Staff at Live Oak Rehab Center found the resident multiple times in late January wrapping her gown strings and gastrostomy tube around her finger. None of the assistants who discovered her reported the incidents to supervisors or documented them in her care plan.
The resident had already lost tissue on her left pointer finger from wrapping behavior before arriving at the facility. That gangrene had since resolved, but the woman continued the same actions that had caused the original injury.
On December 2025, one nursing assistant found the resident with a call light cord wrapped around her finger and removed it. The assistant told inspectors she knew staff should put away items the resident could use to wrap her fingers, but she never alerted other workers about what she had seen.
Another assistant discovered the resident on Tuesday night, January 27, 2026, with her gown cord and gastrostomy tube wound around her fingers during routine rounds. She removed the items but told no one.
A third nursing assistant made a similar discovery the same Tuesday, finding the resident with strings wrapped around her finger. Like the others, she removed the items and stayed silent.
The Director of Nursing learned about the incidents only when inspectors arrived. She told them Tuesday that one of the nursing assistants had noticed the resident wrapping her gown string and gastrostomy tube around her finger, removed everything, but failed to notify anyone.
"The CNA should have notified other staff to ensure Resident 1 was being monitored and the behavior was care planned," the director said.
She identified multiple safety hazards for the resident: tangled call light cords and coiled cables from bed controls posed ongoing risks for someone with compulsive wrapping behavior.
When inspectors asked to review the resident's care plan for finger wrapping behavior, the director could not locate one. The facility had no specific interventions documented for the woman's dangerous habit.
The resident did have a care plan focused on injury risk, dated July 21, 2025. But the director admitted it was not specific to the wrapping behavior and contained no interventions for providing a safe environment related to her compulsions.
The facility's own safety policy, revised in July 2017, required staff to make the environment "as free from accidental hazards as possible." The policy designated resident safety and accident prevention as "facility wide priorities."
The same policy mandated that safety risks and environmental hazards be identified "on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes."
None of that happened. Multiple nursing assistants observed the same dangerous behavior over several weeks and chose not to report it through any process.
The gastrostomy tube that the resident wrapped around her finger delivers nutrition, fluids, and medications directly through her abdominal wall into her stomach. Cutting off circulation to fingers with medical tubing designed to sustain life represents exactly the kind of hazard the facility's policies were written to prevent.
Each nursing assistant who found the resident wrapping items around her fingers made an individual decision to handle the situation alone. They removed immediate dangers but left the underlying problem unaddressed.
The pattern continued until federal inspectors arrived to investigate a complaint. Only then did supervisors learn their staff had been finding and hiding evidence of serious self-harm behavior for weeks.
The resident's history made the stakes clear. She had already suffered gangrene from wrapping her finger. The tissue death that results from cutting off blood circulation had resolved, but the behavior that caused it had not.
Staff knew she would wrap anything available around her fingers. They knew this had caused permanent damage before. They knew their facility's policy required them to identify and report safety hazards.
They removed the strings and said nothing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Live Oak Rehab Center from 2026-01-29 including all violations, facility responses, and corrective action plans.