Folkston Park Care and Rehabilitation Center

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement a person-centered comprehensive care plan for one of five residents (R) (R1) receiving a pureed diet. Specifically, the facility failed to address the resident's diet, behaviors of wandering into other residents' rooms, and seeking non mechanically altered food items. This failure resulted in R1 choking and expiring on 10/25/2025. The facility's failure to develop and implement a person-centered comprehensive care plan caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide adequate supervision to prevent an avoidable accident for one of five residents (R) (R1) on A Hall (the secured memory unit) with a pureed diet. Specifically, R1 was ordered a pureed texture, nectar consistency, with no rolls or bread. R1 was left unsupervised, resulting in him obtaining a non-mechanically altered food and subsequently choking. This failure resulted in R1 expiring on 10/25/2025. The facility's failure to provide adequate supervision to prevent an avoidable accident caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide sufficient nursing staff to monitor one of 23 residents (R) (R1) on A Hall (the secured memory unit), resulting in R1 choking and expiring on 10/25/2025. Specifically, the facility failed to have sufficient nursing staff to provide nursing and related services, considering the number, acuity, and diagnoses of the facility's resident population. The facility's failure to provide sufficient nursing staff and related services caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. [...]

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's documents titled, Licensed Nursing Home Administrator and Director of Nursing (DON), the administration failed to provide sufficient nursing staff to monitor one of 23 residents (R1) on A Hall (the secured memory unit ). This resulted in an avoidable choking accident and the death of R1 on 10/25/2025. Specifically, Administration knew there was insufficient staffing on A Hall (secured memory unit) and failed to staff A Hall in manner that efficiently maintained the highest practicable physical, mental, and psychosocial well-being of each resident. The failure to take action caused R1 to be left unsupervised, resulting in his death. The facility's failure to provide sufficient nursing staff caused or was likely to cause serious injury, harm, impairment, or death to a resident. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Medication Administration Guidelines, the facility failed to notify the provider and obtain an order to administer medication for one of three sampled residents (R) (R7). This failure placed the resident at risk not to receive the treatment and care in accordance with professional standards of practice.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Medication Administration Guidelines and Tube Feeding Management, the facility failed to ensure a medication error rate of less than five percent. There were three errors from 36 opportunities observed for a medication error rate of 8.33%. This deficient practice has the potential to place Residents (R) R2, R3, and R9 at risk of medical complications.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure pureed therapeutic diets were properly prepared for one out of eight residents (R) (R4) receiving a therapeutic pureed diet. This deficient practice had the potential to cause medical complications and place the resident at risk for unmet nutritional needs.

Inspectors wroteBased on staff interviews and record review the facility failed to accurately maintain medical records for one of three sampled residents (R) (R7). Specifically, the facility failed to ensure R7's allergies was updated. This failure has the potential to place resident at risk for an allergic reaction or clinical decline.

Inspectors wroteBased on observation, interviews, and record review, and review of the facility's policy titled, Infection Control Preventionist, the facility failed to use gloves to handle pills to crush medication for two of seven sampled residents (R) (R2 and R3). This deficient practice had the potential to place residents at high risk for infection.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide information so that residents and/or visitors were aware of how to report complaints, abuse or neglect, to the state survey office. The facility census was 71 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Food Handling Procedures, the facility failed to maintain the cleanliness of the facility minimizing the risk of food-borne illness and to promote safe food handling practices. The deficient practice had the potential to place residents who received an oral diet from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to protect and maintain the rights and dignity of three of 34 sampled residents (R) (RA, RB, and RC). Specifically, the facility failed to ensure that facility staff nurse, Licensed Practical Nurse (LPN) (LPN CC) treated RA, RB, and RC with dignity and respect in a manner and environment that promoted, maintained, or enhanced their quality of life. The deficient practice had the potential for negative psychosocial outcomes related to fear of retaliation if staff found out that residents reported the nurse.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Resident Funds: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year, the facility failed to assure that residents with trust funds were able to get access to requested funds. The deficient practice affected three of 74 residents (R) (R276, R29 and R11) with trust funds.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Advance Directive, the facility failed to provide residents and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment for four of 34 sampled residents (R) (R38, R49, R34, and R32).

Inspectors wroteBased on record review, staff interview, and the facility policy titled, Advance Beneficiary Notices (ABN) 2025, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for three of 34 sampled residents (R) (R32, R42, and R56).

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Freedom of Abuse, Neglect, Exploitation and Abuse Prevention: Fast Alerts, the facility failed to report abuse and neglect for two of 34 sampled residents (R) (R11 and R21) to the State Agency (SA).

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, RAI (Resident Assessment Instrument) /Care Planning Management, the facility failed to create and revise /update (as needed) a comprehensive care plan related to a Stage two pressure ulcer for one of three sampled residents (R) (R1). The deficient practice had the potential to prevent R1's needs from being met.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Skin Management Standard, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented for one of three residents (R) (R1). The deficient practice had the potential to prevent healing and promote infection and the development of new pressure ulcers.

Inspectors wroteBased on record review, staff interviews and review of the facility policy titled, Skin Management Standard, the facility failed to obtain physician orders for treatment of a stage two pressure ulcer for one of three residents (R) (R1). The deficient practice had the potential for R1's pressure ulcer to worsen, become infected, or develop new pressure ulcers.

Inspectors wroteBased on record review, staff interviews, and the review of the policy titled, Fall Management Standard, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by using appropriate techniques, to prevent accidents, for two residents (R#9 and R#35) of three residents reviewed for falls. Actual harm occurred on 11/24/2022, when a Certified Nursing Assistant (CNA), rolled R#9 away from her while providing ADL care. Subsequently, R#9 fell from the bed resulting in a right femur fracture.

Inspectors wroteBased on observations, interviews, and review of policy titled Operations: Description of Steps in the Laundry Process, the facility failed to maintain an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced appropriate techniques when folding clean laundry; storing clean mop heads; housekeeping carts stored in the area in direct contact with a clean linen cart; lint trap of dryers with large accumulation of lint buildup; chipped white paint and personal items on folding table; laundry aide siting with feet on the folding table; an accumulation of lint, dust and debris in the laundry room. The census was 73.

Inspectors wroteBased on staff interviews, resident interviews, review of facility policy titled, Food Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for lunch were at 135 degrees Fahrenheit (F) when being served to residents on one of three halls (Hall C). Findings Include: Review of facility undated policy titled, Food Temperatures number eight Proper Hot Holding: Internal temperature of food should be checked every two hours to ensure temperature is kept above 140 F. Interview on 1/6/2023 at 8:59 a.m. with Resident (R)#18 revealed that most meals that are served from the kitchen come to her room cold. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy titled Bed Safety, the facility failed to ensure one resident (R)(R#9) of 18 sampled residents were accurately assessed for the use of side rails.

Inspectors wroteBased on observations, an staff interviews the facility failed to ensure the ceiling air vents in resident bathrooms on two of three halls were clean and not heavily covered in dust, failed to ensure that the hall ceiling air vents were clean on two of three halls, failed to ensure that the privacy curtains for four rooms on two of three halls were clean for four resident rooms (217,301, 305 or 307), failed to ensure that the wall between two closets in in the corner of one room (room [ROOM NUMBER]) on one of three halls was in good repair without peeling paint and chipping sheetrock, and failed to ensure that the B bed in room [ROOM NUMBER] had a foot board that didn't have the stripping loose and hanging off.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage Guidance the facility failed to ensure disposal of expired medications by the appropriate expiration date, the facility also failed to ensure that insulin stored in the refrigerator in one of one medication room was properly dated with open and expiration dates for three of 13 residents (R#3, R#10, and R#24) receiving insulin coverage resident. Findings Include: Observation on 5/4/21 at 3:50 p.m. of the facility medication storage room revealed the area was located to the right of the centralized nursing station. The refrigerator was clean, and insulin was stored in individual plastic bins. [...]

Inspectors wroteBased on observations, staff interviews and review of the facility policy titled, Infection Control Manual the facility failed to store patient care equipment (wash basins and a specimen collector pan) in a sanitary manner to prevent the spread of infection in four of 10 bathrooms on the B hall. Findings Include: Review of the facility policy titled, Infection Control Manual dated 2/2016, revealed: The facility will appropriately care for resident care equipment and supplies to prevent them from becoming sources of infection. The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. An observation made on 5/03/21 at 11:00 a.m. revealed: [...]