Appling Nursing and Rehabilitation Pavilion

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure accurate administration of medications for two of 25 medication opportunities observed resulting in a medication error rate of eight percent (8%.) This deficient practice resulted in residents receiving incorrect medication dosages, which has the potential to cause adverse drug reactions, ineffective treatment, and adverse clinical outcomes.

Inspectors wroteBased on observations, interviews, record review, and review of facility policies titled, Medication Storage and Medication Expiration (Pavilion), the facility failed to ensure all medications and biologicals were stored and labeled properly. Specifically, expired medications were found in one of two medication storage rooms. This deficient practice has the potential to affect resident health and safety because expired medications may undergo chemical changes, lose potency, or become ineffective.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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. [...]

Inspectors wrote2. Review of the facility policy titled, Safe Transfers - Hoyer Lift, last revised on 8/29/22, revealed All residents require handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Review of R#33's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to, Alzheimer's Disease (admitting diagnosis), encounter for other orthopedic aftercare, fracture of lower end of left femur (12/31/24). [...]

Inspectors wroteBased 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. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on March 11, 2025, at 9:55 am. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review and review of the facility policy, titled Abuse, Neglect, and Exploitation Prevention and Reporting, the facility staff failed to timely report an allegation of staff to resident abuse for one of two residents reviewed (Resident (R) #50).

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders to ensure that residents receive treatment and care in accordance with professional standards of practice for one resident (R) #290 of one resident reviewed for quality of care.

Inspectors wroteBased on record review, resident and staff interview, and review of the facility policy titled, Management and Protection of the Resident Personal Fund Account, the facility failed to provide a quarterly financial statement to the resident and/or responsible party (RP) for 66 of 66 residents with trust fund accounts managed by the facility.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain sanitary and clean conditions related to cross contamination on three of three hallways (A Hall, B Hall, and C Hall). Specifically, the facility failed to ensure the Treatment Cart was cleaned and sanitized after being utilized in residents rooms during wound care treatment, failed to ensure residents foley catheter drainage bags were positioned below the bladder and not resting on the residents bed and linens, and the facility failed to ensure residents positioning equipment was not stored on the floor before use.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, IDT/Care Plan Activities, the facility failed to develop and implement a care plan for pressure ulcers for one of four residents (R) (R5). The deficient practice had the potential to prevent R5 from receiving care and services to maintain the highest quality of life possible.

Inspectors wroteBased on observations, record review, staff interviews and review of the policy titled Appropriate Use of Indwelling Catheters, the facility failed to promote, maintain, and protect resident's dignity for three of six residents (R) (R#17, R#72, and R#46) with an indwelling urinary catheter.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled, IDT/Care Plan Activities, the facility failed to implement the care plans for four residents (R) (R#17, R#72, and R#46) related to privacy bags with an indwelling urinary catheter; and R#26 for use of Geri-sleeves to prevent skin tears.

Inspectors wroteBased on observation, interview, and review of the policy titled Restraint Free Environment, the facility failed to ensure that one resident (R) (#50) was free from restraint use out of nine residents reviewed for restraints.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled IDT/Care Plan Activities, the facility failed to ensure the baseline care plan for one newly admitted resident (R) (R#229) included goals and interventions for diagnosis of Influenza A. The sample size was 40 residents.

Inspectors wroteBased on record review, staff interviews, and review of the policy titled Transfer and Discharge including AMA of a Resident, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a post discharge plan of care, or a final summary of the resident's status for one resident (R) (R#79) from a sample of three residents reviewed for discharge.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow Physicians Orders (PO) for one of 40 sampled residents (R) (R#26) related to applying Geri sleeves to prevent skin tears.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled, Equipment Cleaning, the facility failed to ensure oxygen concentrators were free from dust build up, had oxygen filters on the concentrators, and failed to ensure the CPAP and Trilogy masks were properly stored when not in use for three of 12 residents (R) (R#42, R#29, and R#46) receiving respiratory care.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) beyond 14 days and failed to document the reason for the extension or the period during which the extended order should be in effect for two residents (R) (R#13 and R#42), of five residents reviewed for unnecessary medications.