Lakehouse Healthcare & Rehabilitation Center

confirmed she did not flush the jejunal port with 30 cc as ordered. LPN-A stated she did not see the

LPN-D put R1's enteral feeding on hold and disconnected tube. LPN-D placed air into enteral tube

and the gastric port with 30 cc of water. LPN-D was connecting syringe with crushed medication and water mix to the jejunal port, and LPN-E directed LPN-D to stop and administer medications into the gastric port. LPN-D flushed the gastric port with 30 cc of water after medication administration.

LPN-D placed additional water in syringe and was directing syringe to jejunal port, and LPN-E directed LPN-D to gastric port. LPN-D flushed the gastric port with 120 cc of water. LPN-D reviewed R1's orders and verified R1's order to flush 120 cc six times per day did not indicate water or what to flush the port with. LPN-D stated R1 used to have gastric ports only and the jejunal port was new.R1's medication and treatment administration record printed on 4/29/26 at 11:14 a.m., directed staff to use gastric port for medications only and flush port with 30 cc water before and after medication administration to prevent the tube from clogging during the day, evening, and night shift.

The document included the amount of fluids used to flush R1's gastrojejunal tube and varied between 30 and 60 cc's.During interview on 4/29/26 at 3:59 p.m., LPN-B stated staff documented intakes on the medication administration record if the order directed them to. LPN-B stated all residents were at risk for dehydration, and residents with tube feedings were at an increased risk of dehydration. LPN-B reviewed R1's documents, and the order which had varied documentation of 30 and 60 cc flushes administered. LPN-B stated she would want to educate the staff to ensure they documented and gave the correct flushes.During interview on 4/30/26 at 9:12 a.m., registered dietician (RD)-C completed monthly charting on high-risk residents such as R1. RD-C stated they reviewed resident medication and treatment administration records to ensure nursing provided appropriate interventions to support residents' nutritional needs. RD-C reviewed R1's order documentation which indicated staff varied giving 30 and 60 cc flushes. RD-C stated they would follow up with nursing to ensure the staff provided R1 with the appropriate flushes. RD-C stated inadequate or incorrect flushing of enteral tube feeding ports could cause clogging or dehydration if there were multiple missed flushing opportunities. RD-C stated administration of medications in the jejunal port instead of the gastric port could affect medication absorption and cause interactions between the feeding formula and medication.

During an interview on 4/30/26 at 5 p.m., the director of nursing (DON) expected staff to give residents flushes as ordered, with free water flushes considered a separate amount than flushes with medications, to ensure proper hydration and tube patency.

The DON expected staff to give medications and flushes in the correct ports to support proper medication absorption and tube patency.

245055 04/30/2026

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

precautions (EBPs) were followed for 1 of 1 resident (R1) when medication was administered via

syringes and containers used for flushing enteral tubes for 2 of 3 residents (R1, R4) reviewed for enteral tubes.

Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required staff assistance with activities of daily living. R1 had a feeding tube and diagnoses which included stroke, hemiplegia or hemiparesis, heart failure, kidney disease, diabetes mellitus, aphasia, malnutrition, and respiratory failure.R1's infection care plan revised 4/24/26, indicated R1 was at risk for infection due to gastric tube.

The care plan directed staff to follow enhanced barrier precautions with all contact cares due to R1's gastric tube.During an observation on 4/29/26 at 8:40 a.m., licensed practical nurse (LPN)-A donned gloves and no gown to administer R1's medications through his gastrojejunostomy tube.

During an interview on 4/29/26 at 11:53 a.m., LPN-A stated staff wore gloves and gowns to complete cares, such as dressing and toileting, and foley catheter cares for residents who were on enhanced barrier precautions. LPN-A stated they did not need a gown to administer R1's medications through his gastrojejunostomy tube.R1's physician order dated 5/27/25, directed staff to change out syringe and canister for free water every day during the night shift.During observation on 4/28/26 at 4:13 p.m., R1's nightstand had an irrigation syringe with a plunger in it, and the syringe was in an irrigation container filled with water.

The syringe and bottle did not have a date.

There was no barrier under the container.During interview on 4/28/26 at 4:27 p.m., LPN-C stated the night shift changed the irrigation syringe and bottle every night. LPN-C verified the irrigation syringe and container were not dated and stated the container should be emptied and the plunger separated from the syringe barrel to allow the equipment to dry.R4R4's quarterly MDS dated [DATE], indicated R4 had moderate cognitive impairment and was independent with activities of daily living. R4 had a feeding tube and diagnoses which included cancer, malnutrition, and depression.R4's physician order dated 3/30/26, directed the staff on the night shift to replace graduate, syringe, and dressing every night.

Staff were to replace tubing daily if an open enteral system was used or for up to 48 hours if a closed enteral system was used.During observation on 4/28/26 at 4:49 p.m., R4's nightstand had an irrigation syringe, with a plunger in it, in a gray mug with a handle filled with water and not dated. A clear container with water was labeled with the date 4/28/26 and had a syringe with a plunger in it.

There were no barriers under the water mug or clear container.During interview on 4/28/26 at 4:56 p.m., registered nurse (RN)-A verified the observations and stated staff were to empty the water from the containers and separate the plunger from the syringe barrel and rinse out before using again.

During an interview on 4/29/26 at 3:59 p.m., LPN-B, the facility infection control nurse, expected staff to wear gloves and gowns to administer medications through a resident's gastrojejunostomy tube. LPN-B stated enhanced barrier precautions protected staff and residents and prevented the spread of germs.During interview on 4/30/26 at 4:25 p.m., LPN-B expected staff to dump out the water from irrigation containers after use.

Standing water and used syringes sitting in water caused germs.

During an interview on 4/30/26 at 5 p.m., the director of nursing (DON) stated R1 was on enhanced barrier precautions related to his gastrojejunostomy tube and expected staff to wear a gown and gloves to prevent contamination when the tube was accessed.

The DON did not want irrigation syringes left in water for infection control reasons, such as prevention of waterborne pathogens.Facility policy Flushing a Feeding Tube dated 10/2024, directed staff to remove plunger from barrel and air dry after administration of water.Facility policy Enhanced Barrier Precautions dated 10/2025, indicated EBP was the use of gowns and gloves during high contact resident care activities to reduce transmission of multidrug-resistant organisms.

High contact resident care activities included feeding tube device care and use.