Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Live Oak Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple food safety lapses, including unlabeled and undated beverages in the kitchen, heavy ice build-up in the walk-in freezer, and dented food pans with crevices on the clean rack. In a resident refrigerator, staff observed a personal bag with food and drinks that were not labeled or dated, along with an unlabeled container of fruit and an open soda pack, while a charge nurse confirmed the refrigerator was for residents only and staff items should not be stored there.
The facility failed to maintain an effective QAPI process to identify and correct infection control problems across nursing, laundry, and dietary-related care. Surveyors observed a resident with wounds and dressing changes who was not placed on EBP and had no PPE signage or supplies available, an LPN administering G-tube meds without a gown despite EBP signage, wound care performed with inadequate hand hygiene, and multiple CNA peri-care encounters with glove and hand hygiene issues. Laundry items were also observed drying on the dirty side of the laundry area, and the ICP and DON acknowledged gaps in surveillance and oversight.
The facility failed to maintain infection control practices during wound care, enteral medication administration, incontinent care, and laundry processing. Staff did not perform proper hand hygiene during wound care, an LVN gave G-tube medication without a gown, CNAs provided incontinent care without required gowns and with improper glove/hand hygiene practices, and a resident who should have been on EBP had no signage or PPE available. Laundry items were also observed drying on the dirty side of the laundry area, and wet linen was left in the washer overnight.
A resident with dementia, Alzheimer's disease, DM2, anemia, and HTN reported that her room and restroom were hot and uncomfortable, and she said she had told staff before without resolution. Surveyors observed the room and restroom temperatures above acceptable levels, with the restroom reaching 87.7 F. The ADM and MD stated sunlight, a closed restroom door, and a malfunctioning exhaust manifold contributed to the heat, with the exhaust issue present for about a month.
Expired influenza vaccines were found stored in the medication refrigerator in the med room, with ten unopened boxes past the manufacturer expiration date. The ADON said the vaccines had not been given during flu season and that she was responsible for checking and disposing of expired meds, while the DON said the last flu vaccines were administered months earlier. Facility policy stated expired meds are not to be used and must be disposed of per policy.
A resident with essential hypertension and severe cognitive impairment had an order for daily amlodipine with instructions to hold the dose if BP was below a specified parameter. On multiple occasions, an LVN documented the medication as held on the eMAR but did not record the corresponding BP readings, despite stating that BP was always checked beforehand. The DON confirmed that BP should be measured and documented on the eMAR whether or not the medication is given, and facility policy required vital signs to be recorded on the MAR for medications requiring them, which did not occur in this case.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents experienced significant medication errors involving anticonvulsant drugs due to failures in order transcription, medication reconciliation, and administration verification. One resident received a triple dose of phenytoin for several days, resulting in toxicity, while another received an incorrect dose of carbamazepine at bedtime. Staff interviews revealed inconsistent practices and a lack of proper review of new admission orders, contributing to these errors.
Three residents with respiratory conditions did not receive oxygen therapy at the flow rates ordered by their physicians, as nursing staff failed to verify and adjust oxygen concentrator settings according to care plans. CNAs were not responsible for these settings and were unaware of the correct levels, while LVNs admitted to not checking the settings for several days. This resulted in oxygen being delivered at incorrect rates for multiple residents with diagnoses such as COPD and respiratory failure.
A CNA failed to maintain a resident's dignity during perineal care by showing the soiled wipe to the resident twice and accidentally covering the resident's face with a blanket. The resident, who had severe cognitive impairment and required two staff for care, was left feeling disrespected. Staff interviews and video evidence confirmed the inappropriate actions, which were not in accordance with the resident's care plan or facility policy.
Two residents with cognitive and behavioral impairments were involved in an incident where one slapped the other on the buttocks, prompting a physical retaliation. Both had documented histories of behavioral issues, and staff were aware of their tendencies. The facility did not prevent the altercation, resulting in both residents experiencing abuse.
A resident with severe cognitive impairment and multiple comorbidities experienced a fall resulting in a right arm fracture. The facility did not complete a Significant Change MDS assessment within the required timeframe, and the quarterly MDS did not accurately document the major injury, contrary to facility policy and regulatory requirements.
A resident with dementia and a history of falls suffered a right arm fracture after a fall, but the care plan was not promptly updated to address the new injury. The only interventions related to the fracture were added more than two months later, and staff interviews revealed errors in care plan management, including improper deletion and delayed updates, contrary to facility policy.
A resident with dementia and severely impaired cognition sustained a facial scratch during an altercation, but the LVN failed to accurately document the skin injury in the medical record, despite evidence of the wound and physician orders for treatment. This resulted in incomplete and inaccurate clinical documentation, contrary to facility policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS did not document a pacemaker, and another resident's MDS incorrectly indicated the use of bed rails as a restraint. Both errors were acknowledged by the DON and MDS Coordinator.
The facility failed to develop comprehensive care plans for two residents, omitting critical information about a pacemaker and code status, despite these being documented in their medical records. The omissions were acknowledged by the MDS Coordinator, DON, and Social Worker.
The facility failed to maintain proper infection control practices as two CNAs did not follow hand hygiene protocols during incontinent care for two residents with cognitive impairments and incontinence. This lapse could lead to cross-contamination and the spread of germs.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and in a resident-designated refrigerator. During the initial kitchen tour, surveyors observed 8 trays of varied beverages in covered plastic glasses that were not dated or labeled. The walk-in freezer door was difficult to open and close, and there was approximately a half-inch layer of ice around the door seal and jam, with heavy ice build-up behind the fan/condenser and tubing. Multiple dented food-holding pans were also observed on the clean rack, including 4 pans with crevices in the corners from dents. In the 400 hall resident refrigerator, surveyors observed a personal bag containing mustard, water, and zip-type baggies with sandwich meat, bread, and fruit; none of these items were labeled or dated. A plastic container of fruit that appeared soggy was also unlabeled and undated, and an open 12-pack of soda with a resident's name was next to the personal bag. On revisit of the walk-in freezer, the ice that had been chipped off the fan/condenser and tubing was found in chunks on the floor and on top of boxes of product, with black objects stuck in the ice similar to insulation. Interviews confirmed that dietary staff were responsible for labeling and dating items, that the freezer door issue had been entered as a work order about a month earlier, and that staff were unaware the dented pans could harbor bacteria. A charge nurse stated the resident refrigerator was for residents only and that staff personal items had no place in it.
QAPI and Infection Control Oversight Deficiencies
Penalty
Summary
The facility failed to develop and implement a QAPI plan that described how quality assessment and assurance activities would be conducted and how quality deficiencies would be identified and corrected. Record review showed no evidence that the facility identified, monitored, trended, or implemented corrective actions related to hand hygiene, PPE use, Enhanced Barrier Precautions, wound care practices, G-tube medication administration, or laundry processes. The QAA committee policy stated the facility would maintain a QAA committee to identify quality issues and develop plans of action through an interdisciplinary approach, and that the infection preventionist would report on the infection prevention and control program and related incidents on a regular basis. During survey observations, multiple infection prevention and control deficiencies were identified in nursing, laundry, and dietary-related processes. For Resident #3, who had an acquired sacral pressure ulcer, a left first toe wound, a right BKA, and dressing changes ordered for a surgical incision/site, there was no EBP signage outside or inside the room and no PPE readily available. The WCN stated Resident #3 should have been on EBP, that orders existed for EBP, and that gowns were not used during dressing changes. The DON and ICP also acknowledged the resident should have been on EBP, while the ICP stated she was not familiar with the facility policy and believed only open wounds needed EBP. Additional observations showed LVN B administered medications through a G-tube for Resident #49 without wearing a gown even though EBP signage was posted. For Resident #1, the WCN washed hands for approximately 6 seconds before wound care, CNA A washed hands for approximately 4 seconds before assisting, and the WCN removed gloves and continued wound care without hand hygiene before resuming. In the laundry area, a sling and heel protector were observed drying on the dirty side, and the ES stated washed items were hung there because that was the process she had been taught. The survey also observed CNA C, CNA D, and CNA E performing incontinent care for Residents #10 and #8 with glove changes and hand hygiene inconsistencies, and CNA C cleaned Resident #10 from back to front during peri-care. The ICP and DON stated they were responsible for infection control oversight, but the record review showed no routine surveillance or monitoring in these areas and no QAPI documentation reflecting these deficiencies.
Infection Control Failures During Wound Care, EBP Care, and Laundry Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents receiving wound care, enteral medication administration, incontinent care, and enhanced barrier precautions, as well as for laundry handling. For one resident with a stage 3 pressure ulcer to the right heel, the wound care nurse washed her hands for approximately 6 seconds before wound care, the CNA assisting washed for approximately 4 seconds, and the wound care nurse did not perform hand hygiene after removing gloves during the procedure. The wound care nurse stated hand hygiene should be performed after glove removal, and the infection preventionist stated handwashing should be performed for at least 20 seconds with lathering. Laundry observations showed a sling used for a mechanical lift transfer and a heel protector drying on the dirty side of the laundry area. The environmental services staff stated the items were hung there because no other location was available and that this was the process she had been taught. The same staff member also stated wet laundry had been left in the washer overnight and then moved to the dryer the next morning. The infection preventionist stated she was unaware that infection control oversight included monitoring the dietary and laundry departments and had not conducted routine surveillance or monitoring in those areas. She also stated slings and heel protectors should not be hung to dry on the dirty side because they could become contaminated by airborne microorganisms, and wet linen should not be left in the washer overnight because microorganisms could grow on the linen. The facility also failed to follow enhanced barrier precautions for multiple residents. For one resident with a feeding tube and severe cognitive impairment, an LVN administered medication through the G-tube while wearing gloves but not a gown, despite an EBP sign posted at the room entrance and an order requiring gown and gloves for high-contact care. For another resident requiring EBP for a history of MSSA, two CNAs performed incontinent care without gowns; one CNA also cleaned the peri-area back to front at one point, and another changed gloves without performing hand hygiene before continuing care. For a third resident with ESBL, wounds, and dressing changes, there was no EBP signage and no PPE readily available in or outside the room, and the wound care nurse stated gowns were not used during dressing changes even though the resident should have been on EBP. The DON, ICP, and nursing staff acknowledged the EBP expectations and stated the residents should have had the precautions in place.
Excessive restroom heat in resident room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for one resident whose restroom temperatures remained above 81 F for approximately one month. The resident was an older female with diagnoses including Alzheimer's disease, dementia, type 2 diabetes, anemia, and hypertension, and her quarterly MDS reflected a BIMS score of 6 with severe cognitive impairment. She used a walker and was independent with eating, toileting, oral hygiene, showering/bathing, dressing, and personal hygiene. During interview, she stated her room and restroom were hot and uncomfortable, that her family had brought in two fans, and that she had previously reported the issue to staff without seeing a resolution. Observations showed the resident's room temperature at 80.3 F and the restroom at 83.4 F, and later the room at 79.3 F with the restroom at 87.7 F. The ADM stated the resident kept the blinds open, allowing direct sunlight into the room, and kept the restroom door closed, with a high window adding sunlight to the area. The MD stated the exhaust manifold above the room was not functioning properly for about one month, causing cooled air to be exhausted from the room, and reported that room temperatures stayed around 77 F while the restroom could reach about 84 F. The resident and her roommate were later relocated to another room until repairs could be completed.
Expired Influenza Vaccines Stored in Medication Refrigerator
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals in one medication room when expired influenza vaccines were left stored in the refrigerator. During an observation of the medication storage room, ten unopened boxes of influenza vaccines with an expiration date of 6/30/2026 were found in the refrigerator. The vaccines had been received during the flu season that began in October 2025, and the ADON stated the vaccines were not given during that time. During interviews, the ADON said she was responsible for checking expired medication and disposing of medication as needed, and that the pharmacy consultant performed in-services on disposing medication and checked for expired medication. The DON stated that March 2026 was the last time influenza vaccines were administered and that the ADON monitored expiration dates and removed medications from the medication storage room. The facility policy stated that expired medications are not to be used and that all expired medications will be disposed of per facility policy.
Failure to Document Blood Pressure Readings When Holding Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with essential primary hypertension. The resident, an older female with severe cognitive impairment (BIMS score of 7), had a care plan problem for hypertension with an intervention to administer antihypertensive medications as ordered. The physician’s order for amlodipine 10 mg daily included parameters to hold the medication for blood pressure less than 100/60. Review of the resident’s electronic MAR for March 2026 showed that on four specific dates, the nurse signed out the amlodipine as held due to low blood pressure, but no corresponding blood pressure readings were documented on the eMAR for those dates. During interview, LVN A stated she always checked the resident’s blood pressure before administering any blood pressure medication and confirmed she was able to sign the eMAR as held without entering the blood pressure reading. LVN A expressed confidence that the resident’s blood pressure had been below the ordered parameters on the four days in question and acknowledged the importance of accurate and complete documentation for medication adjustment and monitoring trends. The DON stated that blood pressure should always be measured before administering blood pressure medications and documented in the eMAR whether or not the medication was given, emphasizing the need for accurate history when reviewing records. Facility policy on Medication Administration required staff to sign the MAR after administration and to record vital signs on the MAR for medications requiring vital signs, which was not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving anticonvulsant medications. In the first case, a male resident with epilepsy and severe cognitive impairment was admitted with an order for phenytoin sodium extended-release capsules, 300 mg at bedtime. However, due to a transcription error by an LVN, the order was entered as 900 mg at bedtime, resulting in the resident receiving a triple dose for seven consecutive nights. This error was not identified during the daily morning meetings where new admission orders were supposed to be reviewed by the ADONs and DON. The resident subsequently developed symptoms consistent with phenytoin toxicity, including altered mental status, ataxia, and slowed speech, and was sent to the hospital where a toxic phenytoin level was confirmed. In the second incident, a female resident with a seizure disorder and moderate cognitive impairment had an order for carbamazepine to be administered as 400 mg in the morning and 100 mg at bedtime. The medication was only available in 200 mg tablets, and on at least one occasion, the resident received 200 mg at bedtime instead of the ordered 100 mg. Nursing staff were inconsistent in their administration practices, with one LVN stating she did not break tablets before crushing them, while another reported cutting the tablet in half. The resident's care plan did not address carbamazepine use, and the MAR reflected the incorrect administration. Both incidents revealed failures in medication reconciliation, order transcription, and verification processes. Staff interviews indicated a lack of consistent review and double-checking of new admission orders, as well as discrepancies between medication orders, MARs, and actual medication administration. The facility's policies required verification of medication orders and reconciliation with hospital records, but these procedures were not effectively implemented, leading to significant medication errors for the residents involved.
Removal Plan
- Licensed nurse completed a head-to-toe assessment, vital signs and neurological check on Resident #235 and findings revealed no abnormalities noted. Attending physician was notified and no new orders were given.
- Director of Nursing and/or Designee completed medication reconciliations to ensure that medications are given as ordered and documented on the MAR.
- Director of Nursing and/or designee conducted a review of all residents' changes in conditions, changes in level of care and signs and symptoms that possibly could have been medication toxicity. None was identified.
- Director of Nursing and/or designee conducted a review of all admissions/readmissions and ER visits to ensure medication orders are reconciled.
- Director of Nursing and/or designee conducted a toxicity Monitoring orders for all drugs with narrow therapeutic range and were added to EMAR.
- DON and/or Designee completed 100% medication reconciliation and MAR to Cart audit to ensure that medication on hand matches order and are administered as ordered.
- All licensed nurses were re-educated by the Director of Nursing or designee on the following: Abuse/Neglect and Exploitation, Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation, Change of Condition-signs/symptoms of medication toxicity and Md/RP notifications, Clinical Admission Process in EMR, 2 nurse verification on all new admission/readmission orders.
- 100% licensed nurses were re-educated on the following: Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation on new and medication order changes, Verification of medication label prior to medication administration.
- Licensed nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training during orientation prior to providing care to residents. The training will include the above-stated educational components.
- Admission/readmission/new and medication order changes will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital records and verified with physician. New and medication order changes will be reviewed to ensure medication is administered as ordered to include verification of medication label to match physician's orders. Review will also ensure that monitoring of adverse effects is ordered, completed, and documented and physician is notified for abnormal findings.
- Weekend RN and/or ADON will complete and review Medication reconciliation for admission/readmissions/new orders/medication order changes over the weekend.
- Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration.
- Director/Designee will monitor compliance each weekday morning of new admission/readmission reconciliation completion and review medication order listing report to ensure new and changed medications are administered as ordered.
- Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the order listing and medication reconciliation process is followed during clinical meetings.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal.
Failure to Ensure Accurate Oxygen Administration for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required oxygen therapy, as evidenced by observations, interviews, and record reviews. For each of these residents, the oxygen concentrator settings did not match the physician's orders or the care plan interventions. Specifically, one resident's oxygen was set at 4.5 liters per minute instead of the ordered 2.5-3 liters, another resident's oxygen was set at 2 liters per minute instead of the ordered 3 liters, and a third resident's oxygen was set at 2.5 liters per minute instead of the ordered 3 liters. These discrepancies were observed during routine checks and confirmed through interviews with staff and review of medical records. Interviews with Certified Nursing Assistants (CNAs) revealed that they were not responsible for checking or adjusting oxygen concentrator settings and were unaware of the correct settings for the residents. The responsibility for verifying the oxygen settings was assigned to the nursing staff, specifically Licensed Vocational Nurses (LVNs), at the start of each shift. However, the LVN interviewed admitted to not checking the oxygen concentrator settings for the affected residents over the previous four days, resulting in the settings remaining incorrect for an extended period. Further interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that nurses on each shift were expected to verify that oxygen concentrator settings matched physician orders. The facility's policy required regular assessment and correct administration of oxygen therapy, but this was not followed, as evidenced by the failure to ensure the prescribed oxygen flow rates were maintained for the residents in question. The residents involved had significant respiratory diagnoses, including COPD, respiratory failure, and hypoxia, and were dependent on accurate oxygen administration as part of their care.
Failure to Maintain Resident Dignity During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a resident with dignity and respect during perineal care. The resident, an elderly female with Alzheimer's Disease and a severe cognitive impairment (BIMS score of 3), required assistance from two staff members for all activities of daily living (ADLs) due to her condition and history of being resistive or combative during care. Despite this, the CNA provided care alone and, during the process, wiped the resident's buttocks and showed her the soiled wipe with feces on it twice. The CNA also accidentally placed a blanket over the resident's face while repositioning it for care, which the resident immediately removed. The incident was witnessed by a family member, who reported the CNA's actions to facility leadership, describing the behavior as disrespectful and abusive. Surveillance video confirmed that the CNA intentionally held the dirty wipe in the resident's plain view on two occasions. Interviews with other staff members, including another CNA, an LVN, and the DON, confirmed that such actions were inappropriate and not in line with treating residents with dignity and respect. The facility's policy emphasized the importance of promoting and maintaining resident dignity during care. The resident's care plan specified the need for two staff members during care and encouraged resident participation in ADLs as tolerated. The CNA's actions, including providing care alone, showing the soiled wipe, and covering the resident's face with a blanket, were inconsistent with the care plan and facility policy. The resident was unable to respond to interview questions due to her cognitive impairment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse during an incident where one resident slapped another on the buttocks, and the second resident responded by hitting the first in the face. The first resident, a male with dementia, cognitive communication deficit, and a history of inappropriate sexual behavior, was known to have a habit of touching or grabbing people as they walked by. His care plan indicated a need for a structured environment and noted his behavioral issues, including inappropriate sexual behavior and agitation. On the day of the incident, he slapped another male resident on the buttocks, which was documented in progress notes and confirmed by staff interviews. The second resident involved had diagnoses including bipolar disorder, schizoaffective disorder, and schizophrenia, with a history of behavioral problems such as indecent exposure, public touching, and physical aggression when triggered by inappropriate touch. His care plan also indicated a need for a structured environment and noted poor impulse control. After being slapped on the buttocks, he immediately turned and punched the first resident in the face, causing a superficial scratch and redness. This reaction was consistent with his care plan, which stated he could be triggered for physical aggression when touched in a way he perceived as inappropriate. Staff interviews revealed that both residents had known behavioral issues, and staff were aware of the potential for such incidents. Multiple staff members described the first resident as "grabby" but not aggressive, and the second resident as someone who did not like to be touched due to past trauma. The facility's policy defined abuse as any non-consensual sexual contact or willful infliction of injury, and staff acknowledged that the incident could have caused physical or psychological harm. Despite this, the facility failed to prevent the incident, resulting in both residents being exposed to abuse.
Failure to Complete Timely Significant Change Assessment After Major Injury
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days following a significant change in condition for one resident who experienced a fall resulting in a major injury. Specifically, the resident, an elderly female with diagnoses including dementia, history of falls, macular degeneration, lack of coordination, and muscle wasting, suffered a fall in her room that resulted in an acute right humeral neck fracture. Documentation showed that after the fall, the resident complained of right arm pain, was medicated for pain, and had an x-ray confirming the fracture. Despite this significant change in her physical condition, a Significant Change Minimum Data Set (MDS) assessment was not completed within the required timeframe. Further review of the resident's records indicated that the quarterly MDS assessment did not accurately document the fall with major injury, and the significant change MDS assessment was omitted entirely. Interviews with the DON and MDS nurse confirmed that a fall with a fracture is considered a significant change and should have triggered a timely assessment. The facility's policy also requires completion of a significant change assessment within 14 days of such an event, but this was not followed in this case.
Failure to Timely Update Care Plan After Resident Fall with Major Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant change in condition. The resident, an elderly female with diagnoses including dementia, history of falls, impaired mobility, and muscle wasting, experienced a fall resulting in a right arm fracture. Despite this significant event, the care plan was not promptly revised to address the new injury, and the only interventions related to the fracture were added more than two months after the incident. The resident's medical records indicated severe cognitive impairment and a history of falls, with multiple documented incidents of falling, including one that resulted in a major injury. The care plan in place was not updated in a timely manner to reflect the resident's new needs following the fracture. The only care plan interventions related to the arm fracture were initiated over 70 days after the fall, and there was evidence that previous care plan entries may have been deleted or replaced incorrectly, rather than being properly resolved or cancelled. Interviews with facility staff revealed confusion and errors in the care planning process, including the deletion of care plan items and lack of timely updates following significant changes in the resident's condition. The facility's own policy required prompt review and revision of care plans after a status change, but this was not followed, resulting in the resident's care plan not accurately reflecting her current needs after the injury.
Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when a licensed vocational nurse (LVN) did not properly document a skin assessment following an altercation. The resident, who had diagnoses including dementia and severely impaired cognition, was involved in an incident where he was struck in the face by another resident, resulting in a superficial scratch on the bridge of his nose and redness to his left cheek. Documentation inconsistencies were noted: the LVN's weekly skin evaluation stated there were no abnormal skin areas or wounds, despite other records and interviews confirming the presence of a scratch that required treatment with triple antibiotic ointment. Interviews with the LVN, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed the presence of the abrasion and the need for accurate documentation. The facility's own documentation policy requires that each resident's medical record accurately reflect the resident's experiences and include complete, accurate, and timely information. The failure to document the skin injury as observed and treated resulted in incomplete and inaccurate clinical records for the resident.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. Resident #18's MDS did not document the presence of a pacemaker, despite the resident having a diagnosis of Parkinson's and a pacemaker, as indicated in the physician order report. The MDS Coordinator acknowledged the omission and stated that the MDS should have included the pacemaker but it was missed. The Director of Nursing (DON) also admitted to not noticing the missing information in the MDS, which was her responsibility to update and revise as needed. For Resident #10, the facility inaccurately documented the use of bed rails as a restraint in the MDS. The resident's care plan and physician order summary indicated that the bed rails were used for assistance with repositioning and transfers, not as a restraint. The DON and MDS Coordinator both confirmed that the bed rails were never intended to be a restraint and that the error was due to human oversight. The MDS Coordinator admitted to accidentally checking the restraint box and had already started a modification to correct the error. Both residents' MDS inaccuracies could potentially impact their care plans and the quality of care they receive.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents. Resident #18's care plan did not address his pacemaker, despite his medical records indicating he had one and a physician's order to check its status. The MDS Coordinator acknowledged that the pacemaker should have been included in the care plan but was missed. The Director of Nursing (DON) also admitted that it was her responsibility to ensure care plans were updated and had not noticed the omission. The Administrator confirmed that the pacemaker should have been care planned to prevent improper care of the resident. Resident #61's care plan did not address her code status, even though her medical records indicated she was a full code. The Social Worker, responsible for starting care plans for code status on all admissions, was unsure why the code status was not showing up in the electronic medical records. The facility's policy on comprehensive care plans emphasizes the importance of developing and implementing a person-centered care plan with measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to deficiencies in hand hygiene practices by two CNAs during incontinent care for two residents. CNA A did not wash or sanitize her hands before putting on gloves or after changing gloves while assisting a resident with Parkinson's and muscle wasting. This resident had a BIMS score indicating moderate cognitive impairment and was frequently incontinent. CNA A admitted to forgetting the hand hygiene steps due to nervousness, which could lead to cross-contamination and the spread of germs. Similarly, CNA B did not wash or sanitize her hands before putting on gloves or after changing gloves while assisting a resident with Alzheimer's Disease and severe cognitive impairment. This resident was always incontinent of both urine and bowel movements. CNA B performed perineal care and changed the resident's brief without following proper hand hygiene protocols, which could also lead to cross-contamination. Interviews with the LVN, DON, and Administrator confirmed that the staff did not follow the facility's policies on hand hygiene and perineal care. The facility's policies clearly state the need for hand hygiene before and after glove use and during glove changes, especially when moving from dirty to clean tasks. The failure to adhere to these protocols was acknowledged by the staff and administration, highlighting a significant lapse in infection control practices.
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 6 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near George West
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hacienda Oaks At Beeville | 23.1 mi | ★★★★★ | 4 | 0 |
| Avir At Beeville | 24.2 mi | ★★★★★ | 2 | 0 |
| Palma Real | 25.1 mi | ★★★★★ | 7 | 0 |
| Bluebonnet Nursing & Rehabilitation | 34.7 mi | ★★★★★ | 10 | 0 |
| Kenedy Health & Rehabilitation | 34.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Live Oak Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.