The Gardens at Foley: Wound Care Neglect Ignored - MN
She had noticed the redness shortly after admission. Then came the pain, sharp enough that she could feel it when the bedsheet touched her skin or when she laid on the area. She brought it to staff's attention more than once. Staff looked at her buttocks on a few occasions when she pressed them. They denied her concerns.
This went on for days.
She told inspectors she had expected that when staff first saw the redness, they would have updated her doctor so something could be put on it. "She feels it would not have gotten worse," the inspection report states. She said she didn't know whether the wound was avoidable, but believed there was a chance it would not have gotten as bad as it did.
She had been going to outside appointments during this period and spending extended time in her wheelchair, which she thought may have been a factor. She had brought her own cushion to the facility on admission and said the facility never provided her a different one.
The Director of Nursing, interviewed on October 29, was direct about what should have happened. She said she expected that interventions specific to R1's skin condition would have been developed at admission and updated as problems emerged. When the redness didn't resolve on the first day, she said, the provider should have been contacted before the end of that shift. Therapy should have been brought in to evaluate pressure reduction surfaces. Documentation should have been completed at the end of every shift where concerns were identified, and especially when staff identified an open area. R1 should have been added to wound care rounds.
The Director of Nursing acknowledged that R1 had received what she called "a very good gamut of interventions" at some point, but she was unable to say what would have happened differently if admission staff had followed those expectations from the start. She said education was clearly needed, along with a review of processes.
The facility's own Skin Assessment and Wound Management policy, last revised in February 2025, spelled out exactly what was supposed to happen when a new skin problem was identified: notify the nurse, the provider, the resident's representative, and the wound nurse; initiate a skin and wound evaluation; make referrals to dietary and therapy if appropriate; and update the plan of care. None of that happened in the days when R1 was reporting pain and staff were telling her nothing was wrong.
The regional consultant, an RN interviewed the same morning, said the facility had already identified areas for improvement and had started working on a plan addressing assessments, provider notifications, and documentation.
The medical director said she would have expected a provider update for redness more so if the area deteriorated, and acknowledged she could not say what would have occurred if admission staff had followed expectations. She called R1's situation "an error of omission."
That phrase carries weight. An error of omission is not a mistake made in the middle of a complex procedure. It is the absence of a basic response to a patient who said, plainly and repeatedly, that something was wrong and that it was getting worse. Staff looked. Staff dismissed her. The sheet stuck to the wound. She kept asking.
It was not until the wound was open that anyone confirmed what she had been trying to tell them for days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Gardens At Foley LLC from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
The Gardens at Foley LLC in FOLEY, MN was cited for neglect violations during a health inspection on October 29, 2025.
She had noticed the redness shortly after admission.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.