Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Live Oak Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe Food Storage and Unsanitary Nourishment Areas: Water was observed pouring from the dishwasher onto the kitchen floor and pooling there, and staff stated this had been occurring routinely. Thawed nutritional supplements were found in nourishment room refrigeration and freezer areas without thaw dates, a freezer lacked a working thermometer, and the ice machine had black and brown buildup with discolored, wet flooring nearby. The CDM acknowledged the supplements should have been dated and that they should have been used by residents the prior night.
A resident with a psychosis diagnosis had an outdated PASRR that did not include the mental health condition. The resident’s record and psych progress note documented psychosis, and the ADON confirmed the Level I PASRR had not been updated. The SS Director stated the IDT is responsible for PASRRs, and the facility policy defined significant change as requiring interdisciplinary review and/or care plan revision.
Inaccurate PASRR screening for residents with mental health diagnoses: The facility failed to ensure PASRRs accurately reflected mental illness for two residents at admission. One resident had major depressive disorder, agitation, depression symptoms, and psychotropic treatment, yet the PASRR showed no mental illness. Another resident had dementia, anxiety, and cognitive impairment, but the PASRR also showed no mental illness. Staff stated PASRRs were reviewed on admission and that diagnoses not checked should be investigated or updated.
Failure to Administer Ordered Topical Medication: A resident with multiple chronic conditions and a cognitively intact BIMS score had a red, swollen elbow and reported not receiving the ordered treatment. The MAR/TAR showed inconsistent administration of topical diclofenac products, including missed or incomplete dosing of a gel ordered for the elbow, while an LPN stated she applied the medication to the shoulder and back but was unaware it was also ordered for the elbow and was unsure of the correct dose.
A resident with hypertensive retinopathy was observed without eyeglasses, and she stated she had an eye appt but had not received the glasses she was told were coming. The optometry consult documented that bifocal eyeglasses were ordered, but the facility had no documentation that the glasses were received or provided. Social Services stated the monthly eyeglass shipment did not include the resident’s glasses and that no follow-up had been made with the optometry provider about the delay.
An unsecured portable oxygen cylinder was observed standing on the floor in a resident’s room, first while the resident was present and later while the resident was out of the room. Staff, including a CNA, an LPN, and the ADON, stated the tank should be secured in a cart, holder, or on the wheelchair, and the facility’s oxygen administration policy required portable cylinders to be secured to an O2 cart or wheelchair.
Oxygen Administered Without Physician Order: A resident with encephalopathy, ESRD, renal dialysis dependence, and unspecified dementia was observed receiving O2 at 2 L/min via nasal cannula, but the record contained no physician order for oxygen. Staff and the DON confirmed that oxygen should have a physician order specifying the rate, delivery method, and duration, and that the oxygen administration was not documented on the MAR.
Failure to use PPE for Contact precautions occurred when a housekeeper entered one resident’s room wearing gloves only and a CNA entered another resident’s room without a gown or gloves. Both rooms had Contact Isolation signs and PPE available at the door, and the residents had orders for Contact isolation related to ESBL and MRSA/Enterococcus faecalis.
Failure to Follow Midodrine Hold Parameters: An LPN administered Midodrine to a resident despite BP readings above the physician-ordered hold parameters on multiple occasions, and no physician notification was documented. The resident had complex medical conditions including ESRD on dialysis, diabetes with neuropathy, bilateral BKA, and hypertension. A later order also included a higher hold parameter, but the resident again received Midodrine when SBP was above the ordered limit, and staff confirmed the doses were medication errors.
The facility did not post daily nurse staffing information as required. Observations revealed outdated staffing data in the reception area, confirmed by the Administrator, who also noted the lack of a formal policy for daily postings.
The facility failed to ensure physicians documented their rationale for pharmacy recommendations and did not implement agreed changes for three residents. Recommendations for tapering or discontinuing medications due to risks like falls and dizziness were not addressed, and agreed changes were not reflected in physician orders. The DON confirmed the lack of physician review and implementation of recommendations.
The facility experienced a medication error rate of 10.81%, exceeding the acceptable threshold. Errors included incorrect dosages and omissions of medications by LPNs, and improper administration of a delayed-release medication via a gastric tube by an RN. These incidents highlight lapses in following established medication administration protocols.
The facility failed to maintain accurate medical records and medication administration for several residents. A resident with end-stage renal disease had incomplete dialysis documentation, while another had conflicting resuscitation orders. Blood pressure and insulin medications were not administered as per parameters, and oxygen was given at incorrect rates. These issues highlight significant documentation and communication errors within the facility.
A facility failed to ensure the accuracy of an MDS assessment for a resident's discharge. The resident, who was supposed to be discharged home with skilled nursing and physical therapy, was incorrectly recorded as being discharged to a short-term general hospital. The MDS Coordinator confirmed the error during an interview, stating that the resident was discharged home, not to a hospital.
A facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including pseudobulbar affect. The resident was prescribed Nuedexta for this condition, but the care plan did not address it. The MDS Coordinator confirmed the omission, which violated the facility's policy for person-centered care plans.
The facility failed to adhere to professional standards in medication administration for two residents. One resident was left with medications at her bedside without orders for self-administration, while another had a pill found on their shirt, indicating improper supervision during administration. Staff acknowledged these practices were against protocol.
The facility failed to provide necessary ADL assistance for two residents, resulting in poor personal and oral hygiene. One resident was observed with oily skin and dry, cracked lips, while another had discolored teeth and a dry mouth. Both residents were dependent on staff for care due to medical conditions. Staff interviews indicated that high resident-to-CNA ratios hindered the ability to meet all residents' needs.
A resident received blood pressure medications despite physician orders to hold them if systolic blood pressure was less than 110 or pulse was less than 60. The MAR showed multiple instances where medications were administered outside these parameters. Interviews confirmed that staff should follow physician orders and contact providers for clarification.
A resident did not receive oxygen therapy as prescribed, with observations showing incorrect flow rates and undated equipment. Staff interviews revealed a lack of verification of the prescribed oxygen rate, contrary to facility policy.
The facility failed to label food items in a nourishment room, as observed during a tour with the CDM. Unlabeled and undated items, including a Chicken BLT salad bowl, a Chef salad bowl, and a container of blackberries, were found in the refrigerator. The CDM confirmed that all foods must be labeled with the resident's name, the date it was brought in, and an expiration date. This was in violation of the facility's policy on safe handling of foods from visitors.
A resident's catheter bag was found lying on the floor, violating the facility's infection control policy. An LPN confirmed the bag should not be on the floor, and the DON expected nurses to check catheter bags during medication passes. The facility's policy mandates that catheter tubing and drainage bags be kept off the floor.
A facility failed to accommodate a resident's service dog, impacting their mental health and quality of life. The resident, with a history of diabetes and mental health issues, was denied permission to have their service dog unless they could afford a private room or sitter. The absence of the service dog caused the resident distress and anxiety, as noted by their ARNP. The facility administrator had not engaged with the resident's concerns until shortly before the surveyor's interview.
A resident did not receive the correct dosage of pain medication as ordered due to unavailability in the pyxis system. The nurse administered a lower dose without notifying the supervisor, pharmacy, or NP, contrary to facility policy. This led to a deficiency in medication administration.
A facility failed to prevent infection spread during hygiene care for a resident. Two CNAs did not follow proper infection control procedures, including failing to change gloves and perform hand hygiene after cleansing the peri-area and before applying barrier cream. Additionally, a soiled linen bag that fell on the floor was placed back on the resident's bed without changing the linens. Interviews revealed these actions did not meet the facility's infection control expectations.
Unsafe Food Storage and Unsanitary Nourishment Areas
Penalty
Summary
Food items were not stored in a safe and sanitary manner in the main kitchen and nourishment rooms. During observation, water was pouring from the dishwasher in the main kitchen onto the floor and pooling there. The Certified Dietary Manager stated the water had routinely poured from the dishwasher during her employment, and a Dietary Aide stated it had been like that for a while and thought a part may be broken. In the East Hall nourishment room refrigerator, two thawed 4-ounce containers of nutritional supplement were observed without a thawed-on date, despite carton instructions directing that the thawed substance be used within 14 days of thawing. In the South Hall nourishment room freezer, there was no working thermometer, one thawed supplement carton without a thawed-on date, speckled black and brown substances on the interior top, right, and left sides and lower metal guards of the ice machine, and discolored flooring with pooled water at the nourishment room door. The Certified Dietary Manager stated the supplements should have been given to residents the prior night and acknowledged the supplements should have been dated when thawed.
Failure to Update PASRR for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure an updated Preadmission Screening and Resident Review (PASRR) was completed for a resident with a serious mental disorder. Resident #7’s face sheet documented a diagnosis of psychosis not due to a substance or known physiological condition with an onset date of 3/19/2025, but the resident’s PASRR dated 06/14/2024 did not document that diagnosis. A psychological progress note dated 5/18/2026 documented psychosis as a diagnosis. During interviews, the Assistant Director of Nursing confirmed that a Level I PASRR had not been updated to include the mental health diagnosis of psychosis, and the Social Services Director stated that the IDT team is responsible for PASRRs. The facility policy titled Administration PASSR Significant Change stated that a significant change requires interdisciplinary review and/or revision of the care plan.
Inaccurate PASRR Screening for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate PASRR was completed for residents with serious mental disorder diagnoses at the time of admission for 2 of 6 residents reviewed. Resident #15 was admitted and later readmitted with diagnoses including major depressive disorder, recurrent, unspecified, and restlessness and agitation. Although the PASRR dated 5/08/2026 documented no mental illnesses or suspected mental illnesses, the resident’s psychiatric admission note dated 5/15/2026 documented an active mental health diagnosis, including major depressive disorder, recurrent, mild, and restlessness and agitation, with symptoms of depression, anxiety, insomnia, loss of energy, and diminished interest. The resident’s care plan and physician orders also reflected depression, agitation, and treatment with escitalopram and quetiapine. Resident #176 was admitted with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The PASRR dated 6/17/2026 documented no mental illness or suspected mental illness. However, an acute care progress note dated 6/19/2026 described the resident as a medically complex skilled nursing facility resident with encephalopathy, acute kidney failure, dementia, end stage renal disease, and dependence on renal dialysis. The note stated the resident had underlying cognitive impairment and communication limitations, was alert and oriented, and had limited speech with brief verbal responses and nonverbal gestures. During interviews, the Regional Nurse Consultant stated the Social Services Assistant was responsible for reviewing PASRRs when residents were first admitted and that the IDT reviewed them the next day to identify whether a resident might need special services or a level II PASRR. The Social Services Assistant stated she reviewed PASRRs on admission and would look for diagnoses that might trigger special services or additional review, and if a diagnosis was not checked she would investigate whether there was a history of the condition, whether it was active, or whether the resident was being treated. The ADON stated that if a resident was admitted with a diagnosis of mental illness and it was not on the PASRR, the PASRR should have been updated.
Failure to Administer Ordered Topical Medication
Penalty
Summary
The facility failed to ensure Resident #24 received the ordered topical medication for the left elbow as prescribed. On observation, the resident’s left elbow was red and swollen, and the resident stated that an x-ray had been done but no treatment was being provided. The resident’s record showed diagnoses including cellulitis, type 2 diabetes mellitus, acute kidney failure, atrial fibrillation, peripheral vascular disease, history of TIA, and cerebral infarction without residual deficits. The resident was cognitively intact with a BIMS score of 14 out of 15. Physician orders directed Diclofenac Sodium External Gel 3% to the left elbow every 8 hours for inflammation for 5 days, and later Diclona External Gel 1-4.5% to the low back, shoulder, and elbow four times daily for pain for 10 days. The MAR/TAR showed the first gel was documented as administered three times daily from 6/04/2026 through 6/09/2026, but the second gel was not administered per the physician’s order. Documentation showed it was initialed inconsistently, including twice on 6/17/2026 and three times on 6/21/2026 through 6/22/2026, rather than four times daily as ordered. During interview, the resident stated nurses were supposed to be putting something on the elbow four times a day but had not been doing so. An LPN stated she had applied Voltaren to the shoulder and back but was not aware it was also supposed to be applied to the elbow. She also stated she used a medicine cup when dosing the gel but did not fill it completely, and that the order was usually dosed in grams and she would need to check with the physician about how much to apply. The order lacked a documented amount or dose, and the facility policy required orders to be clear and accurate and to clarify questions regarding the right dose.
Failure to Provide Ordered Eyeglasses
Penalty
Summary
The facility failed to ensure an assistive optical device was provided for Resident #57, who had a diagnosis of hypertensive retinopathy. During observation, the resident was watching television and was not wearing eyeglasses. The resident stated she had an eye appointment in January but had not received the glasses she was told would be coming for her. The optometry consultation dated 01/21/2026 documented that bifocal eyeglasses were ordered. Staff in Social Services stated the facility’s optometrist visits monthly and eyeglasses are typically delivered monthly, but no eyeglasses for Resident #57 were included in the last shipment. Staff also stated she had not contacted the optometry provider to determine the status of the eyeglasses. The record contained no documentation that the ordered eyeglasses had been received by the facility or provided to the resident, and no documentation that staff followed up with the optometry provider regarding the delayed delivery.
Unsecured Oxygen Cylinder in Resident Room
Penalty
Summary
The facility failed to ensure an area was free from accident hazards when it did not secure a portable oxygen cylinder in Resident #176’s room. During an observation on 6/22/2026 at 9:40 AM, Resident #176 was sitting in her wheelchair beside her bed, and an oxygen cylinder/tank was standing unsecured on the floor between the resident’s bed and the bathroom. A later observation on the same day at 11:30 AM found the resident out of the room, and the oxygen tank, containing over 1000 PSI of oxygen, was still standing unsecured on the floor in the same location. During interviews, Staff E, CNA, stated the oxygen tank should not be sitting on the floor and should be in a rolling cart or on the resident’s wheelchair, and that it was not clean and not safe. Staff C, LPN, stated the oxygen tank had to be in a holder for safety reasons. The ADON stated portable oxygen tanks needed to be kept in either rolling carts or strapped on the resident’s wheelchair. The facility policy titled Nursing - Oxygen Administration, last reviewed 1/28/2026, stated that a portable oxygen cylinder should be secured to an O2 cart or wheelchair and noted that E-tanks have a high amount of pressure and can be dangerous if not properly secured.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #176, who was admitted with encephalopathy, dependence on renal dialysis, end stage renal disease, and unspecified dementia. During observation, the resident was seen sitting in a wheelchair beside the bed and later lying in bed while receiving oxygen at 2 liters per minute via nasal cannula attached to an oxygen concentrator. Review of the medical record showed no physician order for oxygen administration during the reviewed period. Staff stated that if a resident was on oxygen, there should be an order and the oxygen administration should be documented on the MAR, and the admission nurse should contact the MD if there was no order. The DON confirmed the expectation that oxygen requires a physician order including the rate, delivery method, and duration, and also confirmed there was no physician order in the record for Resident #176's oxygen.
Failure to Use PPE for Contact Precautions
Penalty
Summary
The facility failed to prevent the possible spread of infection when staff did not use appropriate PPE when entering rooms under Contact Isolation precautions for two residents. One resident had physician orders for Contact isolation for ESBL in urine every shift for 7 days. During observation, a housekeeper entered that resident’s room with a spray bottle and cloth wearing gloves only, remained in the room for about five minutes, and was overheard speaking with the resident. The housekeeper later indicated she had seen the isolation sign and PPE holder on the door, and she did not speak English. A second resident had physician orders for Contact isolation for MRSA/Enterococcus faecalis in a wound every shift for 10 days. During observation, a CNA entered the resident’s room, picked up an item, and spoke with the resident without donning gloves or a gown. The CNA later stated she knew for Contact precautions she needed to put on PPE and that she should have worn a gown and gloves before entering the room, but said she did not think the resident was in the room. The Infection Preventionist stated that for residents on Contact Isolation precautions, staff should wear a gown and gloves and put them on before entering the room and remove them before leaving.
Failure to Follow Midodrine Blood Pressure Hold Parameters
Penalty
Summary
The facility failed to ensure staff followed physician-ordered blood pressure parameters for Midodrine administration for one resident. The resident had multiple diagnoses including ESBL resistance, urinary tract infection, subacute osteomyelitis, bilateral below-knee amputations, type 2 diabetes mellitus with diabetic polyneuropathy, end stage renal disease with dialysis dependence, and essential hypertension. A physician order dated 8/12/2025 directed Midodrine HCl 10 mg every 6 hours for hypotension and to hold the medication for systolic blood pressure greater than 110. Review of the MAR showed the resident received Midodrine on 8/15/2025, 8/17/2025, 8/18/2025, 8/19/2025, and 8/24/2025 despite systolic blood pressures above the hold parameter, including readings of 114/76, 115/67, 114/67, 114/74, and 122/80. Progress notes from 8/15/2025 through 8/25/2025 showed no physician notification for these administrations. A later physician order dated 9/3/2025 changed the Midodrine dose to 1.5 tablets every 6 hours with a hold parameter for systolic blood pressure greater than 130, and the MAR showed the resident received doses on 9/26/2025 at 12:00 PM and 6:00 PM when the blood pressure was 152/53; progress notes from 9/26/2025 through 9/27/2025 also showed no physician notification. Staff interviews confirmed these were medication errors, and the DON stated medications and treatments are to be administered as ordered and that nurses should clarify questions with the physician.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted on a daily basis. Upon entrance to the facility, it was observed that the nurse staffing information displayed in the reception area was outdated, showing the date of Friday, 1/31/2025, instead of the current date. During an interview, the Administrator confirmed that the posted data was not current and acknowledged the absence of a policy for posting nurse staffing information, although he expected it to be posted accurately each day.
Failure to Document and Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented their rationale related to pharmacy recommendations and did not implement the physician's agreed changes for three residents. For Resident #23, multiple drug regimen reviews by the consultant pharmacist recommended tapering or discontinuing medications such as Lamotrigine, Alprazolam, Trazodone, Aripiprazole, and Gabapentin due to risks of dizziness, falls, and other concerns. Despite these recommendations, there was no documented physician response, and agreed changes regarding pain parameters for Oxycodone and discontinuation of Lactulose were not implemented in the physician's orders. Resident #101's drug regimen reviews highlighted concerns with medications like Tramadol, Senna, Acetaminophen, Oxcarbazepine, and Lorazepam, among others. The consultant pharmacist recommended evaluating the need for these medications and considering alternatives or discontinuation due to risks such as falls and lack of recent use. However, the physician either disagreed without documenting a reason or did not respond to the recommendations, leaving the issues unaddressed. For Resident #124, the consultant pharmacist's recommendations included evaluating the use of Megestrol, Lansoprazole, Mirtazapine, Hydrocodone/APAP, and Quetiapine due to risks of falls, thromboembolic events, and other concerns. Despite these recommendations, there was no physician response documented, and the issues remained unresolved. The Director of Nursing confirmed that the pharmacist's recommendations had not been reviewed by physicians and that agreed changes were not implemented, highlighting a systemic issue in the facility's medication management process.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with the observed rate being 10.81 percent. This deficiency was identified through multiple incidents involving medication administration errors. In one instance, a Licensed Practical Nurse (LPN) was observed preparing medication for a resident but failed to administer the correct dosage of Tizanidine and omitted Trazodone entirely. The LPN acknowledged the error upon review. Another incident involved a resident questioning the contents of their medication cup, which was prepared by a different LPN. The resident's multivitamin was initially omitted, and the error was corrected only after the resident inquired about it. In a separate case, a Registered Nurse (RN) was observed preparing a delayed-release Lansoprazole capsule for administration via a gastric tube, which is against the facility's policy. The RN realized the error and sought clarification, leading to a change in the medication form to liquid to prevent potential clogging of the tube. The Director of Nursing later confirmed that delayed-release medications should not be administered via gastric tubes and emphasized the importance of verifying medication orders against the Medication Administration Record (MAR). The facility's policies and procedures for medication administration were reviewed, highlighting the requirement for staff to verify medications against prescriber orders and ensure the correct administration method. Despite these guidelines, the observed errors indicate lapses in adherence to established protocols, contributing to the elevated medication error rate.
Deficiencies in Medical Record Accuracy and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate medical records for several residents, leading to deficiencies in care. Resident #80, who was admitted with end-stage renal disease, sepsis, and anemia, had incomplete documentation in the Dialysis Hand Off Communication Report, lacking details on the presence of bruit/thrill, catheter dressing, and signs of infection. Additionally, there was no current physician order for dialysis, despite the resident attending dialysis sessions regularly. Resident #127's records showed inconsistencies regarding their resuscitation status. Although a Do Not Resuscitate (DNR) order was signed, the physician order incorrectly indicated a full code status. Interviews revealed that the resident did not want CPR, yet staff were under the impression that the resident was a full code, highlighting a critical communication and documentation error. For Resident #40, the Medication Administration Record (MAR) showed multiple instances where blood pressure medication was not administered due to vitals being outside parameters, yet there was no documentation of communication with the provider. Similarly, Resident #122's MAR showed insulin was held or not administered without proper documentation or provider notification. Resident #15's MAR also had missing entries for insulin administration, and Resident #28 received oxygen at incorrect rates compared to the physician's order, with staff unaware of the discrepancies. These issues reflect a broader problem with documentation and adherence to medical orders within the facility.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident who was reviewed for discharge. The resident was admitted to the facility and had a physician's order for discharge home with skilled nursing for wound care and physical therapy. However, the Discharge Return not Anticipated MDS assessment inaccurately recorded the resident's discharge status as being to a short-term general hospital. During an interview, the MDS Coordinator confirmed the error, acknowledging that the resident was actually discharged home, not to a hospital. The facility uses the Resident Assessment Instrument (RAI) specified by the State for MDS assessments.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including encephalopathy, seizures, major depressive disorder, pseudobulbar affect, schizoaffective disorder, and mood disorder due to a known physiological condition. The resident was prescribed Nuedexta to manage pseudobulbar affect, a condition characterized by involuntary episodes of laughing or crying. However, the resident's care plan did not include a focus on care and services related to pseudobulbar affect. During an interview, the MDS Coordinator confirmed that the care plan lacked this focus, which was contrary to the facility's policy requiring comprehensive, person-centered care plans to meet residents' needs.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards for two residents. In the first instance, a resident was observed with a small plastic cup containing medications on her bedside while eating breakfast. The resident stated she preferred to take her medication with food, although there were no physician orders allowing her to self-administer medications. A registered nurse admitted to leaving the medication at the bedside, acknowledging it was against normal practice. The Director of Nursing confirmed that leaving medication unattended was not protocol and suggested a potential change in the medication administration timing. In the second instance, a white oval pill was found on another resident's shirt during an observation. A licensed practical nurse confirmed the presence of the medication and stated that the nurse should have stayed until the medication was taken. The facility's policy on medication administration requires that staff ensure residents swallow all medications, which was not adhered to in this case.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for residents who are unable to perform these tasks independently, specifically affecting two residents. Resident #88 was observed with oily skin, dry and cracked lips with a crusty substance, and a dry mouth, indicating a lack of personal and oral hygiene care. The resident's records showed dependency on staff for personal hygiene due to conditions such as encephalopathy and muscle weakness. Staff interviews revealed that the high number of residents assigned to each CNA made it difficult to meet all residents' needs, particularly for newer staff members. Similarly, Resident #131 was observed with cracked lips, a buildup of substance on them, discolored teeth with a thick film, and a dry mouth, suggesting inadequate oral care. This resident also depended on staff for oral hygiene and other personal care tasks due to medical conditions like acute respiratory failure and muscle weakness. Staff interviews confirmed that the resident had not received ADL care on the day of observation due to the workload of the CNAs. The Director of Nursing expected staff to provide care according to each resident's care plan, but no policy on ADL assistance was provided when requested by the surveyors.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident received blood pressure medications according to the specified parameters set by the physician. The resident had physician orders for Amlodipine Besylate, Losartan Potassium, and Propranolol HCl, all of which included instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60. Despite these parameters, the resident was administered these medications on multiple occasions when their systolic blood pressure and pulse were below the specified thresholds. The Medication Administration Record (MAR) for January 2025 showed that the resident received Amlodipine, Losartan, and Propranolol on several dates when their vital signs were below the parameters. Interviews with the Director of Nursing and an Advanced Practice Registered Nurse confirmed that the nursing staff is expected to follow the physician's orders and contact the provider if there are any questions or clarifications needed. The facility's policy on administering medications also emphasized the importance of adhering to prescriber orders and current standards of practice.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as prescribed by the physician. During multiple observations, it was noted that the resident was either not receiving oxygen or was receiving it at incorrect flow rates. Specifically, the resident was observed without oxygen on one occasion and with oxygen at 3.5 and 4.5 liters per minute on other occasions, despite a physician's order for 2 liters per minute. The oxygen tubing and humidification bottle were also not dated, which is a deviation from the facility's policy. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen rate. A registered nurse admitted to assuming the oxygen rate was correct without verifying it, and the respiratory therapist was unaware of who was altering the oxygen flow rate. The East Wing Unit Manager and the Director of Nursing both expressed expectations that nurses should confirm the correct oxygen rate as per the physician's order. The facility's policy on oxygen administration clearly outlines the need to verify physician orders and document the oxygen flow rate, which was not followed in this case.
Failure to Label Food Items in Nourishment Room
Penalty
Summary
The facility failed to ensure proper labeling of food items in one of the nourishment rooms, as observed during a tour conducted by the Certified Dietary Manager (CDM). During the observation, it was noted that there was an unlabeled and undated grocery bag containing a Chicken BLT salad bowl, an unlabeled and undated Chef salad bowl, and an unlabeled and undated clear plastic container of blackberries on the bottom shelf of the refrigerator in the nourishment room located on the 300 hallway. The CDM confirmed that all foods brought in must be labeled with the resident's name, the date it was brought in, and an expiration date set for seven days after it was brought in. The facility's policy titled 'Food: Safe Handling for Foods from Visitors,' last reviewed on January 13, 2025, specifies that when food items are intended for later consumption, the responsible facility staff member must label the foods with the resident's name and the current date. This policy was not adhered to, leading to the deficiency noted during the survey.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards for catheter care, which was observed during a survey. Specifically, a resident's catheter bag was found lying on the floor, which is against the facility's policy for maintaining clean technique and preventing infection. During an interview, an LPN acknowledged that the catheter bag should not have been on the floor. The Director of Nursing stated that it was expected for nurses to check catheter bags during medication passes. The facility's policy on catheter care, last reviewed in January 2025, clearly states that catheter tubing and drainage bags should be kept off the floor to maintain infection control.
Failure to Accommodate Resident's Service Dog
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not allowing Resident #135 to have their service dog with them, despite the resident's expressed need for the animal to manage their diabetes and emotional well-being. The resident, who has a history of type 2 diabetes mellitus, major depressive disorder, and anxiety, reported that the absence of their service dog caused significant distress, depression, and agitation. The resident had been attempting to gain permission to bring the service dog into the facility since November 2024, but was denied unless they could afford a private room or a sitter, which was not financially feasible for them. The resident's Advanced Registered Nurse Practitioner (ARNP) noted the resident's frustration and anxiety related to the absence of the service dog during evaluations in December 2024 and January 2025. The ARNP acknowledged the resident's severe anxiety and other mental health challenges, but did not attribute these solely to the absence of the service dog. The facility administrator admitted to having no prior interaction with the resident until shortly before the interview conducted on February 6, 2025, indicating a lack of engagement with the resident's concerns. This lack of accommodation for the resident's service animal and the resulting impact on their mental health and quality of life constitutes a deficiency in the facility's care practices.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident, leading to a deficiency in medication administration. The resident had a physician's order for Oxycodone HCl 5 mg to be given every 4 hours as needed for pain, which was later updated to 10 mg for non-acute pain. On the day of the incident, the resident requested pain medication, and the nurse administered the lower 5 mg dose instead of the newly ordered 10 mg dose because the higher dosage was not available in the pyxis system. The nurse did not notify the supervisor, pharmacy, or the nurse practitioner (NP) about the unavailability of the correct dosage, which was against the facility's policy. Interviews with the Director of Nursing, Regional Nurse Consultant, and the involved staff revealed that the nurse had difficulty remembering the resident and did not follow the expected protocol of escalating the issue when the correct medication was unavailable. The facility's policy required medications to be administered safely and timely as prescribed, and any issues with medication availability should be communicated to the appropriate personnel. The failure to administer the correct dosage as per the physician's order and the lack of communication about the medication issue led to the deficiency.
Infection Control Deficiency During Resident Hygiene Care
Penalty
Summary
The facility failed to prevent the possible spread of infection during hygiene care for a resident. During an observation, two CNAs were performing peri-care for a resident. Staff C, CNA, did not follow proper infection control procedures by cleansing the resident's groin area in a manner that could transfer bacteria from the outside to the inside. Additionally, Staff C did not change gloves or perform hand hygiene after cleansing the peri-area and before applying barrier cream. Furthermore, a bag used for collecting soiled linens fell on the floor, and Staff B, CNA, placed it back on the resident's bed without changing the bed linens. Interviews with the Director of Nursing (DON) and Staff B, CNA, revealed that the actions observed did not meet the facility's expectations for infection control. The DON stated that CNAs are expected to wash their hands after personal care and before touching reusable items, as well as change gloves and wash hands after cleaning the peri-area. Staff B acknowledged that gloves should have been changed before applying barrier cream and that the trash bag should not have been placed back on the bed after falling on the floor. The facility's policies on peri-care and hand hygiene emphasize the importance of handwashing to prevent infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 35 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Live Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Surrey Place Nursing Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Suwannee Valley Nursing Center | 16.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Center | 16.4 mi | ★★★★★ | 11 | 0 |
| Solaris Healthcare Lake City | 20.1 mi | ★★★★★ | 0 | 0 |
| Lafayette Nursing And Rehabilitation Center | 20.2 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Live Oak Healthcare And Rehabilitation Center.
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.