Live Oak Rehab Center: Finger Wrapping Safety Failure - CA
The resident already had a history of gangrene on her left pointer finger.
A complaint inspection completed January 29, 2026 documented the incident and what followed: no notification, no monitoring, no care plan for a behavior the facility had apparently observed long enough to know about but never formally addressed.
The resident, identified in inspection records only as Resident 1, has a gastrostomy tube, a tube inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications. On the night of January 27, 2026, a certified nursing assistant identified as CNA 3 found the resident during rounds with the cord of her gown and the gastrostomy tube wrapped around her fingers. CNA 3 removed everything. Then she said nothing to any staff member on the floor.
She told inspectors she had not notified anyone.
The Director of Nursing confirmed the sequence during an interview on January 29. The CNA noticed the wrapping on Tuesday. The CNA removed it. The CNA did not tell anyone. The Director of Nursing said the CNA should have notified other staff so the resident could be monitored and the behavior formally care planned.
Should have. Past tense. After the fact.
When inspectors asked to review Resident 1's care plan on January 29 at 12:15 in the afternoon, the Director of Nursing said she could not find any care plan entry addressing the resident's behavior of wrapping her fingers around objects. There was a care plan entry focused on risk for injury, dated July 21, 2025, but the Director of Nursing acknowledged it was not specific to this behavior. Interventions to provide the resident with a safe environment had not been implemented.
The Director of Nursing also told inspectors that tangled call light cords and the coiled cables of the bed control unit are safety hazards for this particular resident. Those hazards were present in the room. The care plan did not address them.
What the record shows is a facility that knew, at least in general terms, that this resident was at risk for injury, documented that risk six months earlier, and still had no plan specific enough to capture the one behavior that had already sent her to the edge of something far worse. Gangrene on a finger does not arrive without warning. It arrives after circulation is cut off long enough for tissue to begin dying.
The facility's own safety policy, last revised in July 2017, states that safety risks and environmental hazards are identified on an ongoing basis through employee training, employee monitoring, and reporting processes. CNA 3's decision to stay silent was a failure of exactly that reporting process. But the absence of a care plan specific to this resident's behavior meant that even if CNA 3 had reported what she saw, there was no documented protocol waiting on the other end.
Inspectors classified the harm level as minimal and resolved. The behavior was caught before the finger was injured again. That is the narrowest version of a good outcome — not because the system worked, but because the cord came off before it stayed on long enough.
The Director of Nursing did not dispute any of the findings. She confirmed them, one by one, in real time, while sitting with inspectors and searching a care plan that did not contain what it needed to contain.
Resident 1 is still there. Her finger has a history that the care plan, as of January 29, 2026, had not yet caught up to.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LIVE OAK REHAB CENTER in SAN GABRIEL, CA was cited for violations during a health inspection on January 29, 2026.
The resident already had a history of gangrene on her left pointer finger.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.