Centennial Post Acute: Assessment Failures - AK
The makeshift repair occurred at Centennial Post Acute when Resident #1's gastrostomy tube developed an internal tear. Instead of following standard procedures to clamp and replace the tube, Licensed Nurse #4 fashioned a temporary fix using non-medical materials.
"I used the resident's clean room tape; the rubber band functioned as a clamp," LN #4 told inspectors on August 29. "The rip was internal to the tubing; meds were delivered past the tear."
The nurse acknowledged the improvised solution wasn't ideal but said medications were still reaching the patient beyond the damaged section. However, facility experts disagreed with this assessment.
The facility's Infection Preventionist stated that using tape or rubber bands to manage a leaking tube was "not acceptable." A medical grade clamp should have been used to prevent leakage and electrolyte imbalance, the IP explained.
"Using rubber bands poses infection control risks," the Infection Preventionist said, noting that proper clamps were available at the facility. Staff had not been trained to use rubber bands for medical tube repairs.
The gastrostomy tube required replacement the same day. Progress notes from May 10 at 8:00 AM documented that orders were received to insert a new tube later that day. A 15 French tube was placed using sterile technique, with 15 cc added to fill the balloon. The site was cleaned, ointment applied, and a proper drainage tube cover installed.
Resident #1's care plan, last revised March 3, specifically outlined tube monitoring requirements. The plan called for checking the gastrostomy site for signs of skin irritation, discomfort, leakage, infection symptoms, or skin ulceration before each feeding, tube flush, or medication administration.
The Director of Nursing acknowledged systemic problems during the August 29 inspection. When asked about the rubber band incident, the DON admitted that "no specific follow-up was done at that time and the use of rubber bands was not the standard practice promoted by the facility."
The DON also revealed that infection control audits "were not consistently conducted and needed to be revamped."
Facility policy explicitly prohibits the type of improvised repair LN #4 attempted. The gastrostomy feeding tube policy, last reviewed in March 2019, requires clean technique including gloves when handling tubes. It mandates monitoring for leakage and signs of infection.
The facility follows Lippincott procedures from 2009, which provide clear guidance for troubleshooting leaking gastrostomy tubes. The protocol requires nurses to follow aseptic technique and manufacturer guidelines, verify tube placement and condition, and use only medical-grade devices such as proper clamps.
The Lippincott standards specifically warn that nurses "should not improvise with non-sterile or non-medical materials to patch the tube."
Despite having these protocols in place, LN #4 used materials readily available in the resident's room rather than obtaining proper medical equipment. The nurse later recognized that the makeshift solution "should involve provider notification and replacement as soon as possible."
The Infection Preventionist confirmed that gastrostomy tubes can be replaced on-site when supplies are available, making the improvised repair unnecessary. Medical grade clamps were accessible to prevent leakage while arranging proper tube replacement.
Federal inspectors cited the facility for failing to ensure infection prevention and control practices. The violation affected few residents but created potential for actual harm through contamination risks.
The incident highlighted broader issues with infection control oversight at Centennial Post Acute, where auditing practices had fallen behind facility standards and staff training on proper medical device use proved inadequate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Centennial Post Acute from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
CENTENNIAL POST ACUTE in ANCHORAGE, AK was cited for violations during a health inspection on August 29, 2025.
The makeshift repair occurred at Centennial Post Acute when Resident #1's gastrostomy tube developed an internal tear.
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.