PruittHealth Ocilla: Tube Feeding Safety Failures - GA
The resident vomited before the nurse even disconnected the syringe.
Federal inspectors visiting PruittHealth Ocilla on September 17 and 18, 2025 documented what happened during an 8:06 a.m. tube feeding for a resident identified in inspection records as R31. The resident is a woman with congenital stenosis and stricture of the esophagus, meaning she cannot eat by mouth and depends entirely on a gastrostomy tube for nutrition. She also has type 2 diabetes, a history of cerebral infarction, chronic nausea and vomiting, and dysphagia. Her cognitive assessment, completed the previous month, placed her in the range of moderate impairment.
Her physician had written specific orders to manage the risks that come with tube feeding a patient in her condition. Before every feeding, a nurse was required to check the tube's placement and measure the residual, the amount of formula still sitting in her stomach from the previous feeding. If that residual exceeded 100 milliliters, the nurse was supposed to stop and call the doctor. After each feeding, the nurse was required to flush the tube with exactly 200 milliliters of water.
The licensed practical nurse who administered the 8:06 a.m. feeding, identified in the report as LPN CC, did neither check.
She did not check placement. She did not measure the residual. She poured water from a drinking cup into the syringe, eyeballing it to somewhere around the 60-milliliter line, then poured in a bit more to reach roughly 50 milliliters on a second pass. The total flush was well short of the 200 milliliters the physician had ordered.
R31 vomited immediately after the feeding ended.
The nurse offered nausea medication. The resident declined.
When inspectors interviewed LPN CC the following morning, she confirmed everything. She had not checked residuals. She had not verified placement. She had not measured the water. She acknowledged that she had received in-service training on tube feeding procedures.
The Assistant Director of Health Services described the expected process to inspectors in plain terms: gather supplies, follow barrier precautions, check residuals, administer formula and flush per physician orders. The Director of Health Services said the expectation is that nurses follow policy, that nurses are trained, and that annual competency assessments on tube feedings are part of the job.
The inspection report cited the facility's own enteral nutrition policy, reviewed as recently as September 2024, which requires physician orders for formula, rate, route, and flush instructions.
The gap between what the policy requires, what the physician ordered, what the director described as expectation, and what actually happened at 8:06 a.m. on September 17 was the entire width of R31's safety.
Checking tube placement before a feeding matters because a dislodged or mispositioned gastrostomy tube can send formula into tissue or the abdominal cavity rather than the stomach. Checking residual volume matters because delivering a full bolus feeding into a stomach that hasn't emptied from the last meal raises the risk of vomiting and aspiration. For a resident with a documented history of chronic nausea and vomiting, those risks are not theoretical.
CMS classified the violation as having the potential for actual harm.
R31 vomited, declined the offered medication, and the feeding was over. The inspection report does not say whether she vomited again that day, whether a physician was notified, or whether anyone reviewed how many prior feedings had been administered the same way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth - Ocilla from 2025-09-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
PRUITTHEALTH - OCILLA in OCILLA, GA was cited for violations during a health inspection on September 18, 2025.
The resident vomited before the nurse even disconnected the syringe.
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.