East Park Care Center: Moldy Feeding Tube Sent Resident to ER - OH
The resident, identified in inspection records only as Resident 10, lives at East Park Care Center on East Park Circle. He is bedbound, severely cognitively impaired, and dependent on staff for everything. He cannot eat on his own. A surgically implanted tube in his stomach, a percutaneous endoscopic gastrostomy tube, delivers formula and water directly into his body four times a day.
Nurses were supposed to flush that tube with 300 milliliters of water every four hours.
They apparently had not been looking at what was inside it.
On August 25, 2025, a nurse noticed the tubing had turned brown and sent Resident 10 to the hospital. The facility's own health status note described "dark discoloration of the tubing" and raised concern for "possible infection or internal bleeding." The note was careful, clinical, measured. The hospital was not.
When Resident 10 arrived at the emergency room, a registered nurse there reported he had a moldy PEG tube with large black and bulging spots. The ER physician's report, written just after midnight on August 26, recorded the same finding without ambiguity: mold around the PEG tube. The tube was replaced in the emergency room. Resident 10 was discharged back to the facility.
After the hospital visit, inspectors interviewed Nurse 300, who had been the one to send him out. She confirmed there was mold in the tube. She said she hadn't wanted to flush it in that condition. Then she described what happened when she asked the certified nursing assistants about it.
They told her it had been like that for a while.
The aides, she explained, were not nurses and did not know what they were looking at. None of the nurses, she said, remembered seeing any discoloration or mold in the tubing. Then she said something that clarified exactly how it got that way: if they had been flushing the PEG tube as ordered, they would have seen it.
The flush order had been in place since April 2024. Every four hours, 300 milliliters of water, around the clock. The formula feedings ran at midnight, 3 a.m., 6 a.m., and 9 p.m. Every one of those interactions required a nurse or aide to handle the tube. The mold did not appear overnight. The aides said it had been there for a while, and none of the nurses had noticed.
Resident 10 carries a diagnosis list that reads like a catalog of compounding vulnerabilities: cerebral infarction, anoxic brain damage, traumatic brain injury, hemiplegia of the left side, aphasia, dysphagia, diabetes, peripheral vascular disease, adult failure to thrive. He cannot report symptoms reliably. He told hospital staff he felt mild discomfort at the PEG site but denied abdominal pain, nausea, or vomiting. His vital signs were stable at the time of transfer. The hospital found no fever, no hemodynamic instability.
What the hospital found was mold.
East Park Care Center had a written policy for gastrostomy tube care, dated September 2021, stating that licensed nurses would provide routine care to maintain the patency of the tube and skin integrity. There was also a standing order to clean the PEG site daily with soap and water and apply a fresh dressing. The site itself, when Resident 10 arrived at the hospital, appeared intact. The skin around it was clean and dry with only minimal redness. The problem was inside the tube, where no one had apparently been looking.
Federal inspectors cited the facility for failing to provide appropriate care for a resident with a feeding tube. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting one of three residents reviewed for feeding tubes during the complaint inspection. The facility census at the time was 48.
The inspection was conducted October 14, 2025, following a complaint. The complaint number listed in the citation is 2603716.
Resident 10 was discharged from the emergency room and returned to East Park Care Center with a new tube. Whether the staff who flushed the old one understood what they had been missing, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Park Care Center from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
EAST PARK CARE CENTER in BROOK PARK, OH was cited for violations during a health inspection on October 14, 2025.
The resident, identified in inspection records only as Resident 10, lives at East Park Care Center on East Park Circle.
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.