Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Folkston Park Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, cognitive communication deficit, and swallowing disorder was on a pureed, nectar-thick diet and had documented wandering, exit-seeking, and impulsive behaviors. The care plan addressed general nutritional and cognitive issues but did not include the resident's diet restrictions, entering other residents' rooms, or seeking and eating non-food items. The resident was later found face down on the floor with a biscuit in his mouth and was pronounced expired after emergency response.
A resident on a secured memory unit with Alzheimer’s disease, a swallowing disorder, and a pureed diet was left without adequate supervision and obtained a biscuit, then choked and died. Staff notes documented unsafe eating behaviors, wandering, and eating nonfood items, and interviews showed the unit was staffed with only one LPN and one CNA for 23 residents, including several who needed feeding assistance and close monitoring.
Insufficient nursing staffing on a secured memory unit led to a resident choking and expiring while the unit was staffed with only one LPN and one CNA for 23 residents. The resident had dementia, was dependent for feeding, and had a history of unsafe eating, wandering, and entering other residents' rooms. Staff and leadership acknowledged the assignment was not adequate to monitor residents with elopement risk, feeding needs, and other care needs, and that staffing was based on census rather than acuity.
Insufficient staffing on a secured memory unit led to a resident choking death after the unit was staffed with only one CNA and one nurse for 23 residents with significant care needs, including elopement risk, incontinence, total ADL assistance, and feeding assistance. The DON and Administrator both acknowledged the staffing was not adequate and that the residents were not being monitored when the choking incident occurred.
A resident with severe cognitive impairment and diagnoses including CHF, HTN, Alzheimer’s disease, and metabolic encephalopathy received Benadryl without a provider order. The EMR and MAR had no documentation of the medication, and the DON confirmed the nurse used an old standing order even though standing orders had been discontinued. The Medical Director said he did not recall being called and noted the resident was sent out the next morning when the NP evaluated the resident.
Medication administration errors exceeded the allowed rate, with 3 errors in 36 observed opportunities. An LPN crushed aspirin EC for two residents even though it was on the do-not-crush list, and for one resident gave aspirin EC instead of the ordered chewable form. For another resident receiving hydrocodone via g-tube, the LPN crushed the medication and flushed the tube without first checking tube placement or residual. The DON confirmed the tube-placement expectation, and the pharmacy consultant stated aspirin EC should not be crushed and is not interchangeable with aspirin chewable.
Improperly Prepared Pureed Diet Served to A resident: A resident with dementia, dysphasia, and severe cognitive impairment was ordered a pureed, thin-consistency diet but was observed eating a meal that was not pureed. The tray was labeled for puree, yet the beef, corn, and bread were lumpy and contained visible particles; the Admin and Corporate Nurse confirmed the meal was non-pureed, and the RD later agreed the food items were not fully pureed.
Failure to update a resident’s allergy information in the EMR. A resident with severe cognitive impairment and multiple diagnoses was readmitted with hospital records showing allergies to codeine, dilaudid, morphine, and lisinopril, but the EMR continued to list no known allergies. An LPN, another LPN, the consultant pharmacist, and the DON all confirmed the allergy list had not been updated in the record.
Failure to use gloves when handling medications. An LPN used bare hands to pick up pills and place them in a pouch for crushing for two residents whose orders allowed medications to be crushed. The LPN confirmed the practice and stated she should always wear gloves, and the RN Unit Manager/Infection Preventionist and DON confirmed staff were expected to wear gloves when handling residents' pills.
Surveyors found that the facility did not have clear or accessible signage informing residents and visitors how to report complaints, abuse, or neglect to the state agency. The required information was missing from common areas, and the only notice posted was small, hard to read, and poorly placed, making it difficult for individuals to access the necessary contact details.
Surveyors found that food items in the kitchen refrigerator were stored past their use by dates or lacked proper labeling, and an ice machine contained black flakey residue and rust, indicating failures in food storage and equipment cleanliness standards.
Three residents with complex medical needs reported that an LPN repeatedly treated them disrespectfully, withheld or delayed medications, ignored requests for assistance, and created a hostile environment, especially during night shifts. Residents expressed fear of retaliation if they reported the LPN, leading to underreporting of grievances. These issues were corroborated by resident interviews, council minutes, and an Ombudsman report, and were compounded by chronic understaffing and missing signage for reporting abuse.
Several residents experienced delays in accessing their trust funds due to insufficient petty cash on hand and a process that required waiting several days for additional funds from corporate. Money was distributed on a first-come, first-served basis, and not all residents received their requested amounts promptly, contrary to facility policy stating 24/7 access.
The facility did not provide written information regarding the right to accept or refuse medical or surgical treatment to four residents or their representatives, as required by policy. Despite having significant medical conditions and, in some cases, completed POLST forms or physician orders, there was no documentation that these individuals received the necessary information upon admission.
Three residents who were discharged from Medicare Part A skilled services but remained in the facility did not receive the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) informing them or their responsible parties about Medicare coverage and potential liability for non-covered services. The MDS Coordinator was unaware of the requirement and did not provide the necessary notices.
Two residents with intact cognition reported being subjected to verbal abuse, neglect, and retaliation by an LPN, including being ignored, disrespected, and exposed to strong air freshener. Despite being informed of these allegations, facility administration did not report the incidents to the State Agency within the required timeframe, as they initially misclassified the events as customer service issues rather than abuse or neglect.
Failure to Update Care Plan for Diet and Wandering Behaviors
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident who was receiving a pureed diet. The resident had diagnoses including Alzheimer's disease, cognitive communication deficit, need for personal care, and anxiety disorder, and the MDS indicated the resident was dependent with eating and personal hygiene. The resident's diet order required a large portion diet with pureed texture, nectar consistency, and no rolls or bread with meals. A psychiatry note documented that the resident was on a secure unit due to wandering and exit-seeking behaviors, with increased agitation and impulsivity reported by staff. A behavior note described the resident as completely uncontrollable, impossible to redirect, entering other residents' rooms, getting into their beds, using their restroom and leaving feces or urine on the floor, taking food or drinks from them in the dining room, and eating items that were not edible, including pillow stuffing and a blanket. The care plan dated 10/1/2025 addressed nutritional problems and impaired cognitive function, but it did not address the resident's diet, wandering into other residents' rooms, or seeking non mechanically altered food items. On 10/25/2025, while a CNA was feeding another resident, she heard a thud and found the resident face down on the floor in Room A7 with a biscuit hanging out of his mouth; emergency care was initiated and EMS later pronounced the resident expired.
Inadequate Supervision on Secured Memory Unit
Penalty
Summary
The facility failed to provide adequate supervision to prevent an avoidable accident for a resident on the secured memory unit who was ordered a pureed diet with nectar consistency and no rolls or bread. The resident had Alzheimer’s disease, cognitive communication deficit, swallowing disorder, and was dependent for eating and personal hygiene. Behavior notes documented that he stuffed food into his mouth and choked, could not be redirected, wandered into other residents’ rooms, and had begun eating nonfood items such as pillow stuffing and his blanket. On 10/25/2025 at about 9:03 a.m., a CNA was feeding another resident when she heard a thud and left that room. She entered another room and found the resident face down on the floor with a biscuit hanging out of his mouth. The CNA reported the incident to an LPN, emergency care was started at 9:06 a.m., EMS was called at 9:09 a.m., and the resident was pronounced expired at 9:40 a.m. The record also showed that the resident had been on a mechanically altered diet and had known swallowing and behavior concerns before the incident. Staff interviews and the staffing assignment sheet showed that the secured unit had one LPN and one CNA assigned for 23 residents, including residents at risk for elopement, residents needing total assistance with feeding, and residents needing extensive ADL care. The LPN, CNA, DON, scheduler, Administrator, and Medical Director all acknowledged that the staffing level was not adequate to monitor the unit’s residents, including the resident who required constant supervision because of wandering and unsafe eating behaviors. Staff stated that when they were occupied with feeding residents or passing medications, no one was available to monitor the other residents on the hall.
Insufficient Nursing Staffing on Secured Memory Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to monitor a resident on the secured memory unit, and the resident choked and expired on 10/25/2025. The resident had diagnoses including Alzheimer's disease and dementia with agitation, was dependent for eating and personal hygiene, and was on a mechanically altered diet. Records also showed ongoing unsafe eating behaviors, including stuffing food into his mouth, choking, and later eating nonfood items such as pillow stuffing and a blanket. He was also documented as being on the secured unit because of wandering and exit-seeking behaviors. On the day of the incident, the staffing assignment for the secured unit showed one LPN and one CNA caring for 23 residents. The unit census included residents at risk for elopement, residents who were incontinent, a resident needing two-person total assistance with ADLs, and multiple residents requiring total assistance with feeding. Staff interviews stated that the two assigned staff could not adequately monitor and care for all residents while also assisting with feeding. Staff reported that when one staff member was passing medications or helping a resident, no one remained to monitor the other residents, including those who wandered or had unsafe behaviors. Interviews with the LPN, CNA, DON, scheduler, and Administrator confirmed that the unit was staffed with one CNA and one nurse and that staffing was based on census rather than acuity. They acknowledged that the resident required constant monitoring because he wandered into other residents' rooms and attempted to eat food and other objects, and that the unit had multiple residents needing feeding assistance. The DON and Administrator admitted that one CNA and one nurse were not adequate to supervise the secured unit and that no additional staffing changes had been implemented before the choking death occurred.
Insufficient Staffing on Secured Memory Unit
Penalty
Summary
Administration failed to provide sufficient nursing staff on A Hall, the secured memory unit, to monitor one of 23 residents, resulting in an avoidable choking accident and the death of the resident on 10/25/2025. The deficiency was identified as an Immediate Jeopardy on 11/13/2025 and was determined to have existed on the date of the incident. The report states that the facility knew there was insufficient staffing on A Hall and failed to staff the unit in a manner that maintained the highest practicable physical, mental, and psychosocial well-being of each resident. The facility documents for the Licensed Nursing Home Administrator stated responsibility for ensuring residents receive care in a manner that maintains or enhances quality of life and for maintaining an adequate number of appropriately trained personnel on duty at all times. The DON job summary stated responsibility for planning, organizing, developing, and directing nursing operations to ensure the highest degree of quality care. Staffing sheets from 9/1/2025 through 10/27/2025 showed A Hall was staffed with one CNA and one nurse while the census ranged from 21 to 23 residents. On 10/25/2025, the assignment sheet showed one LPN and one CNA caring for 23 residents, including 17 residents at risk for elopement, 13 incontinent residents, one resident requiring two-person total assistance with ADLs, and four residents requiring total assistance with feeding. The DON stated one CNA and one nurse was not adequate to supervise A Hall and confirmed residents were not being monitored when the resident choked to death. The Administrator also confirmed awareness that staffing on the unit was a concern and that no staffing changes had been implemented.
Medication Given Without Provider Order
Penalty
Summary
The facility failed to notify the provider and obtain an order before administering Benadryl to R7. Review of the facility policy titled Medication Administration Guidelines stated that a physician order must be in place prior to administering medications. R7’s most recent MDS showed a BIMS score of one, indicating severe cognitive impairment, and listed diagnoses including congestive heart failure, hypertension, Alzheimer’s disease, and metabolic encephalopathy. Review of the EMR showed no order for Benadryl as of 10/30/2025. A nurse practitioner note dated 8/12/2025 documented that R7 received Benadryl, but the August 2025 MAR did not show documentation of the medication. During interviews, the LPN unit manager confirmed there was no order for Benadryl and no MAR documentation for it. The DON confirmed the nurse gave Benadryl without an order and stated the nurse found an old standing order in the narcotic box, even though standing orders had been discontinued in 2024. The Medical Director stated he did not recall receiving a call from the nurse and said that if he had been contacted, he would have ordered Benadryl and prednisone together for an allergic reaction; he also stated the resident was sent out the next morning when the NP evaluated R7.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors observed 3 medication errors out of 36 opportunities, resulting in an 8.33% error rate. The cited deficiencies involved medication administration for three residents and were identified through observation, interview, record review, and review of the facility’s Medication Administration Guidelines and Tube Feeding Management policies. For one resident, an LPN crushed aspirin enteric coated (EC) 81 mg and mixed it with pudding even though the medication was listed as EC and the facility’s do-not-crush list identified aspirin EC as not to be crushed. For another resident, the MAR showed aspirin chewable 81 mg, but the LPN again crushed and administered aspirin EC 81 mg instead of the chewable form, despite a physician order allowing medications to be crushed and the chewable medication being available on the cart. For a third resident receiving hydrocodone via g-tube, the LPN crushed the tablet and flushed the tube with water before and after administration but did not check tube placement or residual before flushing. The LPN confirmed the omission, and the DON stated that tube placement should be verified before administering medication through a g-tube.
Improperly Prepared Pureed Diet Served to Resident
Penalty
Summary
The facility failed to ensure that a resident receiving a therapeutic pureed diet was provided food prepared in the proper form. R4 had diagnoses including Alzheimer disease, dementia, amnesia, TIA, and dysphasia, and the Quarterly MDS indicated severe cognitive impairment with a BIMS score of 99 and a mechanically altered diet requiring puree food. The physician order specified a regular pureed texture with thin consistency. During observation, R4 was seen in the dining room eating a meal that was not pureed and was eating independently without staff assistance. The meal tray was labeled for pureed, thin consistency, but the food observed included beef that was lumpy with ground particles, corn that was thick and lumpy with kernels, and bread that was thick and lumpy. The Administrator and Corporate Nurse confirmed at the time of observation that the meal was of non-pureed consistency, and the Administrator stated the facility did not have a dietary manager and that the error resulted from a lack of guidance. The RD later reviewed a photo of the meal and confirmed that the beef, corn, and roll were not fully pureed, with only the rice item being a true puree.
Failure to Update Resident Allergy Information
Penalty
Summary
The facility failed to accurately maintain medical records for one of three sampled residents, R7, by not updating the resident’s allergy information in the EMR. Review of the most recent quarterly MDS showed R7 had a BIMS score of one, indicating severe cognitive impairment, and diagnoses that included congestive heart failure, hypertension, Alzheimer's disease, and metabolic encephalopathy. Review of the EMR on 10/30/2025 showed no known allergies listed, while the hospital discharge record dated 8/13/2025 showed allergies to codeine, dilaudid, morphine, and lisinopril. Staff interviews confirmed the allergy information had not been entered into the EMR after R7’s readmission. An LPN confirmed the EMR showed no known allergies and stated allergies would normally be listed in red. Another LPN confirmed the resident’s EMR still reflected no known allergies and stated she should have updated the EMR when the resident was readmitted with the listed allergies. The consultant pharmacist also confirmed the EMR listed no known allergies and noted that admission and readmission reviews included hospital paperwork showing the allergies, but the allergies were not updated. The DON confirmed the EMR listed no known allergies and described the process for entering admission orders and allergies into the EMR.
Failure to Use Gloves When Handling Medications
Penalty
Summary
The facility failed to use gloves when handling pills to crush medications for two residents. A review of the facility policy titled Infection Control Preventionist stated that the Infection Control Preventionist is responsible for activities aimed at preventing healthcare associated infections and ensuring sources of infections are isolated to limit the spread of infectious organisms. The policy also stated that the ICP conducts rounds, monitors infection prevention practices, collects infection data, maintains records for healthcare associated infections, conducts outbreak investigations, trains staff on infection incidents, reports incidents to the appropriate department, and ensures availability of infection prevention supplies. A review of the medication order for one resident showed an order allowing all medications to be crushed, and observation of medication administration on A Hall showed an LPN used bare hands to pick up pills and place them in a pouch for crushing. A similar observation for a second resident with an order allowing all medications to be crushed showed the same LPN used bare hands to pick up pills and place them in a pouch for crushing. The LPN confirmed she used her bare hands and stated she should always wear gloves to handle residents' pills. The RN Unit Manager/Infection Preventionist and the DON both confirmed that nursing staff were expected to wear gloves when handling residents' pills.
Failure to Post Accessible Complaint and Abuse Reporting Information
Penalty
Summary
Surveyors observed that the facility failed to provide adequate signage or notices informing residents and visitors about how to report complaints, abuse, or neglect to the state agency. During tours of multiple areas within the facility, including resident halls, the front entrance, common areas, nurses station, and dining area, no signs were found that provided this critical information. The Administrator confirmed during an interview that the required signage was missing and attributed its absence to a recent visit by the Ombudsman, who may have inadvertently removed the facility's signs while updating her own contact information. Further observation revealed that a small, hard-to-read notice was eventually posted beneath the Ombudsman poster at the far end of one hall. This notice contained contact information for reporting concerns or complaints, but its size and placement made it difficult to notice and read. The lack of clear, accessible information on how to report complaints or abuse constituted a deficiency in ensuring residents and visitors were aware of their rights and the process for reporting issues to the state agency.
Deficient Food Storage and Equipment Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and cleanliness standards in the kitchen and food service areas. During an inspection of the kitchen's two-door stand-up refrigerator, a clear plastic container labeled breakfast meat was found with a use by date that had already passed, as well as a box of bell peppers with an expired use by date. Additionally, a sealable plastic bag containing meat was found opened and without any use by date. The Dietary Manager confirmed these findings, acknowledging that the breakfast meat and bell peppers were past their use by dates and that the opened meat lacked a date label. The facility's policy requires leftovers to be discarded after three days, but these items were not managed according to that standard. Further inspection revealed that the ice machine on one of the facility's halls contained a black flakey substance and rust, indicating a lack of proper cleaning and maintenance. The Dietary Manager confirmed the presence of these substances in the ice machine. These observations demonstrate a failure to adhere to professional standards for food storage, preparation, and equipment cleanliness, as outlined in the facility's own food handling procedures.
Failure to Ensure Resident Dignity and Protection from Retaliation by LPN
Penalty
Summary
The facility failed to protect and maintain the rights and dignity of three residents by not ensuring that a staff nurse, an LPN, treated them with dignity and respect in a manner that promoted or enhanced their quality of life. Multiple residents reported that the LPN displayed a consistently negative attitude, did not communicate during care, and failed to ask about their well-being or needs. Residents described instances where the LPN withheld or delayed medications, did not respond to call lights, and ignored requests for assistance, often telling residents to ask a CNA instead. There were also reports that the LPN spoke negatively about residents to others and made disparaging remarks, particularly targeting smokers and certain groups, and used strong sprays in residents' rooms after making negative comments about the smell of smoke. Residents expressed a pervasive fear of retaliation if they reported the LPN's behavior, stating that the LPN would ignore them, withhold care or medications, and generally make their lives more difficult if she discovered they had complained. This fear led to underreporting of grievances and complaints, despite residents being aware of the grievance process. The issue was corroborated by interviews, resident council minutes, and a Long Term Care Ombudsman report, all of which documented ongoing concerns about disrespectful treatment, delayed care, and a hostile environment created by the LPN, especially during night shifts. The facility also experienced high management turnover and chronic understaffing, particularly on nights and weekends, which contributed to unmet resident needs and further reluctance to report issues. The affected residents had significant medical and functional needs, including conditions such as diabetes, multiple sclerosis, amputations, depression, anxiety, and chronic pain, requiring regular assistance with activities of daily living and timely administration of medications. Despite these needs, the LPN's conduct resulted in residents feeling anxious, neglected, and apprehensive about seeking help. The lack of visible signage for reporting abuse or complaints further hindered residents' ability to seek recourse, as confirmed during a facility walkthrough where required posters were found missing.
Failure to Provide Timely Access to Resident Trust Funds
Penalty
Summary
The facility failed to ensure that residents with trust funds had timely access to their requested funds, as required by facility policy and state guidelines. Multiple residents reported consistent delays in receiving their money, with distributions occurring on a first-come, first-served basis and not all residents receiving their funds when requested. One resident stated that she had not received her money for the current month and only received the previous month's funds a week prior. Another resident indicated that only a third of the residents received their money for a particular month. Review of petty cash withdrawal records confirmed that residents typically received their requested funds two to three days after making the request, rather than having access 24/7 as stated in the facility's policy. Staff interviews revealed that the facility maintained a petty cash fund of approximately $600, which was not sufficient to meet all residents' requests, especially when multiple residents requested the maximum allowable amount. When petty cash ran low, the Business Office Manager had to request additional funds from corporate, a process that took several days. The Administrator acknowledged that the facility did not keep enough cash on hand to fulfill all requests and that money was distributed on a first-come, first-served basis. On nights and weekends, only a small amount of petty cash was available on the nurses' cart. The Regional Accounts Receivable confirmed that the facility did not have enough petty cash to meet all resident requests.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide four residents and/or their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. The policy specifies that upon admission or readmission, the Social Services Director is responsible for informing and educating residents or their Power of Attorney in writing about these rights. However, record reviews for four sampled residents revealed no evidence of signed acknowledgements or documentation that written information about these rights was provided. In each case, the Social Services Coordinator/Social Worker did not complete the advance directive checklist at admission, resulting in the absence of required documentation in the residents' records. The affected residents had various significant medical conditions, including hemiplegia, chronic obstructive pulmonary disease, atrial fibrillation, end stage renal disease, dementia, and other chronic illnesses. Some residents were cognitively intact, as indicated by their BIMS scores, while others were not. Despite the presence of physician orders and, in some cases, completed POLST forms, there was no documentation that the residents or their representatives received written information about their rights to accept or refuse treatment, as mandated by facility policy.
Failure to Provide Required Medicare Coverage Notices Upon Discharge from Part A Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to three residents or their responsible parties when they were discharged from Medicare Part A skilled services but remained in the facility. Review of facility policy indicated that the SNFABN, Form CM-10055, should be used to notify residents about Medicare eligibility and coverage for Part A items and services. Documentation showed that the three residents were discharged from Medicare Part A within the last six months, but there was no evidence that the SNFABN was given to them or their representatives. An interview with the MDS Coordinator confirmed that she was unaware of the requirement to use the SNFABN form for these discharges and did not provide the forms to the affected residents or their representatives.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to timely report allegations of abuse and neglect involving two residents with intact cognition. Both residents reported negative interactions with an LPN, including being ignored, treated disrespectfully, and experiencing verbal abuse. One resident described the LPN spraying a strong air freshener in their room, making negative remarks about their smell, and intentionally withholding medications. The other resident reported being ignored by the same LPN and suspected the LPN was telling others not to speak to him, leading to concerns about retaliation among residents. Despite being informed of these allegations by several residents, the facility's administration did not immediately report the incidents to the State Agency as required by their policy, which mandates reporting within two hours for abuse or neglect allegations. The administrator initially considered the issue to be related to customer service rather than abuse or neglect, resulting in a delay in reporting. The report to the State Agency was ultimately made the following day, outside the required timeframe.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Folkston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Hilliard | 11.5 mi | ★★★★★ | 7 | 0 |
| Bayview Nursing Home | 25.3 mi | ★★★★★ | 10 | 0 |
| Senior Care Center - St Marys | 28 mi | ★★★★★ | 12 | 0 |
| Lakeside Center For Rehabilitation And Healing | 32.2 mi | ★★★★★ | 6 | 0 |
| Jacksonville Nursing And Rehab Center | 32.7 mi | ★★★★★ | 0 | 0 |
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