The Gardens At Foley Llc

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

observed redness to her buttocks; however, shortly after admission, she brought concerns to staffs' attention, especially the increased pain she had to her buttock area, especially when the sheet would stick to it or she laid on it. She stated staff looked at her buttocks on a few occasions when she questioned them, but staff denied concerns. She indicated this went on for a few days. It was not until 10/16/25 when she was made aware of an actual open area. She was unsure what the etiology was but her being out at appointments and extended time in the wheelchair may have played a factor. She identified she utilized a cushion in her wheelchair which she brought to the facility on admission and denied the facility provided her

a different one. Resident R1 stated, when staff first saw the buttock redness, she expected they would have updated to the doctor to put something on it. She feels it would not have gotten worse. She did not know if the area were avoidable but there was a chance it would not have gotten so bad. When interviewed on 10/29/25, at 11:47 a.m., for additional follow-up, the DON stated she expected Resident R1 would have had interventions developed specific for Resident R1 and any skin impairments identified during admission, and/or after. As the redness did not go away during her first day, she expected Resident R1's provider would have been updated before

the end of that shift for appropriate treatment. Therapy would have been involved to ensure the appropriate pressure reduction surfaces and thorough documentation would have been embedded within Resident R1's medical

record by the end of each shift where concerns were identified, especially open areas as identified by staff interview. Resident R1 then would have been expected to be added to wound care rounds to ensure appropriate monitoring and treatment. The DON stated Resident R1 had a very good gamut of interventions applied in the beginning. She was unable to speculate on any outcomes for Resident R1 if staff on admission followed her expectations; however, commented that education was clearly needed, along with a review of the processes. During an interview on 10/29/25 at 12:00 p.m., RN-E, the regional consultant, stated they identified areas for improvement and had already started on a plan to fix process concerns related to assessments, updating appropriate people, and documentation processes. During an interview on 10/29/25 at 12:44 p.m., the medical director expected the appropriate staff to be updated, and protocols followed when skin impairments were identified. This included care manager visual assessment of the area, adequate and timely documentation, provider updates, individualized intervention implementation, and monitoring. When it came to provider update for redness, she stated she would expect this more so if the area deteriorated. The medical director was unable to speculate answers surrounding radiation questions or what may have occurred if staff on admission followed expectations; however, commented that Resident R1's situation appeared like an error of omission. A Skin Assessment & Wound Management policy, last revised February 2025, directed the following when a New Skin Problem was identified: notify the nurse, provider,

the resident's representative, and the nurse manager/wound nurse; complete education with resident/resident representative which included risks and benefits; initiate a Skin and Wound Evaluation; referrals to dietary and therapy if appropriate; review and update the plan of care which included interventions, along with skin breakdown identified risks, and to update the resident care lists.

Event ID:

Facility ID:

If continuation sheet