Crossings at East Lake: Infection Control Failures - GA
Both residents had feeding tubes. Both had severe cognitive impairments from cerebral palsy. Both required enhanced barrier precautions under facility policy. Neither received them.
State inspectors documented the infection control failures at The Crossings at East Lake of Journey during an August complaint investigation. The violations placed vulnerable residents at increased risk of infection transmission, according to the inspection report.
The facility had established enhanced barrier precaution protocols for residents with feeding tubes in November 2024. Staff were supposed to wear gowns when providing direct care to these patients. Signs should have marked their doors. The precautions existed specifically to prevent the spread of infections among residents who receive nutrition through tubes inserted directly into their stomachs or intestines.
Resident 5 lived with spastic quadriplegic cerebral palsy, a severe form that affects all four limbs. Staff assessments showed severe cognitive impairment. The resident received all nutrition through a feeding tube due to dysphagia, a swallowing disorder that makes eating by mouth dangerous.
The resident's care plan, revised in September 2023, documented the tube feeding requirement. An intervention added in November 2024 specifically called for enhanced barrier precautions during care.
When the registered nurse entered the room at 2:38 PM on August 19, she performed oral care without the required gown. During the inspector's interview, she confirmed she had not used enhanced barrier precautions.
Resident 9 shared the room and faced similar challenges. Also diagnosed with cerebral palsy and severe cognitive impairment, this resident received all fluids and nutrients through a feeding tube due to swallowing problems related to the underlying disease process.
The roommate's care plan, also revised in September 2023, documented identical feeding tube requirements. The same November 2024 intervention mandated enhanced barrier precautions.
Five minutes after the registered nurse finished with Resident 5, a certified nursing assistant entered the shared room. The assistant washed Resident 5's face, then obtained a new washcloth and moved to provide care to Resident 9.
The assistant used no protective gown for either resident.
"I was not made aware of the need for EBP when caring for R5 or R9," the nursing assistant told inspectors.
Enhanced barrier precautions represent a middle ground between standard infection control and full isolation procedures. They typically require gowns and gloves during direct patient contact, especially for residents at higher risk of harboring or transmitting resistant organisms.
Residents with feeding tubes face particular infection risks. The tubes create direct pathways into the digestive system, bypassing natural barriers that normally protect against bacterial invasion. Patients with severe neurological conditions like cerebral palsy often have compromised immune systems, making them more susceptible to infections and less able to fight them off.
The facility's Director of Nursing acknowledged the breakdown during an interview at 4:30 PM on August 19.
"There should have been a sign on the door and staff should have utilized the PPE," the director told inspectors.
The missing door signs represented another layer of the infection control failure. Visual cues help remind staff of special precautions required for specific residents. Without proper signage, even well-trained staff might forget protocols during busy shifts.
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. These programs must include policies for preventing transmission of infectious agents, training for all staff, and monitoring to ensure compliance.
The inspection found the facility failed to implement its own enhanced barrier precaution policies for residents who clearly qualified under the established criteria. Both residents had feeding tubes. Both required the enhanced precautions according to facility interventions documented eight months earlier.
The violation affected what inspectors classified as "few" residents, but the consequences extended beyond the two roommates. Infection control failures in shared living environments can spread pathogens throughout a facility, particularly when staff move between residents without proper protective equipment.
State inspectors determined the failures created minimal harm or potential for actual harm. However, residents with feeding tubes and severe neurological impairments represent some of the most vulnerable patients in long-term care settings.
The nursing assistant's statement about not being made aware of the enhanced barrier precaution requirements suggests broader training or communication problems within the facility. Staff cannot follow protocols they do not know exist.
The Crossings at East Lake now faces federal oversight and potential penalties for the infection control violations. The facility must demonstrate corrected practices and submit plans to prevent similar failures.
For Residents 5 and 9, the immediate risk has passed. But their continued vulnerability to infection remains, dependent on whether their caregivers consistently follow the protective measures designed to keep them safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crossings At East Lake of Journey LLC, The from 2025-08-20 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
CROSSINGS AT EAST LAKE OF JOURNEY LLC, THE in DECATUR, GA was cited for violations during a health inspection on August 20, 2025.
Both residents had feeding tubes.
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.