Folkston Park: Infection Control Failures - GA
Licensed Practical Nurse FF handled medications without gloves on November 13 while preparing crushed pills for two residents at Folkston Park Care and Rehabilitation Center. Federal inspectors observed her placing pills in pouches barehanded during medication rounds on A Hall.
The first incident occurred at 8:09 a.m. when the nurse prepared medication for a resident whose physician orders from June 2023 allowed crushing all medications. Nineteen minutes later, inspectors watched her repeat the same barehanded process for a second resident with similar crushing orders from April 2022.
When confronted the same day, the nurse admitted her violation.
"She confirmed that she was not using gloves to pick up the pills to place in pouch," according to the inspection report. The nurse acknowledged "that she should always wear gloves to handle residents' pills."
The facility's own infection control policy, updated in January, explicitly requires preventing healthcare-associated infections by isolating sources of contamination. The policy assigns the Infection Control Preventionist responsibility for monitoring infection prevention practices and ensuring staff follow proper protocols.
Both the Registered Nurse Unit Manager, who also serves as Infection Preventionist, and the Director of Nursing confirmed that staff must wear gloves when handling any resident medications. Their interviews occurred five days after the violations were observed.
The nurse's actions violated fundamental infection control principles designed to prevent cross-contamination between residents. Handling multiple residents' medications without gloves creates potential pathways for bacteria and viruses to spread throughout the facility.
Federal inspectors classified the violations as having "minimal harm or potential for actual harm" but noted the practice placed residents "at high risk for infection." The finding suggests the behavior was ongoing rather than an isolated incident.
Medication crushing requires particular care because the process can create powder particles that adhere to hands and surfaces. Without gloves, a nurse's hands become contaminated with one resident's medication residue before moving to the next person's treatment.
The facility's infection control policy outlines extensive responsibilities for preventing healthcare-associated infections. The Infection Control Preventionist is supposed to conduct rounds, monitor staff practices, collect infection data, investigate outbreaks, and train staff on infection incidents.
Despite these written protocols, the nurse's supervisor apparently missed the barehanded medication handling during routine oversight. The policy requires the Infection Control Preventionist to discuss and monitor infection prevention practices with staff members.
The violations occurred during a complaint investigation, suggesting someone had already raised concerns about care quality at the facility. Federal inspectors found the infection control failures while examining other aspects of resident care.
Both residents affected by the improper medication handling had long-standing orders allowing their pills to be crushed. The first resident's crushing order dated back to June 2023, while the second resident had been receiving crushed medications since April 2022.
The nurse's admission that she "should always wear gloves" indicates she understood the requirement but chose not to follow it. Her acknowledgment came only after being directly confronted by federal inspectors about the observed violations.
Medication administration represents one of the most frequent daily interactions between nursing staff and residents. A single nurse typically handles dozens of residents' medications during each shift, making proper infection control protocols essential for preventing disease transmission.
The facility's January 2025 infection control policy demonstrates recent attention to preventing healthcare-associated infections. However, the November violations show a gap between written policies and actual nursing practice.
The inspection report does not indicate whether other nursing staff were observed handling medications improperly or whether the facility has implemented additional training following the violations. The nurse's barehanded medication handling continued despite clear policies requiring gloves for all resident pill contact.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Folkston Park Care and Rehabilitation Center from 2025-11-18 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 21, 2026 · Our methodology
FOLKSTON PARK CARE AND REHABILITATION CENTER in FOLKSTON, GA was cited for violations during a health inspection on November 18, 2025.
Federal inspectors observed her placing pills in pouches barehanded during medication rounds on A Hall.
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.