Autumn Care Of Marion
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, North Carolina.
- Location
- 1264 Airport Road, Marion, North Carolina 28752
- CMS Provider Number
- 345165
- Inspections on file
- 21
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Autumn Care Of Marion during CMS and state inspections, most recent first.
A resident with dementia, hemiplegia, anxiety, and depression, who had shown months of increasing confusion, disorientation in hallways, and need for supervised smoking, exited the building unsupervised through a side door that did not alarm when opened and was not easily visible from the reception area. The resident self‑propeled in a wheelchair down the ramp, out of the parking lot, and into a busy two‑lane road, where a passerby and facility leadership found her in the roadway. Although leadership and the NP knew the resident had actually left the building, the DON’s documentation and verbal reports to multiple staff and a psychiatric provider described the event only as an "attempted elopement," leaving many staff unaware that the resident had been off premises in the road. Surveyors determined the facility failed to provide adequate supervision to prevent the unsupervised exit and failed to ensure staff were fully informed of the elopement.
The facility failed to maintain an accurate medical record when the DON documented that a resident had an “attempted elopement” and was “intercepted,” despite later stating in interview that the resident actually left the building and was found in the road past the gravel parking lot with altered, manic mentation and resisting efforts to return. A visitor alerted staff during a morning meeting that a resident was in the road, and the Administrator confirmed that staff then caught up to the resident, who had exited through a side door and was sitting in a wheelchair across the road. The Administrator expressed uncertainty about why staff did not recognize that the resident had fully eloped and questioned the discrepancy between the DON’s note and the actual circumstances, emphasizing an expectation that medical record entries be accurate.
The facility failed to submit required Level II PASRR evaluations for several residents who developed new or additional mental health diagnoses after admission or readmission. Each affected resident had a prior Level I PASRR indicating that paperwork should be resubmitted for Level II if new mental health conditions or significant changes occurred. Despite subsequent diagnoses such as PTSD, major depressive disorder, anxiety disorder, and psychotic disorders, documented as active on the MDS and in some cases treated with antidepressant and antipsychotic medications, there was no evidence that Level II PASRR requests were made. The SW and administrator confirmed the SW was responsible for PASRR submissions and acknowledged that Level II evaluations should have been completed for these residents based on their documented mental health conditions.
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting and investigation when a pharmacy reported missing Oxycodone tablets from a sealed controlled medication return bag for a discharged resident. An ADON did not promptly return the pharmacy’s initial call, then delayed notifying the DON after being informed of the missing narcotics, and the DON further delayed notifying the Administrator. During this time, nurses associated with the narcotic returns continued to work, and notification to law enforcement about the missing narcotics was delayed and not clearly documented. These delays resulted in the Administrator not being immediately informed of the allegation of misappropriation of narcotic medication as required by facility policy.
A resident had a PRN oxycodone 5 mg order, with documentation showing several doses administered and seven tablets remaining at discharge. An RN completed a controlled substance return form and sealed the remaining oxycodone in a return bag without having a second nurse verify the medication, while another nurse signed the form without seeing or counting the drugs. A third nurse later released the sealed bag to the pharmacy driver after only confirming the bag’s serial number matched the pick-up ticket, without checking the contents. The pharmacy documented that no oxycodone was in the bag upon receipt and reported the discrepancy to facility staff, and the missing tablets were never located.
A resident was found with a bottle of 2% miconazole powder and a tube of 10% zinc oxide cream left in plain view on the bedside nightstand, despite no active physician orders for either medication. The resident reported that NA staff applied both products during incontinence care and that she did not self-administer them. An NA confirmed the items were house-stock medications used by staff and acknowledged they should not have been left in the room. The DON later stated these medications should have been stored on the treatment cart and that a physician order was required for their use.
A resident with a coccyx pressure wound did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy, as there was no EBP signage or PPE outside the room, and the Wound Care Nurse provided incontinence care and wound care wearing only gloves and no gown during high-contact activities. The Infection Preventionist had not placed the resident on the EBP list because she was unaware of the wound, and the nurse did not question the absence of precautions. Both the IP and DON later stated they would have expected the resident to be on EBP and the nurse to use a gown in addition to gloves during these care activities.
Unsupervised Elopement Through Non‑Alarming Side Door and Inadequate Staff Awareness
Penalty
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
Inaccurate Documentation of Resident Elopement Event
Penalty
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.
Failure to Request Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
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.
Failure to Immediately Report and Investigate Missing Narcotic Medication
Penalty
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.
Failure to Account for and Return Controlled Oxycodone Medication
Penalty
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.
Unsecured House-Stock Topical Medications Left in Resident Room Without Physician Order
Penalty
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.
Failure to Follow Enhanced Barrier Precautions During Wound and Incontinence Care
Penalty
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.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
