to the toilet so that Resident 1 can use the restroom prior to the resident's shower. CNA 2 stated, CNA 2 left Resident 1 unattended in the restroom to grab wipes from Resident 1's bed. CNA 1 stated when CNA 2 was outside the restroom to grab the wipes, CNA 2 then heard a noise that was really heavy, went back into the restroom and found Resident 1 sitting on the floor in front of the toilet. During an interview on 8/6/2025 at 1:45 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was assigned to Resident 1 on 7/21/2025 and responded to Resident 1 after the fall and was not there when the fall occurred. LVN 2 stated Resident 1 was in the restroom, when CNA 2 left Resident 1 alone while the resident is using the toilet to grab something from Resident 1's bed, then Resident 1 had an unwitnessed fall. LVN 2 stated Resident 1 is known for trying to be independent with activities of daily life (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) despite needing assistance and has a history of falls in the facility. During an interview on 8/7/2025 at 2:42 PM with LVN 3, LVN 3 stated Resident 1 has periods of cognitive confusion, attempts to be independent with ADLS when Resident 1 believes she can complete the task. LVN 3 stated Resident 1 should not have been left alone in the restroom by CNA 2 on 7/21/2025 because it was unsafe for Resident 1 with the resident's cognition and history of falls. LVN 3 also stated leaving Resident 1 alone in the restroom was unsafe because there was no alarm on the shower chair to alert staff if she was attempting to move and without the alarm or staff supervision, staff cannot ensure resident is safe and does not fall. In addition, LVN 3 stated Resident 1 ultimately had a fall requiring hip surgery after being left alone in the restroom. During an interview on 8/7/2025 at 3:46 PM with the Director of Nursing (DON), the DON stated Resident 1 was left alone by staff on 7/21/2025 after stepping away to grab something from Resident 1's bed and it was unsafe to leave Resident 1 alone because Resident 1 was high risk for falls and according to Resident 1's MDS, Resident 1 is dependent to staff for toileting. The DON stated Resident 1 fell because the resident did not receive the necessary supervision and assistance during toileting. The DON stated, Resident 1 was left alone and unattended during toileting on 7/21/2025 and if Resident 1 was not left unattended, the fall could have been prevented. The DON also stated Resident 1 sustained a fracture to the left hip due to the fall on 7/21/2025. During a review of the facility's P&P titled Safety and Supervision of Residents, revised 7/2017, the P&P indicated:a. The facility strives to make the environment as free from accident hazards as possible.b. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities.c. Facility utilizes resident-centered approach to address safety and accident hazards for individual residents.d. Resident supervision is a core component to the system approach to safety and the type and frequency of resident supervision is determined by the resident's assessed needs and identified hazards in the environment. During a review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, Managing, revised 3/2023, the P&P indicated:a. Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.b. Resident conditions that may contribute to the risk of falls include cognitive impairments and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056127 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Rehab Center 537 W Live Oak San Gabriel, CA 91776 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 incontinence and lower extremity weakness. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056127 If continuation sheet Page 6 of 6