Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 The Gardens At Foley Llc during CMS and state inspections, most recent first.
A resident with traumatic brain injury, seizures, major depressive disorder, and morbid obesity reported using the call light to request toileting assistance and sometimes waiting an hour or more, leading to incontinence and feelings of embarrassment and frustration. Call light logs showed multiple response times exceeding 30 minutes, including waits of about 42, 58, and 60 minutes. The DON acknowledged increasing call light times and that extended waits leading to incontinence could be a dignity issue, while the Administrator stated that 45–60 minutes or longer was unreasonable and noted grievances about long call light waits, in conflict with resident rights and dignity expectations.
A resident with a history of cancer and recent radiation therapy was admitted with buttock redness that was not thoroughly assessed, documented, or communicated to providers by nursing staff. The initial and ongoing skin assessments lacked detail, and there was no evidence of follow-up or provider notification when the redness persisted or worsened. The resident later developed a stage 2 pressure ulcer, with incomplete documentation and missed opportunities for intervention and monitoring by the facility.
Failure to Notify Provider of Ordered Weight-Gain Parameters: A resident with ESRD, anemia, cardiomegaly, and HTN had repeated overnight weight gains that met the provider-notification threshold, but the record showed no evidence the provider or dialysis was updated. The resident also complained of SOB and difficulty breathing, was placed on O2, and staff interviews confirmed the weight parameters were known by some staff but not acted on.
Inaccurate MDS Weight Loss Documentation: A resident with type 2 DM and morbid obesity was documented on the quarterly MDS as having significant weight loss based on a weight that was later identified as inaccurate. The resident appeared significantly overweight and said he did not feel he received enough food at meals, while the CSD completed Section K using the recorded weight before the weights were later struck through as inaccurate in the EMR.
A resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, schizophrenia, depression, anxiety, and PTSD, had a Level II PASARR approval limited to post-hospital rehab for 30 days. The facility did not ensure the reassessment was completed, documented, or retained when the stay extended beyond the approved timeframe, and the SSD stated the resident’s extended stay should have triggered contact with Senior LinkAge Line.
Failure to Reposition Resident With Pressure Ulcers: A resident with severe cognitive impairment, dependence with ADLs, and existing pressure ulcers to the coccyx and left buttock was observed sitting in a Broda chair for extended periods without timely repositioning. The care plan directed staff to turn and reposition the resident every 2 to 3 hours and as needed, and both an LPN and an NA stated the resident could not reposition herself and needed staff assistance. When the resident was later laid in bed, reddened creases were noted above the spinal pressure ulcer, and the coccyx ulcer had no dressing present.
Incomplete oxygen order and empty portable tank: A resident with COPD, hypoxemia, dysphagia, and severe cognitive impairment received oxygen at varying flow rates without a physician order specifying the liter flow. Staff observed the resident on 2 L/min, 2.5 L/min, and 3 L/min, and an LPN confirmed the portable O2 tank was empty, leaving the resident without portable oxygen during movement away from the concentrator.
A resident on dialysis with ESRD and a strict fluid restriction had inconsistent intake tracking, with nursing and dietary documenting fluids separately and no clear total of all fluids consumed. Staff also failed to consistently complete and review dialysis communication forms, and the resident’s complaints of SOB and weight gains were not communicated to dialysis or the provider. Only two dialysis forms were found in the EMR, and the resident’s dialysis contact information was not clearly documented.
An LPN pre-set multiple residents’ crushed medications into plastic cups and stored them unsecured in the top drawer of a med cart to save time. The cups were labeled with resident initials and medication times, but were not individually secured and were kept outside original pharmacy-labeled packaging. Other nursing leaders confirmed this practice was not permitted and was against facility policy because medications must remain in their original containers until administration.
A resident with osteomyelitis and staph infections experienced significant medication errors when antibiotics were administered late and missed entirely. The errors led to symptoms such as confusion, fever, and skin issues, resulting in hospitalizations. The facility's Director of Nursing was unaware of the initial delay, and an agency nurse responsible for a subsequent error was not adequately supervised.
The facility failed to document post-fall neurological assessments for three residents who experienced falls. Despite protocols requiring frequent assessments, documentation was missing due to unavailable forms. Residents had conditions such as dementia and a history of falls, and incidents involved low oxygen saturation, minor bleeding, and self-transferring attempts. Staff acknowledged the protocol but did not document assessments consistently.
During a COVID outbreak, staff at the facility failed to follow CDC guidelines for mask usage. A therapeutic recreation aide and an RN were observed with masks under their chins, not covering their mouths or noses, while near residents. The facility's policy requires proper mask usage, but staff did not comply, contributing to the deficiency.
The facility failed to submit accurate staffing data to CMS for Q2 2024, as required by the PBJ system. Discrepancies were found in weekend staffing levels, with extra staff scheduled despite float staff availability. HR was responsible for agency staff data, while corporate handled facility staff hours. The CNL noted overscheduling due to un-canceled agency staff when facility staff volunteered.
A resident with severe cognitive impairment was observed in a reclined position in a wheelchair that did not provide adequate back support, leading to discomfort and back pain. The facility failed to ensure proper wheelchair positioning, as the last occupational therapy evaluation did not identify the need for intervention, and the current therapist was unaware of the issue.
A facility failed to ensure safe medication administration for three residents. A trained medication aide pre-dished medications for multiple residents at once, contrary to facility policy. The aide signed off on the EMR indicating medications were administered, although they were not given at that time. The DON confirmed that staff were instructed to prepare and administer medications for one resident at a time and document only after administration. The facility's policy prohibited pre-pouring medications in advance.
The facility failed to properly label and store eye drops for two residents, as observed during a medication cart review. Two open bottles of artificial tears lacked labels indicating the specific resident, the date opened, or the expiration date. The LPN acknowledged the oversight, and the DON stated that the facility's policy required using individually packaged dose vials with proper dating. This failure to adhere to policy resulted in a deficiency in medication storage and labeling.
A facility failed to follow infection control practices during eye drop administration. A TMA-C inadvertently touched a resident's eyelid with the tip of an eye drop bottle, contaminating it, but was unaware and returned the bottle to the medication cart. The DON confirmed that the facility's policy requires the dropper tip to avoid contact with the eye or any surface.
A cognitively intact resident with a history of debility, cardiorespiratory conditions, heart failure, anemia, and arthritis fell and sustained a thoracic fracture, leading to hospitalization and death. The resident had gait/balance problems, weakness, and a tendency to self-transfer without assistance. The facility's care plan included an intervention to offer assistance with setting out clothing for the resident's shower, which was not followed by the nursing assistant. The resident's preference for independence and reluctance to ask for help were contributing factors. Staff interviews revealed varying levels of adherence to the care plan.
The facility failed to post required nursing staff data daily before each shift, with 81 out of 176 expected days missing postings. The scheduling coordinator was responsible but was often unavailable, and no audits were conducted to ensure compliance.
Failure to Respond Timely to Call Lights Resulting in Dignity Concerns
Penalty
Summary
The facility failed to provide timely toileting assistance and call light response for a resident, resulting in a dignity concern. The resident had diagnoses including unspecified focal traumatic brain injury, seizures, major depressive disorder, and morbid obesity, and reported being aware of the need to have a bowel movement and using the push-button call light system to request transfer to the toilet or a commode. The resident stated that at times he waited an hour or more for staff to answer his call light, which resulted in episodes of incontinence. He reported feeling upset, frustrated, "like a little kid," and embarrassed when this occurred. Review of the resident’s call light logs showed multiple instances of significantly delayed responses, including unanswered call lights for 42 minutes and 42 seconds, 57 minutes and 59 seconds, 60 minutes and 22 seconds, and 32 minutes and 5 seconds on various dates. The DON acknowledged that staff were encouraged to answer call lights as quickly as possible, that call light times had been increasing, and that extended call light waits resulting in incontinence could negatively affect residents and constitute a dignity issue. The Administrator stated that an acceptable response time was about 6–8 minutes, acknowledged that 45–60 minutes or longer was unreasonable, and confirmed awareness of long call light times and related resident/family grievances. Both the DON and Administrator recognized that prolonged call light response times could negatively affect residents’ quality of life and dignity, contrary to the facility’s Resident Rights policy and the Combined Federal and State Resident Rights requirements.
Failure to Assess, Document, and Communicate Skin Impairments
Penalty
Summary
The facility failed to adequately assess, document, and communicate changes in a resident's skin condition, specifically regarding buttock redness and subsequent open areas, upon admission and during the resident's stay. Upon admission, the resident, who had a history of vulvar cancer, recent chemotherapy, radiation therapy, and a left humerus fracture, was noted to have buttock redness during the initial skin assessment. However, the assessment lacked detailed documentation regarding the extent, size, and characteristics of the redness, and there was no evidence of follow-up actions or provider notification. The baseline care plan referenced perineal and buttock wounds, but the admission assessment only mentioned buttock redness, and no comprehensive wound assessment or monitoring was initiated for the buttock area. Throughout the resident's stay, there were multiple missed opportunities for timely and thorough skin assessments, documentation, and communication among staff and with providers. Nursing staff did not consistently document the status of the buttock redness or any progression to open areas, and there was no evidence that the provider or wound care team was notified when the skin impairment failed to resolve or worsened. Progress notes and treatment records lacked specific information about the wounds, and the required weekly skin assessment was not completed or documented. Staff interviews revealed a lack of clarity and follow-through regarding protocols for skin impairment assessment, documentation, and escalation, with several staff members unable to recall the resident or the care provided. The resident later reported increased pain and was found by a nurse practitioner to have a stage 2 pressure ulcer with sloughing on the buttocks, which was subsequently confirmed and further described during a hospital admission. The facility's own post-discharge skin evaluation form was incomplete, lacking measurements and detailed descriptions. Interviews with facility leadership and staff confirmed that expected protocols for assessment, documentation, provider notification, and intervention were not followed, and the medical record did not reflect appropriate monitoring or care management for the identified skin impairments.
Failure to Notify Provider of Ordered Weight-Gain Parameters
Penalty
Summary
The facility failed to update the provider as ordered when a resident with end stage renal disease, a vascular prosthetic device, anemia, cardiomegaly, and hypertension had repeated overnight weight gains. The resident’s order, dated 8/28/25, directed staff to call the provider if the resident gained 3 pounds or more overnight or 5 pounds in a week. The resident’s weight record showed multiple overnight gains that met or exceeded the ordered parameters, including a 7.2-pound gain, a 5-pound gain, a 3-pound gain, a 6.6-pound gain, and another 3-pound gain over separate overnight intervals. The medical record lacked evidence that the physician was contacted about these weight gains. The record also documented episodes of shortness of breath and difficulty breathing. On 9/7/25, the resident complained of shortness of breath and difficulty falling asleep and was placed on oxygen. On 9/8/25, the resident again complained of shortness of breath and requested oxygen. During interviews, an LPN stated the resident complained of a hard time breathing before dialysis and was not sure whether weight-gain parameters existed, and stated neither dialysis nor the provider had been updated about the breathing complaints or weight gains. An RN later verified the resident had an order to update the provider for the specified weight gains, and a dialysis RD stated the resident’s large weight gains were difficult to safely remove during dialysis and that fluid overload between runs could be related to the shortness of breath. An RN stated the expectation was to update the provider and/or dialysis when the resident met the weight-gain parameters, and also stated a respiratory assessment had not been completed.
Inaccurate MDS Weight Loss Documentation
Penalty
Summary
The facility failed to ensure the resident minimum data set (MDS) assessment was accurately documented for a resident with type 2 diabetes and morbid obesity who was dependent on staff for dressing, bathing, bed mobility, and transfers. The quarterly MDS documented the resident as having experienced significant weight loss and recorded a weight of 356 lbs in Section K Swallowing/Nutritional Status, and the facility’s Resident Matrix also reflected significant weight loss based on the MDS data. During observation, the resident appeared significantly overweight and stated he did not feel he received adequate amounts of food at meals. The clinical nutritional evaluation documented that intake had been great, the resident remained on a 2 gram sodium diet with regular textures and thin liquids, and the current weight of 356 lbs was considered a healthy loss due to the resident’s current weight and BMI. However, the weights used for the quarterly MDS included 356 lbs from the electronic record, while the facility later identified that weights from 8/24/25 and 8/26/25 had been struck through as inaccurate after the MDS was completed. The MDS coordinator stated nursing did not complete Section K and that the culinary services director completed it, and the culinary services director stated the significant weight loss was triggered based on the 356 lb weight before learning the weights were inaccurate.
PASARR reassessment not completed for resident with mental illness
Penalty
Summary
The facility failed to ensure a Level II PASARR reassessment was conducted, documented, and retained for one resident reviewed for PASARR. The resident had intact cognition and required assistance with ADLs, and the resident’s diagnoses included schizoaffective disorder, bipolar type, hypertension, ulcerative colitis, diabetes mellitus, anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The resident’s pre-admission screening indicated a Level II assessment for mental illness was required before admission to the nursing home, and the resident was admitted from assisted living with an anticipated length of stay listed as less than 30 days. The resident’s Level II Preadmission Screening for Persons with Mental Illness Determination for Nursing Facility Admission, completed before admission, approved admission for post-hospital rehabilitative services for 30 days and stated that further assessment and service plan changes must be documented upon a change in condition or when the NF stay is anticipated to exceed 30 days. During interview, the social services director stated being unaware that the Level II assessment was limited to a 30-day admission, reviewed the assessment, and confirmed it was limited to 30 days. The social services director also stated Senior LinkAge Line should have been contacted when the resident stayed in the nursing home past 30 days.
Failure to Reposition Resident With Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to provide timely assistance with repositioning for a resident with existing pressure ulcers. The resident’s admission MDS identified severe cognitive impairment, dependence with ADLs, and risk for pressure ulcers. Diagnoses included pneumonitis due to inhalation of food and vomit, atrial fibrillation, diabetes mellitus, thyroid disorder, seizure disorder, anxiety disorder, COPD, hypoxemia, dysphagia, and unspecified intellectual disabilities. The care plan identified pressure ulcers to the coccyx and left medial gluteus and directed staff to turn and reposition the resident every two to three hours and as needed while in bed and/or in a wheelchair. During continuous observation, the resident was seated in a Broda chair for extended periods while moving between the living room, dining room, and her room. Staff assisted the resident to the dining room, back to the living room, and then to her room, where she remained in the same position for hours. An LPN stated the resident was unable to reposition herself in the Broda chair and needed staff assistance every two hours due to significant pressure ulcers, but was not sure when the resident had last been repositioned. An NA also stated the resident could not reposition herself and needed staff assistance every two hours. When the resident was later laid in bed, reddened creases were observed above the pressure ulcer on her spine, and the area around the pressure ulcers was reddened but blanchable; the coccyx pressure ulcer was reddened and had no bandage or dressing present. The DON stated staff were expected to turn and reposition residents as indicated in the care plan.
Incomplete oxygen order and empty portable tank
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident with severe cognitive impairment who required assistance with ADLs and had diagnoses including COPD, hypoxemia, dysphagia, seizure disorder, atrial fibrillation, diabetes mellitus, thyroid disorder, anxiety disorder, and unspecified intellectual disabilities. The resident’s physician order dated 7/6/25 directed continuous oxygen via nasal cannula and to wean as able every shift, but the order did not specify a liter-flow rate, usage parameters, or maximum dosage, and no clarifying orders were found in the record. During observations, the resident was seen receiving oxygen at different flow rates, including 2 L/min, 3 L/min, and 2.5 L/min, with no physician order documenting those rates and no documentation showing who determined or adjusted the flow. The resident was also observed with a portable oxygen tank that was nearly empty and later confirmed empty by an LPN, leaving the resident without portable oxygen during transport or movement away from the concentrator. Staff interviews confirmed the flow rate was unclear, that staff used their judgment to determine the rate, that there was no written guidance for adjusting oxygen flow, and that portable tanks should not be empty and must be checked each shift.
Incomplete fluid monitoring and dialysis communication
Penalty
Summary
The facility failed to consistently track and monitor fluid intake for a resident on dialysis with a fluid restriction, and failed to ensure dialysis communication forms were consistently completed and reviewed. The resident was cognitively intact, required extensive assistance with ADLs, and had diagnoses including end stage renal disease, a vascular prosthetic device, anemia, cardiomegaly, and hypertension. The resident had orders for a 32-ounce daily fluid restriction and to notify the provider for weight gain of 3 pounds overnight or 5 pounds in a week. The resident was observed drinking coffee and water at lunch while the record showed fluid intake documentation was incomplete and inconsistent. Nursing treatment sheets did not have an order to record fluid intake for August 2025, and September documentation reflected only partial nursing intake entries beginning on 9/3/25. Dietary records separately listed total meal fluid intake for each day, but there was no order or indication that staff totaled nursing-provided fluids with meal fluids to determine whether the resident remained within the restriction. Staff interviews confirmed that nursing recorded only fluids personally given during medication passes or occasionally observed outside meals, while dietary recorded kitchen-provided fluids during meals. Communication with the dialysis center was also inconsistent. Only two dialysis communication forms were found in the resident’s EMR, and those forms did not show that dialysis was updated about weight gains or complaints of shortness of breath between dialysis days. The resident had documented complaints of shortness of breath and was placed on oxygen, but staff stated dialysis and the provider had not been updated about these changes. Interviews further showed uncertainty about where dialysis forms were kept, whether they were reviewed, and whether the resident’s dialysis contact information was even listed in the EMR. The facility’s dialysis policy required ongoing communication and documentation of fluid intake amounts for each shift with a 24-hour total when fluid restriction was in place.
Pre-set medications stored unsecured in medication cart drawer
Penalty
Summary
The facility failed to ensure medications were stored and handled in accordance with professional standards of practice and facility policy. During observation of the medication cart, the surveyor found five plastic medication cups in the top drawer, each containing various crushed medications with resident initials and medication times written on them. The cups were sitting loosely in the drawer without protection from contamination or temperature control. An LPN stated she had pre-set medications for several residents and placed the cups in the drawer to save time, and that the medications had been prepared about 30 minutes earlier. She acknowledged the cups were not individually secured and stated she was not familiar with the unit, so she pre-set all scheduled medications beforehand. During interviews, another LPN stated staff were not permitted to pre-set medications ahead of scheduled administration times and that all medications must remain in their original, labeled packaging until directly administered to the resident. The ADON confirmed that medications were expected to remain secured in their original pharmacy-labeled containers until administration and stated that pre-setting medications and storing them in the cart drawer created an opportunity for medication errors and cross-contamination. The DON also stated medications should not be pre-set and that doing so was against facility policy because staff would be unable to verify the medications against the MAR and physician orders.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident received antibiotics as per physician orders, resulting in significant medication errors. The resident, who was admitted with osteomyelitis and methicillin-susceptible staphylococcus aureus infections, was supposed to receive a continuous infusion of oxacillin. However, the medication was administered over five hours late on one occasion, and on another occasion, it was missed entirely for 12 hours. These errors were discovered through a review of the Medication Administration Record and a Medication Error Report. The resident's condition was compromised due to these medication errors. On one occasion, the resident exhibited symptoms such as confusion, congestion, a nonproductive cough, and a high fever, leading to hospitalization. On another occasion, the resident developed significant pitting edema and skin issues, prompting another hospital visit. The errors were attributed to a lack of proper communication and oversight, particularly involving an agency nurse who was not adequately familiar with the facility's procedures. The Director of Nursing was unaware of the initial delay in administering the antibiotic and acknowledged that the agency nurse, who was responsible for the second error, was not properly supervised. The facility's policy on medication procedures emphasizes the importance of considering the resident's condition, the drug category, and the frequency of errors when determining the significance of a medication error. Despite these guidelines, the errors occurred, highlighting a lapse in adherence to established protocols.
Failure to Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to complete post-fall vital signs and neurological assessments for three residents, R1, R2, and R3, who were reviewed for post-fall assessment and monitoring. R1, who had diagnoses of dementia and heart failure, was found on the floor with low oxygen saturation and was minimally responsive. Despite being sent to the emergency department, R1's medical record lacked frequent post-fall neurological assessments from the time of the fall until he was sent to the hospital. The assistant director of nursing and registered nurses confirmed that post-fall neurological assessments were part of the facility's protocol, but the assessments were not documented. R2, who had a history of falls and was at risk for falls, was found on the floor with minor bleeding on his forehead. Although vital signs were noted, R2's chart lacked frequent post-fall neurological assessments for the 12 hours prior to being sent to the emergency room due to a change in condition. The registered nurses acknowledged that the facility's protocol required frequent post-fall neurological assessments, but the assessments were not documented due to the unavailability of the necessary form. R3, who had severe cognitive impairment and a history of falls, was found on the floor and was thought to be self-transferring. Although neurological assessments were reportedly started and within normal limits, the progress notes lacked post-fall assessment details. The licensed practical nurse stated that she completed the post-fall assessments per protocol but was unable to locate the form in R3's medical record. The facility's neurological procedure document outlined the required frequency of neurological assessments following a fall, but these were not consistently documented for the residents involved.
Improper Mask Usage During COVID Outbreak
Penalty
Summary
The facility failed to adhere to the CDC's Infection Control Guidance for SARS-CoV-2, which requires implementing source control measures to cover a person's mouth and nose to prevent the spread of respiratory secretions. On multiple occasions, staff members were observed not wearing masks properly during a COVID outbreak in the facility. Specifically, a therapeutic recreation aide and a registered nurse were seen with their masks positioned under their chins, not covering their mouths or noses, while in close proximity to residents. This occurred despite the facility's policy and the CDC's guidance requiring masks to be worn correctly in common areas. The Director of Nursing confirmed the facility was experiencing a COVID outbreak, with seven residents affected across different units. The facility's COVID policy, dated March 7, 2024, mandates adherence to infection prevention and control practices, including the proper use of personal protective equipment (PPE). Both the Infection Prevention Nurse and the Medical Director reiterated the expectation for staff to wear masks properly in common areas during the outbreak. Despite these policies and expectations, staff members were observed not complying with the mask-wearing guidelines, contributing to the deficiency noted in the report.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for the second quarter of 2024, as required by the Payroll Based Journal (PBJ) system. This deficiency was identified during a review of staffing schedules and timecard verifications, which revealed discrepancies in weekend staffing levels. Although the facility maintained licensed nursing staff 24/7 and documented registered nurse (RN) coverage for 8 consecutive hours per day, the PBJ report indicated excessively low weekend staffing. However, the facility's schedules showed that several weekends had two extra staff members scheduled, despite the presence of float staff to assist with normal staffing levels. These extra staff members were not listed as being in training, unlike other schedules reviewed. During an interview with the director of nursing (DON), corporate registered nurse (CRN), corporate nurse lead (CNL), administrator in training (AT), and human relations (HR), it was revealed that HR was responsible for gathering information on agency and contractual staff, while corporate utilized the payroll system for facility staff hours. The CNL, who was the DON during the quarter in question, explained that the scheduler had overscheduled on some weekends by not canceling agency staff when facility staff volunteered for open shifts. This oversight may have contributed to the appearance of more heavily scheduled weekends. The facility's policy on PBJ staffing data submissions, which follows CMS guidelines, was also reviewed.
Inadequate Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for a resident, identified as R45, who was severely cognitively impaired and dependent on assistance for most activities of daily living. Observations revealed that R45 was frequently found sleeping in a reclined position in his wheelchair, with the vinyl back of the wheelchair not providing adequate support. This improper positioning caused R45 to arch over the back of the wheelchair, leading to discomfort and back pain, as reported by the resident. The wheelchair's back was noted to be too narrow and too short, failing to provide sufficient support. R45's medical records indicated that the last occupational therapy evaluation was conducted in September 2023, and it was determined that no treatment or interventions were necessary at that time. However, during a recent observation, the contracted occupational therapist identified the inadequacy of the wheelchair's back support. The therapist had not been informed of any issues with R45's wheelchair prior to this observation. The facility's policy on maintaining abilities in activities of daily living emphasizes providing necessary care and services based on comprehensive assessments, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration for three residents, identified as R19, R40, and R61, during a survey. Observations revealed that a trained medication aide (TMA-D) was pre-dishing medications for multiple residents at once, which is against the facility's policy. The medication cups, containing unidentified pills, were labeled only with the residents' initials and were placed in the medication cart. TMA-D had signed off on the electronic medical record (EMR) indicating that the medications had been administered, although they had not been given to the residents at that time. Further observations showed TMA-D removing prefilled medication cups from the cart and entering the residents' rooms without administering the medications. The director of nursing (DON) confirmed that the staff were instructed to prepare and administer medications for one resident at a time and to document the administration only after the resident had received the medication. The facility's policy, dated December 2019, emphasized the importance of adhering to the five rights of medication administration and specifically prohibited pre-pouring medications in advance of the medication pass or for more than one resident at a time.
Improper Labeling and Storage of Eye Drops
Penalty
Summary
The facility failed to ensure proper labeling and storage of eye drops for two residents, R8 and R16, as observed during a medication cart review. Two open multidose bottles of artificial tears were found in the cart without labels indicating the specific resident, the date opened, or the expiration date. The LPN present during the observation stated that these were stock medications used for the residents and acknowledged that staff should have labeled the bottles with an opened and expiration date. However, the exact date of when the bottles were opened was unknown. The Director of Nursing (DON) indicated that the facility's policy was to use individually packaged dose vials of artificial tears, which should be dated with an 'Opened on' and 'Expires on' sticker. The facility's policy from January 2018 required that when a manufacturer's container or vial is initially opened, it should be dated, and a new expiration date should be noted, typically 30 days from opening. The failure to follow this policy led to the deficiency in medication storage and labeling for the residents involved.
Infection Control Breach in Eye Drop Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of eye drops to a resident. During an observation, a trained medication aide (TMA-C) was seen administering artificial tears to a resident. The TMA-C donned a glove and attempted to place a drop in the resident's left eye, but the resident squeezed their eyes shut, causing the tip of the medication bottle to touch the inside of the resident's lower left lid. The TMA-C was unaware of the contact and placed the bottle back into the medication cart, despite acknowledging that a contaminated bottle should not be reused. The director of nursing confirmed that staff are required to ensure the tip of the dropper does not touch the eye or any surface, as per the facility's policy dated December 2019.
Resident Fall Resulting in Thoracic Fracture and Subsequent Death
Penalty
Summary
The report details a deficiency in a nursing home's care practices that resulted in harm to a resident (R4) who fell and sustained a thoracic fracture, ultimately leading to his hospitalization and subsequent death. R4, a [AGE] year-old resident with a history of debility, cardiorespiratory conditions, heart failure, anemia, and arthritis, was identified as cognitively intact in his annual Minimum Data Set (MDS) assessment. Despite being free of falls in the prior three months, R4 was noted to have gait/balance problems, weakness, and a tendency to self-transfer without assistance, as outlined in his risk for falls care plan. The deficiency stemmed from the facility's failure to follow a care planned intervention aimed at reducing R4's risk of falls. Despite the care plan directing staff to offer assistance with setting out clothing for R4's shower, the nursing assistant (NA) responsible for R4 documented offering assistance but did not actually provide it. R4's strong preference for independence in selecting his clothing and his tendency to self-transfer without notifying staff or using his call light were noted as contributing factors to the incident. The investigation revealed that the fall likely led to the thoracic fracture, highlighting the missed opportunity for staff to assist R4 and prevent the fall. Multiple staff interviews conducted post-incident indicated varying levels of awareness and adherence to the care plan among the nursing assistants involved. While some staff members acknowledged the need to follow the plan of care and ensure accurate documentation, others noted R4's reluctance to ask for help and the challenges in providing assistance due to his independent nature.
Failure to Post Daily Nursing Staff Data
Penalty
Summary
The facility failed to ensure required nursing staff data was posted daily before each shift, potentially affecting all 74 residents, staff, and visitors. On 4/15/24, it was observed that the nursing staff data posting was dated 4/11/24, indicating a lapse in daily updates. The regional director of operations and the administrator confirmed the outdated posting and explained that the scheduling coordinator (SC) was responsible for the postings but was out ill that day. The director of nursing (DON) acknowledged the expectation for daily postings and admitted that no audits were conducted to ensure compliance. The DON was unsure of the process when SC was absent, leading to the breakdown in the system. Further observations on 4/15/24 and 4/16/24 revealed inconsistencies in the postings, with the plastic holder being empty at times and a different format being used on 4/16/24. SC admitted to being unaware of the posting requirements and the process when she was not in the building, including weekends. She also mentioned that on days she worked direct care, the postings were not done. A review of the saved Daily Headcount postings from 10/23/23 to 4/15/24 showed that 81 out of 176 expected days were missing postings, with various dates lacking postings across different months. The facility's Nursing Hours Posting policy, dated 10/2/22, directed that nursing staffing data be posted daily at the beginning of each shift.
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Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Foley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of St Cloud | 12.8 mi | ★★★★★ | 0 | 0 |
| St Benedicts Care Center | 13 mi | ★★★★★ | 2 | 0 |
| Good Shepherd Lutheran Home | 13.2 mi | ★★★★★ | 0 | 0 |
| Country Manor Health & Rehab Ctr | 13.6 mi | ★★★★★ | 4 | 0 |
| Sartell Therapy Suites | 14.6 mi | — | 0 | 0 |
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