Crossings at East Lake: Tube Feeding Errors - GA
Resident 5 at Crossings at East Lake of Journey has spastic quadriplegia cerebral palsy and severe cognitive impairment. She receives nutrition through both a gastrostomy tube in her stomach and a jejunostomy tube in her small intestine because she cannot swallow safely.
On July 10, the facility's registered dietician wrote clear orders: Give Osmolyte 1.5 formula at 32 milliliters per hour via the jejunostomy tube continuously, with only a one-hour stop each day to check if any formula remained undigested.
But nurses weren't following those orders.
When inspectors observed the patient on August 18 at 2:15 PM, her feeding pump was turned off and disconnected, though the formula container still hung on the pole. Licensed Practical Nurse 3 entered with a fresh container of Osmolyte 1.5.
The inspector asked how long the patient's feeding pump stayed off each day.
"It's off from 10:00 AM to 2:00 PM each day," the nurse replied.
That four-hour gap directly contradicted the dietician's orders for continuous feeding.
Two days later, the facility's Vice President for Nutrition confirmed the error. When asked if the patient should have her tube feedings held from 10 AM to 2 PM as the nurse stated, she said no.
"The only order I have is for her to have the tube feedings held for one hour and then check for residuals," the VP said.
She explained the confusion stemmed from the patient's recent hospital return. The hospital had ordered a different formula called Osmolyte 1.2, but the nursing home only stocked Osmolyte 1.5. The registered dietician converted the stronger formula to deliver the same nutritional value as the weaker one.
"The RD wanted it to be run continuously at 32ml/hour as R5 experiences vomiting," the VP said.
The vomiting detail was crucial. Continuous feeding helps prevent the nausea and regurgitation that can occur when formula accumulates in the stomach of patients with severe neurological conditions.
Licensed Practical Nurse 4, who had written the order when the patient returned from the hospital, confirmed the mix-up. She said the registered dietician "came in and wrote a new order for Osmolyte 1.5 at 32ml/hour continuously" after discovering the facility lacked the prescribed formula.
But somehow, nurses continued following an outdated schedule.
The facility's electronic medical records showed a discontinued order from October 2024 through July 2025 for a different formula called Jevity 1.5 at 55 milliliters per hour for 20 hours daily, with feeding on at 2 PM and off at 10 AM.
That old schedule matched exactly what nurses were still doing in August — turning off feedings from 10 AM to 2 PM.
Staff had been following a discontinued order for over a month while ignoring the current one.
The Director of Nursing acknowledged the problem when inspectors asked about his expectations for following nutrition orders.
"My expectation is that the orders are to be followed," he said.
Federal regulations require nursing homes to ensure feeding tubes are used appropriately and that residents receive proper care for their feeding tubes. The rules exist because improper tube feeding can cause serious complications including aspiration pneumonia, dehydration, malnutrition, and dangerous blood sugar fluctuations.
For Resident 5, the consequences were particularly concerning. Her cerebral palsy already put her at high risk for vomiting and aspiration. The registered dietician had specifically ordered continuous feeding to minimize that risk.
Instead, she went without nutrition for four hours every day.
The inspection found the facility failed to follow nutrition orders, placing the resident at risk for health complications and weight loss. While inspectors classified the violation as causing minimal harm, the potential for serious consequences was clear.
Resident 5 depends entirely on her feeding tubes for survival. When a facility ignores the dietician's orders designed to prevent vomiting in a patient who cannot protect her own airway, the stakes couldn't be higher.
The error continued for weeks while supervisors remained unaware their most vulnerable patient wasn't receiving the nutrition schedule designed to keep her 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.
Resident 5 at Crossings at East Lake of Journey has spastic quadriplegia cerebral palsy and severe cognitive impairment.
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.