Federal inspectors found that staff skipped required residual volume checks for at least four residents with gastrostomy tubes in September 2025. The checks measure how much food remains in a patient's stomach before adding more nutrition — a basic safeguard against dangerous complications.
Resident #25 arrived at the facility with a feeding tube and tracheostomy after hospitalization. On December 20, 2024, their physician ordered nurses to check residual volumes before each feeding and hold nutrition for two hours if more than 500 milliliters remained in the stomach.
The nursing staff never documented a single residual check since the resident's admission.
The physician's order was explicit: tube feedings should resume only "when residuals are below 500 mls every shift." Without these measurements, nurses had no way to know whether they were pumping Glucerna nutrition formula into an already-full stomach.
Three other residents faced identical risks. Resident #26 was admitted with encephalopathy, a brain injury from bleeding, breast cancer, and adult failure to thrive. Their physician ordered residual checks before each feeding on June 11, 2025, with instructions to hold nutrition for one hour if more than 120 milliliters remained and call the doctor if levels stayed high.
Nurses documented no residual checks in September 2025.
Resident #27 came to the facility homeless, with swallowing difficulties and chronic lung disease requiring a feeding tube after digestive surgery. The same physician order applied: check residuals, hold feedings above 120 milliliters, call if problems persist.
No residual documentation appeared in September records.
Resident #28's case was particularly striking because the facility had written a detailed care plan acknowledging the importance of residual monitoring. The plan, initiated in September 2021 and revised in March 2025, specifically instructed nurses to "check for tube placement and gastric contents/residual volume per facility protocol and record."
The resident suffered from swallowing problems, adult failure to thrive, respiratory failure with low oxygen, and dementia. Their physician gave identical orders on June 11, 2025: check residuals before feeding, hold nutrition if levels exceed 120 milliliters.
Staff documented no residual checks in September 2025 despite having a care plan that explicitly required them.
When inspectors interviewed the facility administrator on September 12, 2025, at 3:38 PM, they requested the tube feeding policy. Forty-two minutes later, the director of nurses and staff development coordinator confirmed what the violations had already demonstrated: nurses should document tube feeding residuals per physician orders when residents receive skilled tube feeding services.
The staff development coordinator's acknowledgment highlighted the gap between policy and practice. The facility knew the requirements. The physicians had written clear orders. The care plans specified the interventions.
Nobody was doing the work.
Residual volume checks serve a critical safety function for tube-fed patients. When nutrition accumulates in the stomach faster than it can be digested, continued feeding can cause vomiting. For residents with compromised airways or swallowing difficulties, vomited stomach contents can enter the lungs, causing aspiration pneumonia.
The consequences are particularly severe for residents like #25, who had a tracheostomy, or #28, who already suffered respiratory failure with low oxygen levels.
Federal inspectors classified the violations as having "minimal harm or potential for actual harm" affecting "some" residents. But the systematic nature of the failures — spanning multiple residents over months, despite explicit physician orders and facility policies — suggested deeper problems with nursing supervision and accountability.
The facility's own tube feeding policy, reviewed during the inspection, confirmed that residual documentation was required. Yet four residents received nutrition without any recorded safety monitoring, their medical records showing a consistent pattern of ignored physician instructions.
For Resident #25, nurses administered Glucerna 1.5 at 50 milliliters per hour for 24 hours daily without ever checking whether the previous feeding had been absorbed. For the other three residents, staff continued tube feedings without knowing whether stomach contents had reached the 120-milliliter threshold that required holding nutrition and potentially calling physicians.
The inspection revealed a facility where written policies existed but weren't followed, where physician orders were documented but ignored, and where residents' safety depended on monitoring that simply wasn't happening.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crescent Cities Nursing & Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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