Centennial Post Acute: Care Quality Failures - AK
The makeshift repair occurred at Centennial Post Acute when Resident #1's gastrostomy tube developed a leak. Licensed Nurse #4 wrapped tape around the damaged tubing and secured it with a rubber band to function as a clamp, allowing medications to continue flowing past the tear in the tube.
"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. At the time I did not identify additional risks beyond leakage, but I recognize the ad-hoc nature isn't ideal."
The improvised solution violated multiple infection control protocols. Facility policy required staff to use clean technique and proper medical equipment when handling gastrostomy tubes, which deliver nutrition and medications directly into patients' stomachs through surgically placed openings.
The facility's Infection Preventionist condemned the nurse's actions during an inspector interview. "Using tape or rubber bands to manage a leaking tube was not acceptable," the IP stated. "A medical grade clamp should have been used to prevent leakage and electrolyte imbalance."
The IP explained that proper procedure required clamping the tube with medical-grade equipment and replacing it on-site if supplies were available. "Using rubber bands poses infection control risks," the IP said, noting that staff were never trained to use such materials when proper clamps were readily available.
Resident #1's care plan, last revised in March, specifically outlined monitoring requirements for the feeding tube. Staff were required to check the tube site for signs of infection, skin irritation, or leakage before each feeding and medication administration. The plan called for tube site care every shift.
The resident's feeding tube was eventually replaced on May 10 using proper sterile technique. Progress notes documented that a 15-French tube was placed, the balloon was filled with 15 cc of fluid, and proper placement was verified through auscultation. The site was cleaned, ointment applied, and a proper drainage covering installed.
But the improvised repair had already occurred, creating unnecessary infection risks for a vulnerable resident dependent on tube feeding for nutrition and medication delivery.
The facility's Director of Nursing acknowledged systemic problems during the inspection. When asked about the rubber band incident, the DON 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."
The DON also revealed that infection control audits "were not consistently conducted and needed to be revamped." Most facilities, the DON noted, maintain standard medical-grade clamps specifically for such situations.
Facility policies explicitly prohibited the type of improvisation LN #4 employed. The gastrostomy feeding tube policy, last reviewed in March 2019, required staff to monitor tube sites for leakage and infection signs. It mandated clean technique, including gloves, for all tube-related procedures.
The facility's adopted medical procedures from Lippincott emphasized that nurses must follow aseptic technique and manufacturer guidelines when troubleshooting leaking gastrostomy tubes. The guidelines specifically warned against improvising "with non-sterile or non-medical materials to patch the tube."
Key troubleshooting steps included verifying tube placement, checking balloon integrity, assessing connections, and using "only medical-grade devices such as clamps or securement devices." When replacement was indicated, procedures called for escalation to appropriate medical staff.
The violation affected few residents but created potential for actual harm through infection risks. Gastrostomy tubes provide critical nutrition and medication access for residents who cannot swallow safely. Improper handling can lead to serious complications including infection, electrolyte imbalances, and compromised nutrition delivery.
LN #4's acknowledgment that the approach "isn't ideal and should involve provider notification and replacement as soon as possible" came only after inspectors questioned the improvised repair. By then, a vulnerable resident had already been exposed to unnecessary infection risks from a rubber band solution that violated basic medical standards.
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 occurred at Centennial Post Acute when Resident #1's gastrostomy tube developed a leak.
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.