Cycle 1
Health 2025-03-13 · Fire 2025-03-13
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Baxley, GA
Appling Nursing And Rehabilitation Pavilion
1-star overall rating with 1-star inspections with Special Focus status with $18,966 in total fines with 7 recent health deficiencies
163 East Tollison Street, Baxley, GA
(912) 367-9841
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
85
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.45
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
5.37
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,026
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.58
Baseline 7.63% · Performance 6.77% · Measure score 3.58 · Achievement 3.58 · Improvement 2.79
Total nurse turnover
3.69
Baseline 56.84% · Performance 48.61% · Measure score 3.69 · Achievement 3.69 · Improvement 2.07
Adjusted total nurse staffing
3.01
Baseline 4.69 hours · Performance 3.93 hours · Measure score 3.01 · Achievement 3.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.17% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 1.72% · Lower 95% interval 5.44% |
| Discharge to community | 57.96% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 61.7% · Lower 95% interval 45.8% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 18.75% |
95.27%
76.5 pts worse
|
Numerator 9 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 51.43% |
53.69%
2.3 pts worse
|
Numerator 18 · Denominator 35 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 21 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 12.5% |
2.29%
10.2 pts worse
|
Numerator 6 · Denominator 48 · Adjusted rate 12.14% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 112 |
| Staff flu vaccination coverage | 61.54% |
42%
19.5 pts better
|
Numerator 80 · Denominator 130 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 21 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 4 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
2.2
1.7 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.0
2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.1% |
91.2%
10.1 pts worse
|
93.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 84.5% · Q3 76.8% · Q4 73.1% · 4Q avg 81.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.0%
1.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 4.9% · Q4 3.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.9%
1.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.3% · Q3 7.1% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
20.7%
8 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 28.8% · Q3 31.9% · Q4 27.9% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
21.4%
1.9 pts better
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 19.0% · Q3 18.9% · Q4 17.2% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.4% |
17.9%
5.5 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 20.3% · Q3 3.8% · Q4 10.4% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
16.2%
3.5 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 12.5% · Q3 13.8% · Q4 28.6% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.1%
1.8 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.5% · Q3 1.4% · Q4 2.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.2% |
2.5%
8.7 pts worse
|
1.7%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.4% · Q3 11.2% · Q4 12.8% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
16.1%
9.3 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 29.8% · Q3 27.1% · Q4 19.7% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.2%
0.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.7% · Q3 8.3% · Q4 3.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.2% |
80.4%
37.2 pts worse
|
81.7%
38.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 54.3% · Q3 28.6% · Q4 39.0% · 4Q avg 43.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.9% |
12.2%
6.7 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 20.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.2%
0.9 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 8.0% · Q3 4.2% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.8% |
78.2%
30.4 pts worse
|
79.7%
31.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
24.2%
8.5 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 35.6% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-09 · Fire 2022-10-09
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-10-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-11-23
Inspection history
Recent health citations
G · Actual harm
2025-05-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-27
J · Immediate jeopardy
2025-03-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-04
J · Immediate jeopardy
2025-03-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
J · Immediate jeopardy
2025-03-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-06-27
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-08-11
F · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-11
D · Potential for more than minimal harm
2024-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-11
E · Potential for more than minimal harm
2022-10-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-23
D · Potential for more than minimal harm
2021-05-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-06-27
C · Minimal harm
2021-05-13
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-06-27
C · Minimal harm
2021-05-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-06-27
Penalties and ownership
What sits behind the stars
$5,272
2025-03-13
Fine
Fine · fine $5,272
Fine
$5,272
2025-03-13
Fine
Fine · fine $5,272
Fine
$8,422
2025-03-13
Fine
Fine · fine $8,422
Fine
$0
2025-03-13
Payment Denial
Payment Denial · denial start 2025-03-30 · 58 days
58 day denial
Ownership
The Baxley And Appling County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Dean, Pam
Corporate Director · Individual
Fernando, Orlando
Operational/Managerial Control · Individual
Hamilton, Beverly
Operational/Managerial Control · Individual
Martin, Shannah
Operational/Managerial Control · Individual
Martin, Shannah
Corporate Officer · Individual
The Baxley And Appling County Hospital Authority
Operational/Managerial Control · Organization
Nearby options
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#3
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