Centennial Post Acute: Medication Error Failures - AK
The makeshift repair violated infection control standards and facility policy requiring medical-grade equipment for feeding tube maintenance. Federal inspectors found the improvised solution created unnecessary infection risks for the resident who depends on the tube for nutrition and medication.
Licensed Nurse #4 discovered the G-tube leak and fashioned a temporary fix using available materials rather than standard medical clamps. The nurse told inspectors the rubber band "functioned as a clamp" and the tear was internal to the tubing, allowing medications to be delivered past the damage.
"I used the resident's clean room tape; the rubber band functioned as a clamp," the nurse explained during the August inspection. "At the time I did not identify additional risks beyond leakage, but I recognize the ad-hoc nature isn't ideal and should involve provider notification and replacement as soon as possible."
The facility's own procedures explicitly prohibit such improvisation. Policy documents accessed by inspectors state nurses "should not improvise with non-sterile or non-medical materials to patch the tube" and must use only medical-grade devices like proper clamps.
Resident #1 had their G-tube replaced on May 10, the same day the leak was discovered. Progress notes show a 15 French tube was placed using sterile technique, with proper balloon filling and placement verification. The resident tolerated the replacement procedure well and received 300 cc of water afterward.
The facility's infection preventionist called the rubber band repair "not acceptable" during inspector interviews. She explained that medical grade clamps should prevent leakage and electrolyte imbalance, and that G-tubes can typically be replaced on-site when supplies are available.
"Using rubber bands poses infection control risks," the infection preventionist told inspectors, though she noted tape was less risky if clean since G-tube care uses clean technique rather than sterile procedures.
The Director of Nursing acknowledged the substandard repair during questioning. When asked about the makeshift dressing and rubber band clamp, the director admitted "no specific follow-up was done at that time and the use of rubber bands was not the standard practice promoted by the facility."
Most facilities keep standard medical clamps readily available, the director confirmed. The conversation revealed broader infection control weaknesses at the facility, with the director stating that audits "were not consistently conducted and needed to be revamped."
Resident #1's care plan, last updated in March, specifically required monitoring for G-tube complications before each feeding and medication administration. Staff were supposed to check for signs of skin irritation, leakage, and infection, with site care performed every shift.
The facility follows Lippincott procedures from 2009 that emphasize aseptic technique and manufacturer guidelines when troubleshooting gastrostomy tube problems. The protocols require nurses to verify tube placement, check balloon integrity, assess connections, and secure the site properly while keeping everything clean and dry.
Key steps include using only medical-grade securement devices and escalating for replacement when indicated. The procedures explicitly state nurses must not improvise with non-medical materials.
The resident's care plan aimed to keep them "free of side effects or complications related to tube feeding." Interventions included checking tube placement after two weeks and monitoring for signs of infection or skin problems at the insertion site.
Staff were trained to provide water flushes before and after medication administration and tube feeds, using clean technique including gloves for all gastric tube procedures. The facility policy called for using closed systems whenever possible for tube feeding administration.
The inspection found the rubber band repair created potential for microbial contamination that proper medical equipment would have prevented. While the resident suffered no apparent immediate harm, the improvised solution violated multiple infection control principles designed to protect vulnerable patients dependent on feeding tubes.
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 makeshift repair violated infection control standards and facility policy requiring medical-grade equipment for feeding tube maintenance.
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.