Folkston Park Care: Medication Crushing Failures - GA
A November 2025 complaint inspection at Folkston Park Care and Rehabilitation Center found that staff had been crushing enteric-coated aspirin 81mg for a resident, identified in records as R2, who required his medications to be administered through a gastric tube. The problem was not a missing policy or an ambiguous order. The facility's own list explicitly identified enteric-coated aspirin as a medication that should not be crushed. The physician had never issued an order authorizing the crushing. Nobody had changed R2's aspirin order when his care needs shifted and tube feeding became necessary.
The Director of Nursing confirmed each of these facts during an interview with inspectors on November 18, 2025. She acknowledged that enteric-coated aspirin appeared on the do-not-crush list. She acknowledged that the physician order for R2's aspirin EC had not been updated when he required crushed medications. She said she expected staff to follow the policies.
Enteric coating on a tablet exists for a reason. The coating is designed to prevent the medication from dissolving in the stomach, allowing it to pass through to the small intestine before breaking down. Crushing an enteric-coated tablet destroys that protection entirely, exposing the stomach lining to a drug formulated specifically to bypass it, and releasing the medication in the wrong location at the wrong time.
A second resident, R3, received a different kind of error. R3 had a physician order for aspirin 81mg chewable. According to the Director of Nursing, that was exactly what the nurse should have given. Instead, the nurse administered a different aspirin formulation. The DON confirmed during the inspection interview that enteric-coated and chewable aspirin 81mg are not interchangeable, and confirmed the nurse had given the wrong one.
The errors extended beyond which aspirin and whether to crush it. For residents receiving medications through a gastric tube, the placement of the tube must be verified before anything is pushed through it. A tube that has shifted position can deliver medication into the wrong part of the digestive tract, or somewhere worse. The DON said during her interview that her expectation was that nurses check tube placement before administering any medication or anything else through the g-tube. LPN OO, interviewed separately at 4:50 p.m. on the day of the inspection, confirmed the same thing: placement should be checked prior to administering medication, each medication should be crushed individually, and the tube should be flushed with the ordered amount of water before and after each medication.
Whether placement checks were being performed consistently, the inspection record does not say.
CMS rated the violations under F0759, the federal tag covering medication errors, with a harm level of minimal harm or potential for actual harm, affecting a few residents. That classification sits near the lower end of the federal scale. It does not mean the errors were inconsequential. Enteric-coated aspirin is formulated to protect the stomach. Crushing it removes that protection for a resident who may already be medically fragile, already dependent on a tube for every medication that enters his body, already relying on nurses to read an order correctly and check a list that the facility itself compiled and posted.
The list existed. The order was never changed. The wrong drug was given to the second resident. The Director of Nursing said she expected staff to follow the policies.
R2 is still there, on his gastric tube, waiting for the next medication pass.
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 20, 2026 · Our methodology
FOLKSTON PARK CARE AND REHABILITATION CENTER in FOLKSTON, GA was cited for violations during a health inspection on November 18, 2025.
The problem was not a missing policy or an ambiguous order.
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.