Marina Pointe Healthcare & Subacute

dated 12/28/2025, the OOP order indicated, OK for out on pass with family member.

The OOP order

Resident 3's diagnoses included unspecified open wound of the left lower leg (non-specific cut or

MDS indicated Resident 3 had moderate cognitive impairment.

The MDS indicated Resident 3 required substantial/maximal assistance for ADLs such as showering/bathing self and required partial/moderate assistance to perform movements such as changing positions from sitting to stand and toilet transfer.During a review of Resident 3's OOP order, dated 12/30/2025, the OOP order indicated, Standing out on pass.

The OOP order did not indicate whether Resident 3 could leave out on pass unaccompanied by a responsible person and the length of time the resident may be on pass.

During an interview on 1/2/2026 at 1:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff should document and ensure that residents are assessed prior to leaving the facility when they go OOP to establish the resident's baseline (state to determine if there was any change) for safety. LVN 1 stated, OOP orders should include how long the primary care provider (PCP) approved the resident to be OOP for.During a concurrent interview and record review on 1/2/2026 at 4:06 p.m., with the Director of Nursing (DON), the following were reviewed:Resident 1's OOP order, dated 12/19/2025Resident 2's OOP order, dated 12/28/2025Resident 3's admission record, dated 12/24/2025Resident 3's OOP, progress notes, and sign out sheet, dated 12/30/2025Facility's P&P titled, Resident Going Out On Pass, dated 8/22/2022.The DON stated, before residents leave the facility OOP, staff should assess and document whether the residents were stable prior to leaving and upon return to the facility to ensure the residents were safe while OOP.

The DON stated Resident 1's OOP order, dated 12/19/2025, did not specify the length of time, when, and who was to accompany Resident 1 when she was to be OOP.

The facility should have ensured Resident 1 had a responsible person to accompany the resident while OOP.

The DON stated Resident 2's OOP order did not indicate the length of time Resident 2 was approved to be OOP for.

The DON stated Resident 3's OOP order, did not indicate if Resident 3 could be unaccompanied while OOP, therefore should have been with a responsible person when Resident 3 was OOP on 12/30/2025. Resident 3's progress notes did not indicate Resident 3 was assessed to be stable prior to leaving and upon return from OOP on 12/30/2025.

The DON stated, staff were not following the facility's P&P.During a review of facility's P&P titled, Resident Going Out On Pass Policy, dated 8/26/2022, the P&P indicated, an Out-on-pass request will be written as physician order in the clinical record to include, but not limited to:Whether the resident should be accompanied by a responsible person while out on pass or may leave the facility unaccompaniedThe length of time the resident may be on passIn the absence of a specific order that indicates the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person.The P&P also indicated Nursing Responsibilities included:1.

Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status and ensure that:The resident and responsible person (if applicable) been instructed of any special needs of the resident during the pass is applicable (e.g. special diet, needs, medications (if any).2.

Licensed Nurse will document the provision of medication to the resident for use while out on pass (if applicable), the time the resident left the facility, the name of the accompanying responsible person as indicated, the destination, and contact phone number if possible, and expected time of return3.

When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident's condition and account for any medication returned after going out on pass, if applicable.