Health inspection·January 21, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1) had an arranged transportation to bring the resident to an outside Primary Care Physician's (PCP) appointment. This deficient practice had the potential to cause delay in treatment and worsening of Resident 1's health condition.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included heart failure (the heart's main pumping chamber [left ventricle] becomes stiff and thick, preventing it from relaxing and filling properly with blood between beats, leading to symptoms like shortness of breath, fatigue, and swelling, despite the heart's normal contraction strength), unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (the underlying cause or specific form of dementia is not documented, the degree of cognitive impairment is not specified [e.g., mild, moderate, severe], the patient lacks symptoms like aggression, wandering, agitation, or significant mood/anxiety issues). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/18/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear and personal hygiene. The MDS also indicated Resident 1 needs substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) in sit to stand, chair/bed-to-chair transfer, walk 10 feet, walk 50 feet with two turns and walk 150 feet. During an interview on 1/20/2026 at 3:56 PM with Family Member 1 (FM1), FM1 stated Resident 1 had two outside PCP appointments on 8/4/2025 and 8/20/2025 and no transportation was arranged by the facility for Resident 1 to bring Resident 1 to the outside PCP appointments. During an interview on 1/20/2025 at 4:37 PM with Social Worker (SSW), SSW stated, only one transportation had bene made by the facility for Resident 1's outside PCP appointment. SSW confirmed, a physician order was required for arranging transportation for Resident 1's to bring the resident to outside doctor's appointment. SSW added, the licensed nurses were responsible for placing the appointment order in the transportation communication binder (a formal, daily record used by care providers, social workers, or transport staff to document the safe movement of clients to and from services. It acts as a critical safety, accountability, and compliance tool to ensure all individuals are accounted for and to verify the delivery of authorized services). SSW stated she did not know that Resident 1 had an appointment with the outside PCP on 8/20/2025. During a review of Resident 1's Physician Orders Summary Report (POSR) dated 7/16/2025, the POSR indicated Resident 1 may have appointment with the resident's outside on8/4/2025 at 11:00 AM, one time only until 8/4/2025. POSR did not indicate Resident 1's PCP appointment on Residents Affected - Few Page 1 of 2 056127 056127 01/21/2026 Live Oak Rehab Center 537 W Live Oak San Gabriel, CA 91776

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/20/2025 for Resident 1. During a concurrent interview and record review on 1/21/2026 at 11:15 AM with the Registered Nurse (RN1), Resident 1's Nursing Progress Note dated 8/4/2025 was reviewed. The Nursing Progress Note indicated Resident 1's follow up appointment was scheduled for 8/20/2025 at 10:30 AM. RN1 stated he forgot to call Resident 1's primary physician from the facility (PCP 2) to obtain an order for the follow up appointment of Resident 1 scheduled for 8/20/2025 and did not endorse it to next shift's licensed nurse. RN1 confirmed, he should have called PCP 2 to obtain an order before leaving shift to prevent delays in treatment or worsening of Resident 1's conditions which could increase risk of complications. During an interview on 1/21/2026 at 1:24 PM with the Director of Nursing (DON), the DON stated she was not able to provide any communication log (a structured, chronological record of interactions [emails, calls, meetings, messages] documenting who said what, when, and why, serving as a vital tool for clarity, accountability, tracking progress, and creating a historical reference for teams) to indicate there was an order for Resident 1's outside PCP appointment. The DON stated the licensed nurse should have called PCP 2 to obtain an order after becoming aware of the resident's follow up visit dates to prevent delays of treatment or worsening conditions, which could increase the risk of complications for Resident 1. During an interview on 1/21/2026 at 2:24 PM with medical record (MR), MR stated she cannot find any policy regarding the licensed nurses' communication about transportation arrangement for residents' outside doctor appointments to other departments. During a review of the facility's Policy and Procedure (P&P) titled, Referrals, Social Services, revised in December 2008, it indicated, social services personnel shall coordinate most resident referrals with outside agencies. The P&P indicated:Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate. During a review of the facility's Policy and Procedure (P & P) titled, Transportation, Social Services, revised in December 2008, it indicated:The facility shall help arrange transportation for residents as needed.Social services will help the resident as needed to obtain transportation. 056127 Page 2 of 2