Appling Nursing And Rehabilitation Pavilion

F-F656)

39786

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 115262 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115262 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Appling Nursing and Rehabilitation Pavilion 163 East Tollison Street Baxley, GA 31513

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate 43637 jeopardy to resident health or safety 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. Residents Affected - Few 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.

The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on March 11, 2025, at 9:55 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on February 2, 2025.

At the time of exit on March 13, 2025, the Immediate Jeopardy remained ongoing.

Findings include:

Review of a nursing progress note, dated 5/20/24 at 2:34 a.m., documented that R #34 was found outside, had sustained a small skin tear to the top of the left foot, and was unable to answer questions.

A review of R#34's In-service for Elopement and Reportable Incidents, held 5/20/24 through 5/27/24, documented an elopement occurred on 5/20/24 at 1:30 a.m. The in-service documented, CONCLUSION: R #34 exited the facility without staff knowledge through a door that had not been reset to alarm.

Review of a facility reported incident revealed a resident eloped from the facility on 2/2/25. The investigation concluded that the exit door, which the resident went out of, did not alarm and staff were not notified that the resident left the building unattended, without staff knowledge.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 115262 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115262 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Appling Nursing and Rehabilitation Pavilion 163 East Tollison Street Baxley, GA 31513

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview with the Administrator on 3/13/25 at 11:49 a.m., the Administrator revealed she was aware of the resident's elopement on 2/2/25. The Administrator revealed after the resident's elopement; the Level of Harm - Immediate Interdisciplinary Team (IDT) met the next day to discuss additional interventions for the resident who eloped. jeopardy to resident health or The Administrator revealed the IDT did not discuss any other residents who had the potential to elope. The safety Administrator revealed at the time, all of the residents were at risk for elopement and the facility should have conducted risk assessments on the residents who were at high risk for elopement. The Administrator Residents Affected - Few revealed door checks were also implemented, however; they were not implemented on all shifts and were implemented just on the day shift. The Administrator revealed a resident could have eloped at any time of the day and that the facility failed to implement door checks on every shift to hold staff accountable and residents safe. The Administrator revealed there were several key areas of concern the facility staff had addressed, however, they failed to implement those interventions until the situation resulted in an IJ. The Administrator revealed moving forward she expected IDT members to discuss any areas of concern in QAPI (Quality Assurance Performance Improvement) meetings to identify care areas of concern and initiate appropriate interventions immediately.

39786

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 115262