Autumn Care of Marion

In the surveyor’s words

From the most serious findings on record at Autumn Care of Marion, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 26, 2026

  Based on observation, record review, and interviews with Guardian, witnesses, resident, Psychiatric Provider, Nurse Practitioner (NP), and staff, the facility failed to provide the necessary supervision to prevent Resident #1 from exiting the facility unsupervised and without staff's knowledge through one of two doors that did not alarm when opened. Resident #1 was at risk for falls, her diagnoses included dementia, and she had been identified with a decline in cognition with signs of increased confusion and disorientation in the months prior to March 2026. Staff reported these signs included getting lost in the hallways, not being able to figure out how to get back to her room and forgetting that she required supervision to smoke. […]

• No harm, potential for more than minimal, patternF644Feb 26, 2026

  Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents with new mental health diagnoses for 5 of 7 residents reviewed for PASRR (Resident #5, Resident #12, Resident #51, Resident #71 and Resident #100). The findings include:a. Review of Resident #5's medical record revealed PASRR level I was completed 2/01/22 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #5 was admitted to the facility on [DATE] with diagnosis that included hypertension, diabetes, and readmitted on [DATE] with diagnosis of… […]

• No harm, potential for more than minimal, isolatedF842Mar 26, 2026

  Based on record review and staff and resident interview the facility failed to maintain a complete and accurate medical record when staff documented a resident attempted elopement and was intercepted by staff. This occurred for 1 of 3 residents (Resident #1) reviewed for accurate medical recordThe findings included:A review of a progress note dated 3/2/26 written at 10:30 AM by the Director of Nursing (DON) indicated that Resident #1 attempted elopement and was intercepted. The DON indicated in the note that reorientation was attempted to her situation without success.An interview with the DON on 3/24/2026 at 2:58 PM revealed on the morning of 3/2/2026 management staff were in the morning meeting a visitor came into the conference room telling them a resident was outside. […]

• No harm, potential for more than minimal, isolatedF607Feb 26, 2026

  Based on record review and interviews with staff and law enforcement, the facility failed to follow their Abuse, Neglect and Exploitation policy when the Administrator was not immediately notified of an allegation of misappropriation of narcotic medications which resulted in delayed protection of other residents and reporting for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:The facility's Resident Abuse Policy: Abuse, Neglect and Exploitation indicated it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. […]

• No harm, potential for more than minimal, isolatedF755Feb 26, 2026

  Based on record review and interviews with the Pharmacist in Charge and staff, the facility failed to have effective systems in place for the return, disposition, and accurate accounting of controlled medications to the pharmacy for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:Resident #134 was admitted to the facility on [DATE].The physicians order dated 3/29/2025 revealed Resident #134 was to receive oxycodone (a narcotic opioid analgesic prescribed to treat moderate to severe pain by acting on the central nervous system) 5 milligrams (mg) every 6 hours as needed (PRN) for pain.The March 2025 medication administration record (MAR) revealed starting on 3/29/2025 Resident #134 received a total of 4 tablets of oxycodone 5mg. […]