Appling Nursing and Rehabilitation Pavilion

In the surveyor’s words

From the most serious findings on record at Appling Nursing and Rehabilitation Pavilion, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Mar 13, 2025

  Based on interviews, record review and review of the facility policy, the facility staff failed to implement care plan interventions for two residents ((R) #33 and R#34) of 30 residents reviewed. Specifically, the care plan was not followed for R#34 resulting in elopement from the facility on two occasions. Additionally, on 12/30/24 R#33 sustained fractures of the distal left femur with mild comminution when staff transferred her without using appropriate number of staff and equipment. […]

• Immediate jeopardy, isolatedF689Mar 13, 2025

  Based on interviews, record review, and review of the facility policy titled Elopement and Wandering Residents and Safe Transfers - Hoyer Lift, the facility failed to ensure one resident (Resident #34) of two residents reviewed for elopement, did not leave the facility without the nursing staff being aware. This failure led to Resident (R) #34 eloping on 2/2/25 for a second time, which could have caused harm or death. The facility also failed to provide one of two residents reviewed the appropriate interventions when transferring (Resident (R) #33). Additionally, on 12/20/24, actual harm was experienced when R#33 sustained fractures of the distal left femur with mild comminution and was transferred to the hospital for further medical treatment. […]

• Immediate jeopardy, isolatedF835Mar 13, 2025

  Based on interviews and record reviews, the facility's Administration failed to ensure it administered in a manner that enabled it to use its resources effectively and efficiently to prevent residents from elopement. This resulted in a lack of supervision and processes, which placed residents at risk for multiple elopements and at risk for serious adverse outcomes. This failure resulted in resident (R)#34 eloping from the facility twice. The census was 81. On March 11, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. […]

• Actual harm, isolatedF689May 23, 2025

  Based on observation, interviews, and record review, the facility failed to provide adequate supervision when offering hot beverages for one resident (R) (1) of three sampled residents. Actual harm was identified on 4/11/2025 when R1 sustained 2nd degree burns when hot tea spilled on him when the beverage temperature was not checked prior to serving. Findings include: A policy was requested but the facility did not have one according to the Administrator. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction and later on 4/16/2025, unspecified dementia, unspecified severity. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2025

  Based on observation, interview, record review, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, which affected all 81 residents in the facility. Findings include: Record review of the facility's policy titled, Infection Prevention and Control Program, last revised 4/30/2020, directed that the Infection Preventionist would consult on infectious diseases, resident room placement, implementation of isolation precautions, and other related tasks. […]