Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Appling Nursing And Rehabilitation Pavilion during CMS and state inspections, most recent first.
A resident who required assistance with eating and drinking sustained second-degree burns after being served hot tea without the temperature being checked. The CNA provided the beverage from a pantry coffee pot and left the resident unattended, resulting in a spill and injury. Prior to the incident, staff did not routinely check hot beverage temperatures, and there was no policy or guidance posted in the facility. Temperature logs showed inconsistent monitoring, and other staff confirmed that temperature checks were not standard practice.
Staff failed to follow care plan interventions for two residents with severe cognitive impairment, resulting in one resident eloping from the facility twice and another sustaining a femur fracture during an improper transfer. Required supervision, risk assessments, and use of transfer equipment were not consistently implemented, leading to serious harm and Immediate Jeopardy status.
The facility did not provide adequate supervision or follow care plans for two residents with severe cognitive impairment, leading to one resident eloping from the facility twice and another sustaining a femur fracture during an improper transfer. Staff failed to use required equipment and did not consistently follow policies for elopement prevention and safe transfers, resulting in actual harm and placing residents at risk.
A resident eloped from the facility twice due to failures in supervision and door alarm procedures. On both occasions, the resident exited through doors that did not alarm or were not reset, and staff were unaware of the resident's absence. The facility's IDT only addressed the specific resident after the incidents and did not assess other residents for elopement risk. Door checks were inconsistently implemented, occurring only on the day shift, leaving gaps in monitoring and resident safety.
The facility did not maintain an effective infection prevention and control program during an Influenza A outbreak, as the DON was unable to provide accurate case tracking, failed to report the outbreak to health authorities, and demonstrated confusion regarding proper isolation precautions. These deficiencies affected all residents and staff during the outbreak.
A resident with moderate cognitive impairment reported to nursing staff that a CNA was rough, manhandled, and yelled at him during a transfer. Although the incident was reported internally the day after it occurred, the administrator did not notify state and local authorities within the required timeframe, resulting in a delay that did not comply with facility policy for reporting abuse allegations.
A resident with diabetes and other medical conditions experienced multiple blood sugar readings above 400 mg/dL. Despite physician orders to send the resident to the ER and withhold insulin until lab confirmation, staff administered insulin and did not send the resident out, only attempting to contact the physician. No negative outcomes were documented.
The facility did not provide quarterly financial statements to residents or their responsible parties for trust fund accounts, as required by policy. Interviews revealed that residents, despite having little to no cognitive impairment, had not received these statements. The Social Service Director admitted to issuing statements every six months without proof of distribution, and the administrator was unaware of this practice until recently informed.
The facility failed to maintain sanitary conditions, leading to cross-contamination. An LPN used a treatment cart for wound care without sanitizing it between rooms, and improperly handled a foley catheter by placing it on a resident's bed instead of below the bladder. The LPN lacked training in wound care and infection control, contributing to these deficiencies.
A resident with multiple sclerosis and moderate cognitive impairment had stage 4 and stage 2 pressure ulcers, but the facility failed to develop a care plan to address these conditions. The facility's policy requires care plans to be updated and communicated with relevant staff, but this was not done, as confirmed by the Administrator, DON, and ADON.
Resident Burned by Unchecked Hot Beverage Temperature
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and unspecified dementia, who required set up or clean up assistance with eating or drinking, was served hot tea without the temperature being checked. The Certified Nurse Assistant (CNA) poured hot water from a coffee pot in the hall's pantry and gave it to the resident, then left the room to assist another resident. After approximately eight minutes, the CNA returned and found that the hot tea had spilled on the resident, resulting in burns. The nurse assessed the resident and noted what appeared to be a third-degree burn on the right hip area, and the resident was subsequently sent to the emergency room and then transferred to a burn unit, where a second-degree burn was confirmed and a skin graft was performed. Prior to this incident, the facility did not have a policy regarding the serving temperature of hot beverages, nor were there postings or thermometers available in the pantries for staff to check beverage temperatures. Staff interviews confirmed that it was not standard practice to check the temperature of hot beverages before serving them to residents. The CNA involved in the incident reported that she could not find a thermometer and relied on the absence of steam to judge the temperature, which proved inadequate. Other staff corroborated that temperature checks were not routinely performed before the incident. Observations and record reviews revealed that the facility's temperature logs for hot beverages showed a wide range of serving temperatures, some of which exceeded safe limits. There were also gaps in documentation for certain dates. Additionally, the Activities Director reported serving coffee during activities without checking temperatures. The lack of a clear policy, absence of temperature monitoring, and failure to provide adequate supervision when serving hot beverages directly contributed to the resident sustaining significant burns.
Failure to Implement and Follow Care Plans Results in Elopement and Injury
Penalty
Summary
Facility staff failed to implement and follow care plan interventions for two residents, resulting in significant negative outcomes. One resident with severe cognitive impairment and a history of Alzheimer's disease experienced two elopement incidents, despite a care plan in place since 2021 that required staff supervision when moving on and off the unit. After the second elopement, additional interventions such as keeping the resident in view of staff at all times and daily door checks were documented, but the resident had not received an elopement risk assessment since admission, and some interventions were not consistently added to the care plan after the first incident. Another resident, also with severe cognitive impairment and dependent on staff for transfers, sustained a fracture of the distal left femur. The care plan specified that transfers required two staff members and the use of a mechanical lift. However, staff interviews revealed that the resident was transferred to a shower chair without the required equipment or sufficient staff assistance. Multiple staff members acknowledged that the resident needed two-person assistance and a lift, but these protocols were not followed during the transfer, likely resulting in the injury. The facility's failure to implement and maintain individualized care plans as required led to serious harm and the likelihood of further injury. The deficiencies were identified as causing or having the potential to cause serious injury, harm, impairment, or death, and Immediate Jeopardy was declared by surveyors. The noncompliance was determined to have existed for over a month prior to the survey exit, and the Immediate Jeopardy status remained ongoing at the time of survey exit.
Failure to Prevent Elopement and Ensure Safe Transfers Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that residents at risk for elopement and those requiring assistance with transfers received adequate supervision and appropriate interventions, resulting in two significant incidents. One resident with severe cognitive impairment and a history of wandering exited the facility without staff knowledge on two separate occasions. The first elopement occurred when the resident left through a door that had not been reset to alarm, and the second incident involved the resident being found outside in a wheelchair. The care plan for this resident included supervision when moving on and off the unit, but there was no evidence that an elopement risk assessment had been completed since admission, nor was the care plan updated after the first elopement. Door lock checks were initiated only after the second incident, and documentation of these checks prior to the second elopement was not available. Another resident, also with severe cognitive impairment and dependent on staff for transfers, sustained a fracture of the distal left femur. The care plan specified the use of a mechanical lift and assistance from two staff members for transfers. However, staff interviews revealed that the resident was transferred from bed to a shower chair and back without the use of a mechanical lift or gait belt, and not always with two staff members present. The facility's investigation could not substantiate the exact cause of the injury but concluded it likely occurred during a transfer due to improper technique and failure to follow the care plan. The Director of Nursing confirmed that the resident requiring two-person transfers was not always assisted according to the care plan and that staff did not consistently use the required equipment. The facility's policies on elopement and safe transfers were not followed, and staff were either unaware of or did not implement the necessary interventions. These failures resulted in actual harm to one resident and placed others at risk for serious injury or death.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Alarm Procedures
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to prevent resident elopement. Specifically, a resident was able to exit the facility without staff knowledge on two separate occasions. On one occasion, the resident was found outside with a small skin tear and was unable to answer questions. Documentation revealed that the resident exited through a door that had not been reset to alarm, and on another occasion, the exit door did not alarm, allowing the resident to leave the building unattended and without staff awareness. Interviews and record reviews indicated that after the first elopement, the facility's Interdisciplinary Team (IDT) met to discuss interventions for the affected resident but did not assess or address the risk of elopement for other residents. Door checks were implemented only on the day shift, leaving other shifts without this safety measure. The Administrator acknowledged that all residents were at risk for elopement and that the facility failed to conduct risk assessments for those at high risk. The lack of comprehensive supervision and processes placed residents at risk for multiple elopements and serious adverse outcomes.
Failure to Maintain Effective Infection Control Program During Influenza Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as required by its own policy and regulatory standards. The Director of Nursing (DON), who also served as the Infection Preventionist, was unable to provide an accurate and up-to-date line list of residents and staff affected by an ongoing Influenza A outbreak. Discrepancies were found between the facility's line list and the resident matrix, with several positive cases not included in the official documentation. The DON also reported that staff illness was only tracked by call-out dates or doctor's notes, and that a significant portion of staff had been out with the flu. Additionally, the facility had not reported the outbreak to the appropriate health authorities, despite state requirements to do so. Further, the DON demonstrated a lack of knowledge regarding proper isolation precautions for influenza, incorrectly equating airborne and droplet isolation and applying multiple types of isolation simultaneously. Observations confirmed that residents were placed under contact, airborne, and droplet precautions, which may not align with best practices for influenza. The DON admitted to not knowing that reporting outbreaks to the health department was required and had not done so. These failures affected all 81 residents in the facility during the outbreak.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to timely report an allegation of staff-to-resident abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including heart disease, anxiety disorder, and dementia. The resident reported to a nurse that a male CNA was rough, manhandled him during a transfer, and yelled at him. The incident occurred during a transfer for a scheduled haircut, and the resident expressed pain and requested that the CNA not enter his room again. The resident initially reported the incident to nursing staff the day after it occurred, and the nurse immediately informed the DON, who began collecting witness statements. Despite facility policy requiring that all allegations of abuse be reported to the state agency and other authorities within specified timeframes (immediately, but not later than 2 hours if abuse is involved, or within 24 hours otherwise), the administrator did not report the incident to state and local authorities until two days after the initial report was made to nursing staff. Interviews with the administrator, DON, and involved staff confirmed the delay in reporting, which was not in accordance with the facility's written procedures for abuse, neglect, and exploitation prevention and reporting.
Failure to Follow Physician Orders for Blood Glucose Management
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes, a history of heart attack, and high blood pressure, who was cognitively intact. The physician's orders specified that if the resident's blood sugar (BS) was over 400 mg/dL two hours after insulin administration, the resident should be sent to the emergency room (ER) and the physician must be notified. Additional orders required repeat finger stick and STAT lab confirmation if BS was less than 40 mg/dL or greater than 400 mg/dL, and to withhold insulin until lab confirmation was received. On two consecutive days, the resident's BS readings were consistently above 400 mg/dL, reaching as high as 505 mg/dL. Despite these elevated readings, the resident was not sent to the ER as ordered, and insulin was administered without waiting for lab confirmation. Documentation showed that staff attempted to contact the physician and faxed information, but the required actions per the physician's orders were not followed. There were no documented negative outcomes for the resident as a result of these actions.
Failure to Provide Quarterly Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and/or their responsible parties for trust fund accounts managed by the facility, affecting all 66 residents with such accounts. The facility's policy requires that individual financial records be made available through quarterly statements and upon request. However, interviews with residents revealed that they had never received these statements, although they could obtain verbal account balances upon request. The residents involved, who had little to no cognitive impairment, confirmed they had not received the required quarterly statements. The Social Service Director (SSD), responsible for managing the resident trust fund accounts, admitted to not having proof that quarterly statements were provided. Instead, she stated that statements were issued every six months, either mailed to families or placed on residents' bedside tables without confirmation of receipt. The SSD also lacked documentation to verify the distribution of these statements. The facility administrator was unaware of this deviation from policy until informed by the SSD, who acknowledged that only one statement had been issued since October 2023, contrary to the quarterly requirement.
Infection Control Deficiency Due to Improper Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary and clean conditions, leading to cross-contamination across three hallways. Specifically, the treatment cart used for wound care was not cleaned and sanitized after being used in residents' rooms. An LPN was observed rolling the treatment cart into a resident's room, where it came into contact with a foley catheter's dignity bag and other surfaces. The LPN did not sanitize the cart after leaving the room and continued to use it in other rooms without cleaning it. Additionally, the LPN placed a foley catheter on a resident's bed, which is not the correct positioning, as it should be below the bladder level. The LPN also placed a wedge on the floor before using it on the resident. Interviews revealed that the LPN lacked training in wound care and infection control, which contributed to the improper handling of the treatment cart and foley catheter. The Director of Nursing acknowledged that the LPN had not received specific training for her role and assumed that the LPN knew the correct positioning for foley catheters. The DON expressed an intention to provide the LPN with a bedside table for treatment supplies and additional education, but these actions were not yet implemented at the time of the report.
Failure to Develop Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with multiple pressure ulcers, which is a deficiency in their care planning process. The facility's policy, titled IDT/Care Plan Activities, mandates that nursing services update care plans as changes occur and communicate these updates with the MDS Coordinator and appropriate staff. However, upon review, it was found that there was no care plan in place for the resident's pressure ulcers, despite the resident having a diagnosis of stage 4 pressure ulcers on the left hip and right buttock, and a stage 2 pressure ulcer on the left heel. The resident, who has multiple sclerosis and a BIMS score indicating moderate cognitive impairment, had two stage 4 pressure ulcers present upon admission. The absence of a care plan was confirmed during an interview with the Administrator, DON, and ADON, who acknowledged that a care plan should have been developed to address the resident's pressure ulcers. This oversight had the potential to prevent the resident from receiving necessary care and services to maintain the highest quality of life possible.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baxley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hazelhurst Court Care And Rehabilitation Center | 16.1 mi | ★★★★★ | 14 | 3 |
| Twin Oaks Convalescent Center | 17.2 mi | ★★★★★ | 0 | 0 |
| Tattnall Healthcare Center | 25.9 mi | ★★★★★ | 10 | 0 |
| Woods At Lumber City Of Journey Llc, The | 26.6 mi | ★★★★★ | 8 | 0 |
| Glenvue Health & Rehab | 27.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.