Autumn Care Of Marion

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision to prevent an unsupervised exit by a cognitively impaired resident. The resident had dementia, hemiplegia/hemiparesis following a cerebral infarction, anxiety, and depression, used a wheelchair, and required assistance with several ADLs. Staff, including multiple nurses and a nurse aide, reported that over several months prior to the incident the resident had experienced a decline with increased confusion, anxiety, disorientation in the hallways, difficulty finding her room, and forgetting that she required supervision to smoke. The resident’s care plan identified needs such as supervised leave of absence, variable mental function, risk for impaired vision, and risk for falls related to decreased mobility and muscle weakness, but there were no documented interventions for these care-planned problem areas. On the day of the incident, the resident was observed by staff and witnesses in her usual routine near the nurse’s station and front area, then left unsupervised and exited the building without staff knowledge. The DON and Administrator later determined that the resident exited through a side door that, at that time, did not have an alarm that sounded when opened and only had a wander management alarm that would activate if a wanderguard bracelet was present; the resident did not yet have such a device. This side door and the front door were the only exterior doors that did not alarm when opened, and the side door was the only door that could not be easily visualized by the receptionist. Staff in the morning meeting were unaware the resident had left until a visitor (Witness #2) entered the conference room and reported that a resident was in the road. Witnesses and staff described that the resident traveled down the ramp and out of the parking lot into a well-traveled two-lane road with blind curves and a posted speed limit of 35 mph. She was found in her wheelchair on the opposite side of the road from the facility, in the roadway, just past the gravel parking lot, attempting to self-propel further up the road. A passerby was present with the resident when staff arrived. The DON, ADON, Administrator, and other staff confirmed that the resident had actually left the building and was in the road, although the DON’s progress note and subsequent communication to several staff and the psychiatric provider characterized the event as an “attempted elopement” that had been intercepted by staff. Multiple staff members, including the assigned NA, several nurses, and the psychiatric provider, reported that they were only told it was an attempted elopement and did not know through the survey date that the resident had exited the building and gone down the road. The resident herself later stated she left the building in her wheelchair, went down the hill and up the road because she felt she needed to go home to care for her adult son, and she did not inform anyone she was leaving. The facility’s leadership, including the DON and Administrator, acknowledged awareness of the resident’s recent cognitive decline and that she had been changed from independent to supervised smoking due to increased confusion and difficulty holding a cigarette. They also acknowledged that prior to the incident the side door did not alarm when opened unless a wanderguard was present, and that the front door and side door were the only non-alarming exterior doors. The DON stated that he believed he had verbally informed all staff that the resident had actually left the facility and gone down the road, but he did not track who he told, and several staff and providers confirmed they were not informed of the full extent of the elopement. The Administrator stated she was not sure why all staff did not know that the resident had actually gotten out of the building and would need to speak with the DON about his progress note describing the event as an attempted elopement. The surveyors concluded that the facility failed to provide necessary supervision to prevent the resident from exiting unsupervised through a non-alarming side door and failed to ensure all staff were aware of the unsupervised exit. The report notes that the resident was not injured but that there was a high likelihood of serious harm, injury, or death, including risks of getting lost, falling without the ability to get out of harm’s way, or being hit by a car. The facility’s noncompliance was cited at Immediate Jeopardy level beginning on the date of the elopement, based on the unsupervised exit, the lack of an alarm on the side door, and the failure to ensure staff were aware of the actual elopement. Immediate Jeopardy was later removed after the facility implemented a credible allegation of immediate jeopardy removal, but the facility remained out of compliance at a lower scope and severity to ensure staff and providers were aware of the elopement and that education and monitoring systems were effective.

Removal Plan

• Returned Resident #1 to the facility without injury by the Administrator, Director of Nursing, and Assistant Director of Nursing
• Administrator and DON conducted an immediate review of the incident
• Administrator and DON determined the root cause was the side exit door lacked an alarm system that alerted staff when the door opened
• Administrator and DON contacted Resident #1's guardian, primary care provider, and Medical Director
• Resident #1's nurse completed a head-to-toe nursing assessment and found no injuries
• Administrator and DON interviewed Resident #1 regarding the incident and her stated desire to go home to care for her son
• Administrator reassured Resident #1 that her son is cared for by a full-time caregiver
• Director of Rehabilitation Services completed a BIMS assessment
• Resident #1's nurse completed an elopement risk assessment and identified Resident #1 as high risk for elopement

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who left the building and was later found in the road. A progress note dated 3/2/26 at 10:30 AM, written by the DON, documented that the resident had an “attempted elopement” and was “intercepted,” and that reorientation to her situation was attempted without success. However, during interview, the DON stated that on the morning of 3/2/26, while management staff were in a morning meeting, a visitor entered the conference room and reported that a resident was outside. Management staff immediately left the meeting and located the resident on the road just past the gravel parking lot. The DON described the resident’s mentation as altered and “manic,” and reported that she was difficult to convince to return to the facility as she continued to try to propel her wheelchair further up the hill, stating she needed to take care of her son. The DON acknowledged in interview that the resident did in fact elope and was found down the road below the gravel parking lot, and he was unable to explain why he had documented in the progress note that the elopement was only attempted and that the resident was intercepted by staff. In a separate interview, the Administrator confirmed that during the same morning meeting a visitor reported a resident in the road, and that staff then caught up to the resident, who was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator stated the resident had exited via a side door and expressed uncertainty as to why all staff did not know the resident had actually gotten out of the building. The Administrator also questioned why the DON’s progress note characterized the event as an attempted elopement and stated that she expected all information entered into a resident’s medical record to be accurate.

Penalty

Inspection fine: $10,364

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to submit required Level II Preadmission Screening and Resident Review (PASRR) evaluations for multiple residents who developed new or additional mental health diagnoses after admission. For each of the five affected residents, a PASRR Level I had been completed prior to admission with explicit recommendations to resubmit paperwork for a Level II evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. Despite these instructions, the medical records for these residents contained no evidence that Level II PASRR requests were submitted after new mental health diagnoses were made and documented. One resident was initially admitted with medical diagnoses such as hypertension and diabetes and later readmitted with new diagnoses of post-traumatic stress disorder (PTSD) and major depressive disorder, which were documented as active on the MDS, yet no Level II PASRR request was found. Another resident was admitted with Parkinson’s disease, heart failure, and multiple mental health conditions including anxiety disorder, major depressive disorder, and a psychotic disorder with hallucinations; these diagnoses were active on the MDS, and the resident had received antidepressant and antipsychotic medications in the prior seven days, but again there was no evidence of a Level II PASRR request. A third resident, originally admitted with heart failure, diabetes, and seizure disorder, was later readmitted with new diagnoses of anxiety disorder, major depressive disorder, and psychotic disorder with delusions, all active on the MDS, without any corresponding Level II PASRR submission. Two additional residents had similar patterns of new or additional mental health diagnoses without subsequent Level II PASRR requests. One was readmitted with a new diagnosis of major depressive disorder, which was active on the MDS, and another, long-term resident with dementia and hypertension was readmitted with new diagnoses of major depressive disorder, PTSD, and anxiety disorder, all active on the MDS, yet neither had documentation of a Level II PASRR request. Interviews with the social worker and the administrator confirmed that the social worker was responsible for completing and submitting PASRR paperwork, that she had only recently received training, and that they were unaware these residents lacked Level II evaluations despite the presence of qualifying mental health diagnoses and prior Level I instructions to resubmit for Level II upon such changes.

Penalty

Inspection fine: $10,364

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its Abuse, Neglect and Exploitation policy requiring immediate reporting of all allegations and suspicions of misappropriation of resident property, including narcotics, to the Administrator/Abuse Coordinator. The policy stated that once notified, the Administrator/Abuse Coordinator would immediately begin an investigation and notify applicable local and state agencies. In this case, the facility became aware through the pharmacy that seven 5 mg tablets of Oxycodone, a narcotic pain medication belonging to Resident #134 and contained in a sealed Controlled Medication Return Bag, were missing after the resident had been discharged. This information was first relayed to the facility on 4/10/2025 when pharmacy staff attempted to contact the facility about an issue with narcotic medication that was supposed to be returned. According to interviews, the ADON was informed on 4/10/2025 by a floor nurse that the pharmacy was on the phone regarding an issue with narcotic medication sent back to the pharmacy, but when the ADON got to the phone, the pharmacy was no longer on the line and she did not attempt to call the pharmacy back. The pharmacy called again on 4/11/2025 and informed the ADON of the missing Oxycodone for Resident #134. The ADON did not notify the DON of the missing narcotics until 4/12/2025, stating she did not know missing narcotics had to be reported immediately and wanted to wait to see if the pharmacy could locate the medication. The DON then delayed notifying the Administrator until 4/14/2025 because he did not know that missing narcotics was a reportable event that required immediate notification and investigation. As a result, the Administrator was not informed of the allegation of misappropriation until several days after the facility first became aware of the missing narcotics. During this period of delayed reporting and investigation, nursing staff who were later identified in the facility’s investigation as involved in the handling of the narcotic returns continued to work. Time records showed that one nurse worked multiple overnight shifts from 4/12/2025 through 4/15/2025, and another agency nurse worked shifts spanning 4/10/2025 through 4/12/2025 after the ADON had been notified by the pharmacy of the missing Oxycodone and before the facility initiated its investigation. Law enforcement notification was also delayed and not clearly documented. The facility’s Initial Allegation Report listed that a police officer was called on 4/15/2025, but the officer reported there were no records of any calls or emails from the facility regarding missing narcotics during that time, and the DON’s call log only showed a call to the officer’s direct number on 4/18/2025. These actions and inactions demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy for immediate reporting and investigation of suspected misappropriation of resident property.

Penalty

Inspection fine: $10,364

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain effective systems for the return, disposition, and accurate accounting of a resident’s controlled medication, specifically oxycodone 5 mg prescribed PRN for pain. The resident was admitted with an order for oxycodone 5 mg every 6 hours as needed and received a total of four doses in March and one dose in April, after which no further administrations were documented. The controlled substance count record showed that seven oxycodone tablets remained after the last documented dose on April 1, and the resident was discharged the following day with those seven tablets still on hand. On April 7, a Controlled Substance Prescription Returned to Pharmacy form was completed indicating that the seven remaining oxycodone tablets were being returned to the pharmacy in a sealed Controlled Medication Return Bag. Nurse #1 reported that he prepared the resident’s oxycodone for return and took the return form to Nurse #2 for signature without bringing the narcotic cards for verification. He acknowledged leaving the medication unattended in the medication room while obtaining the second nurse’s signature and stated that Nurse #2 did not participate in verifying the medications. Nurse #1 then placed the narcotic cards, including the card with seven oxycodone tablets, into the return bag, sealed it himself, and stored it in the locked narcotic drawer. Nurse #2 confirmed she signed the form without verifying the medications or having access to them and later recognized she should not have signed without confirming the contents. On April 8, Nurse #3 and the pharmacy driver signed the pharmacy pick-up slip, verifying only that the serial number on the sealed Controlled Medication Return Bag matched the serial number on the pick-up ticket. Nurse #3 stated she did not verify the contents of the sealed bag at the time of pick-up. The Pharmacist in Charge explained that the pharmacy’s process required matching the bag’s serial number to the pick-up ticket and checking that the seal was intact, but did not require verification of the bag’s contents by the driver. When the pharmacy processed the return on April 9, the pharmacy’s copy of the Controlled Substance Prescription Returned to Pharmacy form included a handwritten note stating that the medication was not in the bag and that the pharmacy had called the facility twice about the issue. The Pharmacist in Charge confirmed that the seven oxycodone tablets never arrived at the pharmacy and stated that the facility remained responsible for following up on the missing medication. Interviews with the ADON, DON, and Administrator confirmed that the missing oxycodone tablets were never found and that the facility’s process at the time relied on serial number verification rather than verification of the actual controlled substances being returned.

Penalty

Inspection fine: $10,364

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves unsecured medications and lack of physician orders for topical drugs used for a resident. Resident #59 had no active physician orders for 2% miconazole antifungal powder or 10% zinc oxide protective cream, according to a review of the physician orders. During an observation of the resident’s room, surveyors noted a 3-ounce bottle of 2% miconazole powder and a 2.75-ounce tube of 10% zinc oxide cream in clear view on the nightstand beside the bed. The resident stated that nurse aide staff applied both products during incontinence care and that she did not wish to self-administer either medication. During an interview and observation, a nurse aide assigned to the hall entered the room, saw the miconazole powder and zinc oxide cream on the nightstand, and identified them as facility house stock. The nurse aide confirmed that staff applied these products during incontinence care but acknowledged they should not have been left in the resident’s room and removed them. In a subsequent interview, the DON, with the Administrator present, stated that the miconazole powder and zinc oxide cream were supposed to be stored on the treatment cart and not left in the resident’s room, and further explained that a physician’s order was required if the resident needed these products.

Penalty

Inspection fine: $10,364

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a coccyx pressure wound. The facility’s policy, revised on 05/19/2025, required staff to don both gloves and a gown for high-contact activities, including incontinence care and wound care, for high-risk residents such as those with wounds. Surveyor observations on two consecutive days showed that there was no EBP signage on the resident’s door and no PPE available outside the room, despite the resident reporting she had a sore on her bottom that was dressed daily. During a wound care observation, the Wound Care Nurse entered the room with wound care supplies in gloved hands, placed them on the bed sheet, and provided incontinence care and wound care without donning a gown at any point. Interviews revealed that the resident had not been placed on the Infection Preventionist’s EBP list because the Infection Preventionist was not aware the resident had a coccyx pressure wound. The Wound Care Nurse stated that the resident was not on the list of those requiring EBP and therefore no precautions had been implemented, although she thought it was odd the resident was not on precautions and did not question it. The Infection Preventionist stated she would have expected the Wound Care Nurse to wear a gown while providing incontinence and wound care, and the DON similarly stated he would have expected the resident to be on EBP and the Wound Care Nurse to use both gloves and a gown during care. These actions and omissions resulted in noncompliance with the facility’s EBP policy for infection prevention and control.