Centennial Post Acute: Drug Storage Failures - AK
The makeshift repair on Resident #1's gastrostomy tube violated infection control standards and facility policy requiring medical-grade devices for tube maintenance. The tube had developed an internal tear that caused leakage during medication administration.
Licensed Nurse #4 told inspectors on August 29 that the rubber band "functioned as a clamp" while tape from the resident's room secured the repair. "The rip was internal to the tubing; meds were delivered past the tear," the nurse explained. "At the time I did not identify additional risks beyond leakage, but I recognize the ad-hoc nature isn't ideal."
The facility's Infection Preventionist called the repair unacceptable during the same day's interview. "A medical grade clamp should have been used to prevent leakage and electrolyte imbalance," she told inspectors. Using rubber bands posed infection control risks, though she noted tape was "less risky if clean" since gastrostomy tube care uses clean technique rather than sterile.
She said the correct response would have been clamping the tube and replacing it on-site, as the facility had supplies available. Staff were never trained to use rubber bands when proper clamps were accessible.
The resident's care plan, last revised March 3, required checking the gastrostomy tube site before each feeding and medication administration for signs of irritation, infection, or leakage. Progress notes show the tube was eventually replaced on May 10 using sterile technique, with a 15 French tube placed and 15cc added to fill the balloon.
Centennial's Director of Nursing acknowledged during an interview that most facilities stock standard medical-grade clamps. The director admitted no specific follow-up occurred after the makeshift repair and confirmed rubber bands were not standard practice at the facility.
The director also revealed infection control audits "were not consistently conducted and needed to be revamped."
Facility policy required staff to monitor feeding tube sites for leakage, infection signs, or skin irritation. The policy mandated clean technique including gloves when stopping, starting, flushing, or administering medications through gastric tubes. It called for using closed systems whenever possible for tube feedings.
The facility's adopted procedures from Lippincott emphasized that nurses "should not improvise with non-sterile or non-medical materials to patch the tube." When troubleshooting leaking gastrostomy tubes, the guidelines required following aseptic technique and manufacturer-specific instructions, including verifying tube placement, checking balloon integrity, and using only medical-grade devices like clamps.
Key troubleshooting steps included keeping the site and tubing clean and dry while escalating for replacement when indicated.
The inspection found the improvised repair created potential for microbial contamination that proper sterile technique and setup are designed to prevent. Federal regulations require nursing homes to ensure residents receive treatment and care according to professional standards of practice.
Gastrostomy tubes deliver nutrition and medication directly to the stomach through a surgically created opening. Proper maintenance prevents complications like infection, leakage, and electrolyte imbalances that can harm vulnerable residents who depend on tube feeding.
The resident's care plan goal stated they would "remain free of side effects or complications related to tube feeding." Interventions included checking tube placement after two weeks and monitoring for complications before each feeding or medication administration.
Licensed Nurse #4 acknowledged the makeshift repair "should involve provider notification and replacement as soon as possible." The nurse recognized additional infection risks beyond the initial leakage concern.
The violation received minimal harm designation, affecting few residents. Inspectors completed their complaint investigation on August 29, documenting the facility's failure to follow proper infection control procedures for medical device maintenance.
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 20, 2026 · Our methodology
CENTENNIAL POST ACUTE in ANCHORAGE, AK was cited for violations during a health inspection on August 29, 2025.
The tube had developed an internal tear that caused leakage during medication administration.
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.