State inspectors found Delta Oaks Post Acute failed to secure treatment orders for Resident 1 and Resident 3, both admitted specifically for gastrostomy tube attention. The thin tubes, inserted directly into the stomach to deliver nutrition and medications, require daily cleaning and dressing changes to prevent complications.
Licensed Nurse 1 confirmed during a September 24 interview that Resident 1 had no treatment order for G-tube site care. "The order should have been there, and it was part of the facility policy to provide treatment to Resident 1's G-tube site every day," the nurse told inspectors. Without proper treatment, "there was a risk of infection and skin breakdown at the site."
Resident 1's treatment records showed no documented evidence of G-tube site care following readmission on August 9, 2024.
The Director of Sub-Acute Services confirmed it was her expectation for residents to have physician treatment orders that included specific G-tube care instructions. Sub-acute services provide more intensive medical care than traditional nursing homes but less than hospital-level treatment.
Resident 3 faced similar gaps in ordered care. Licensed Nurse 2 verified during a September 25 interview that Resident 3 had no active treatment order for G-tube site care from August 20, 2025, through the day of inspection. "Without a treatment order for the g-tube, Resident 3 was at risk for skin breakdown and infection of the G-tube site," the nurse stated.
The Director of Sub-Acute Services confirmed Resident 3 lacked orders for both dressing changes and site cleaning. She emphasized that without proper treatment orders, "Resident 3 was at risk for infection and skin breakdown at the G-tube site."
Both residents carried admission diagnoses of "encounter for attention to gastrostomy," indicating they required routine tasks like cleansing and dressing changes for their feeding tubes. The medical code specifically applies to ongoing management of gastrostomy tubes.
The facility's own policy on enteral feedings mandates following "accepted best practices in enteral nutrition" and keeping "the skin around exit site clean, dry and lubricated." The policy, dated November 2018, establishes clear expectations for gastrostomy tube care that inspectors found were not being followed through physician orders.
Gastrostomy tubes create a direct pathway into the stomach, bypassing the mouth and throat for patients who cannot safely swallow or need long-term nutritional support. The surgical insertion site requires consistent maintenance to prevent bacterial infections that can spread internally or cause painful skin conditions around the tube.
The inspection occurred September 25, 2025, following a complaint. Inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents.
During the review process, nurses and administrators repeatedly acknowledged the risks posed by missing treatment orders. Each interview confirmed that proper physician orders were both expected protocol and necessary for resident safety.
The facility's Order Summary Reports, printed during the inspection dates, provided documentation of the missing treatment orders that should have guided daily care routines for both residents' gastrostomy tube sites.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Delta Oaks Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.