The Gardens at Foley LLC

Inspectors wroteBased on observation, interview and document review the facility failed to ensure they maintained sufficient numbers of staff to assist 5 of 5 residents (R5, R6, R7, R8 and R9) in a timely manner. This had the potential to affect all residents residing on the 300, 400 and 500 units of the facility.

Inspectors wroteBased on observation, interview and document review the facilities Quality Assurance and Performance Improvement (QAPI) committee failed to address resident concerns related to call light wait times which resulted in cares not being performed and toileting tasks not being completed in a timely manner. This had the potential to affect all residents in the facility who required assistance from staff to completed activities of daily living.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a dignified toileting experience for 2 of 3 residents (R5, R9) reviewed for incontinence care.

Inspectors wroteBased on interview and document review the facility failed to accurately code a facility acquired pressure ulcer on the Minimum Data Set (MDS) for 1 of 3 residents (R4) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review the facility failed to investigate the cause of an injury that resulted in pain and a change in transfer status for 1 of 1 resident (R5) reviewed with an injury which occurred during a transfer.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide toileting assistance in a timely manner for 1 of 1 resident (R4), reviewed for dignity.

Inspectors wroteBased on interview and document review, the facility failed to adequately assess, document, and provide appropriate staff and provider updates for treatment orders for 1 of 3 residents (R1), when R1 was found to have buttock redness during an initial skin assessment that did not dissipate with pressure reduction, or when an open area was observed by staff to R1's buttocks the following day. R1 admitted to the facility on [DATE] and discharged on 10/16/25.

Inspectors wroteBased on interview and document review, the facility failed to update the provider as ordered when resident gained weight for 1 of 1 resident (R54) reviewed for dialysis. R54's admission Minimum Data Set (MDS) dated [DATE], indicated R54 was cognitively intact, required extensive assistance with activities of daily living (ADLs). R54 had diagnoses which included end stage renal disease, vascular prosthetic device, anemia, cardiomegaly and hypertension. R54's order summary printed 9/17/25, indicated R54 had an order dated 8/28/25, for weight gain - call your provider if you gain 3 pounds or more overnight, or gain 5 pounds in a week. A review of R54's weight record identified on 8/31/2025, R54 weight was 95.4 pounds (lbs.). When weighed on 9/1/2025, R54 was 103.6 lbs. - a 7.2-pound weight gain overnight. On 9/2/2025 R54's weight was 100.0 lbs. then on 9/3/2025, R54's weight was 105.0 lbs. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the resident minimum data set assessments (MDS) were accurately documented for 1 of 3 residents (R4) in the sample who were reviewed for weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 1 of 3 residents (R53) reviewed for PASARR.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning to promote healing of pressure ulcer for 1 of 1 resident (R1) in accordance with the individualized care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care and services were provided in accordance with professional standards of practice for 1 of 3 resident (R1) reviewed for oxygen therapy. Specifically, the facility administered oxygen without a physician's order specifying the liter-flow rate and failed to ensure the resident's portable oxygen tank was filled and available for use. These deficient practices created the potential for improper oxygen delivery, respiratory compromise, and delayed access to oxygen during mobility or emergencies.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently track and monitor fluid intake for 1 of 1 residents (R54) on fluid restrictions reviewed for dialysis. In addition, the facility failed to ensure communication forms were consistently filled out with updates or reviewed following dialysis for 1 of 1 residents (R54) reviewed for dialysis. R54's admission Minimum Data Set (MDS) dated [DATE], indicated R54 was cognitively intact, required extensive assistance with activities of daily living (ADLs). R54 had diagnoses which included end stage renal disease, vascular prosthetic device, anemia, cardiomegaly and hypertension. R54's order summary printed 9/17/25, indicated R54 had an order dated 8/28/25 for weight gain - call your provider if you gain 3 pounds or more overnight, or gain 5 pounds in a week. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored and handled in accordance with professional standards of practice and facility policy. Specifically, staff pre-set multiple residents' medications into medication cups and stored them in the top drawer of the medication cart, creating a risk for medication errors, contamination, and administration of the wrong medication to residents. This deficient practice had the potential to affect 3 of 3 residents whose medications were observed in the cart.

Inspectors wroteBased on interview and document review, the facility failed to ensure antibiotic was administered per physician orders for 1 of 1 resident (R1) reviewed for medication administration.

Inspectors wroteBased on interview and documentation review, the facility failed to complete post-fall vital signs and neurological assessments for 3 of 3 (R1, R2, R3) residents reviewed for post-fall assessment and monitoring.

Inspectors wroteBased on observation and interview the facility failed to follow the Centers for Disease Control (CDC), Infection Control Guidance: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 19) dated 6/24/24, which directed the facility to implement source control measures to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. On 8/28/24 at 9:50 a.m. a sign on the front door of the facility indicated the facility had a current COVID outbreak. On 8/28/24 at 9:55 a.m., the director of nursing (DON) The DON stated the census of the building was 68 and confirmed there was a current COVID outbreak in the facility. On 8/28/24 at 3:11 p.m., therapeutic recreation aide ([NAME])-A was observed in the dining room in close proximity to three residents while they were all seated at a table, approximately 2 feet apart. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate wheel chair (WC) positioning was maintained for 1 of 2 residents (R45) in the sample reviewed for positioning.

Inspectors wroteBased on observation, interview and document review, the facility failed ensure medications were administered safely for 3 of 6 residents (R19, R40, R61) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure eye drops were labeled for specific resident or dated with opened on date to ensure expired products were not administered for 2 of 2 residents (R8, R16) reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices for administration of eye drops to 1 of 2 residents (R16) reviewed for administration of eye drops.

Inspectors wroteBased on interview and document review, the facility failed to follow a care planned intervention to reduce the risk of falls for 1 of 4 residents (R4) reviewed for falls. This resulted in actual harm for R4 when he fell and sustained a thoracic fracture. R4 required subsequent hospitalization, where he expired. The facility implemented corrective action so the deficient practice was issued at past non-compliance. The past non-compliance began on [DATE], when R4 fell and sustained a fracture after staff failed to follow a care planned intervention. The facility implemented corrective action on [DATE], prior to the start of the abbreviated survey, and was issued as past non-compliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure required nursing staff data was posted daily before each shift. This had potential to affect all 74 residents, staff, and visitors who could wish to review this information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure suction equipment was maintained in working condition for 1 of 2 suction machines.

Inspectors wroteBased on observation, interview and document review, the facility failed to store food in accordance with professional standards for food safety in 1 of 1 unit refrigerators. This had the potential to affect all 20 residents that resided on the unit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide care in accordance with professional standards of practice for 1 of 1 residents (R63) reviewed for catheter cares.

Inspectors wroteResident #10 Based on Observation, interview, and record review, the facility failed to comprehensively assess 1 of 2 residents (R10) for safe use of a lighter. R10's significant change Minimal Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of anxiety, bipolar (highs and lows in mood), and schizophrenia (distorted sense of reality). R10's face sheet indicated admission date on 3/30/23, tobacco user and nicotine dependence. R10 smoking assessment dated [DATE], indicated current smoker able to hold and light own cigarettes. Used a smoking apron. Facility assessment lacked evidence R10 had been assessed to safely keep cigarette lighter on his person. On 9/11/23 at 9:36 a.m., R10 was smoking in designated area. He came back into facility and kept the lighter on his person. On 9/11/23 at 10:05 a.m., R10 was in his room and stated he had just gone out to smoke. [...]

Inspectors wroteBased on observations, interviews, and records review, the facility did not ensure safe disposition of controlled substances for 1 of 3 residents (R1, R9 and R28) reviewed for medication management.

Inspectors wroteBased on observation and interview, the facility failed to ensure doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 2 of 3 refrigerators observed in use for medication storage. This had potential to affect 6 of 6 residents (R1, R7, R9, R21, R28 and R28) who received controlled medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure mechanical lifts were disinfected between resident uses. These findings had potential to affect 6 residents residing on the memory care unit who were assited by a mechanical lift.

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify, report and repair damaged drywall observed in a room on the memory care unit. This had the potentially to affect the resident residing in room [ROOM NUMBER].