The Gardens at Foley: Skin Care Documentation Failures - MN
The medical director, interviewed by inspectors on October 29, described what she expected when a skin impairment was identified: a visual assessment by the care manager, timely documentation, a provider update, individualized interventions, and ongoing monitoring. What she got instead, in at least one resident's case, was none of that. She called it an "error of omission."
She declined to speculate about what might have happened differently if staff had followed protocol on admission, or to answer questions about radiation. What she would say was this: she expected provider notification to happen, especially if an area deteriorated.
The facility's Skin Assessment and Wound Management policy, last revised in February 2025, spelled out exactly what staff were supposed to do when a new skin problem appeared. Notify the nurse, the provider, the resident's representative, and the wound nurse. Complete education with the resident. Initiate a formal skin and wound evaluation. Make referrals to dietary and therapy if appropriate. Update the care plan.
The regional consultant, also interviewed that morning, acknowledged the gaps. Education was clearly needed, she said. Process concerns existed around assessments, documentation, and keeping the right people informed. A plan to fix those concerns had already been started.
The inspection, a complaint survey, identified the harm level as minimal, with few residents affected. The medical director's phrase, though, carried its own weight. An error of omission means the harm that followed was not from something staff did. It was from everything they didn't.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
THE GARDENS AT FOLEY LLC in FOLEY, MN was cited for violations during a health inspection on October 29, 2025.
What she got instead, in at least one resident's case, was none of that.
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.