Autumn Care Of Marion
Autumn Care of Marion in Marion, NC — inspection on February 26, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
related to the allegation of drug diversion for Resident #134's Oxycodone in April 2025.
The facility
Oxycodone for Resident #134 (4/11/2025) and prior to the initiation of the facility's
7:00 AM
During an interview on 2/26/2026 at 11:41 AM the DON stated he was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025.
The DON stated the pharmacy called the facility on 4/10/2025 to report issues with narcotic medication that was supposed to be returned, but when ADON #1 answered the phone the pharmacy was no longer on the line.
The DON indicated ADON #1 should have called the pharmacy back on 4/10/2025.
The DON stated ADON #1 spoke to the pharmacy on 4/11/2025 and was notified of the missing narcotics for Resident #134.
The DON stated on 4/12/2025 he was notified by ADON #1 of the missing narcotics for Resident #134 that were supposed to be sent back to the pharmacy.
The DON revealed that he did not notify the Administrator of the missing narcotics until 4/14/2025 because at the time incident he did not know missing narcotics was a reportable event. He reported that he was now aware that he should have notified the Administrator of the missing Oxycodone as soon as he was notified on 4/12/2025 because missing narcotics was a reportable incident that needed to be investigated.
The DON stated the initial allegation report should have been completed within 24 hours of the facility being made aware of the possible diversion.
The DON spoke about law enforcement notification. He reported that he believed he contacted Officer #1 on 4/15/2025, but there was no evidence on his (the DON's) call logs. He indicated he called Police Officer #1 on a direct phone number on 4/18/2025 and left a voice mail, but there was not a police report available.
The DON's call log showed a call made Police Officer #1's direct number on 4/18/2025.
The DON stated the facility was unable to locate the missing medication or determine how they went missing and the allegation of diversion was unsubstantiated due to lack of evidence.
During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025.
The Administrator revealed she was first notified of the missing narcotics by the DON on 4/14/2025.
The Administrator indicated that the DON reported that ADON #1 spoke to the pharmacy on 4/11/2025 and was informed of the 7 tablets of Oxycodone missing from the sealed narcotic return bag. ADON #1 then notified the DON of the missing Oxycodone on 4/12/2025.
The Administrator stated that when the DON informed her of the missing narcotics on 4/14/2025, an investigation was started.
The Administrator stated she should have been notified of the missing narcotics immediately.
The Administrator stated she believed law enforcement was verbally notified on 4/15/2025, possibly from her cell phone as she was out of the facility at the time.
She verified there was no record of law enforcement notification.
The Administrator stated she expected protocol to be followed for reporting missing narcotics, and she should have been notified immediately by ADON #1 on 4/11/2025 and by the DON on 4/12/2025.
The Administrator stated the facility was unable to locate the missing medication or determine how they went missing, and the allegation of diversion was unsubstantiated due to lack of evidence.The facility presented a corrective action plan to the State Agency that was not accepted.
345165 02/26/2026
Autumn Care of Marion 1264 Airport Road Marion, NC 28752
During an interview on 2/26/26 at 4:30 PM with the Administrator, she revealed the Social Worker would be responsible for completing and submitting PASRR paperwork.
She stated the new Social Worker had only been in the position for a few months and to her knowledge had just received the training from corporate office on completing and submitting PASRR paperwork.
The Administrator revealed she was not aware of the sampled resident's diagnosis or that they did not have a PASRR level II evaluation paperwork completed and did not know why a PASRR level II evaluation request had not been submitted.
She stated that her understanding was that a PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis and that according to the sampled resident's diagnoses a PASRR level II should have been completed.
345165 02/26/2026
Autumn Care of Marion 1264 Airport Road Marion, NC 28752
answer the phone no one was there.
The Pharmacy called back on 4/11/2025 and reported the
to see if the pharmacy had found the missing medication.
The DON stated on 4/14/2025 when the
Nurse #1 took the form to Nurse #2 to sign, Nurse #1 should also have had the medication for verification and not left the medication unattended while he obtained Nurse #2's signature.
The DON stated that when the pharmacy driver picked up controlled medications from the facility the nurse and driver only verified the serial number on the bag and the pickup ticket.
The DON stated the missing oxycodone had not been found.
During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was notified of the missing narcotics on 4/14/2025, and the medications had not been found.
The Administrator stated she expected nurses that signed Controlled Medication Return form to verify the medication that they signed for matched the medication that was placed in the return bag and no staff should sign a Controlled Medication return form without verification of the medications being returned.
The Facility presented a corrective action plan that was not accepted by the state agency due to lack of new interventions.
345165 02/26/2026
Autumn Care of Marion 1264 Airport Road Marion, NC 28752
Findings included:Resident #59 was admitted to the facility on [DATE].Review of Resident #59's physician orders revealed no active orders for 2% miconazole (antifungal) powder or 10% zinc oxide (topical) protective cream.During an observation of Resident #59's room on 02/23/2026 at 11:29 AM, in clear view on the nightstand beside the bed was a 3 ounce bottle of 2% miconazole antifungal powder and a 2.75-ounce tube of 10% zinc oxide protective cream.During an interview on 02/23/2026 at 11:29 AM, Resident #59 stated that Nurse Aide (NA) staff applied the miconazole powder and zinc oxide cream when incontinence care was done and she did not want to selfˆadminister either medication.
During an interview and observation on 02/23/2026 at 11:34 AM, NA #1 entered Resident #59's room and stated she was assigned to the hall.
She observed the zinc oxide cream and miconazole powder on the nightstand and stated those were from the facility's house stock. NA #1 explained the miconazole powder and zinc oxide cream were applied by NA staff when incontinence care was done but should not have been left in Resident #59's room, and she removed both items.An interview was conducted on 02/25/2026 at 12:17 PM with the Director of Nursing (DON) in the presence of the Administrator.
The DON explained that the 2% miconazole powder and zinc oxide cream were stored on the treatment cart and should not have been left in Resident #59's room.
The DON added that if Resident #59 needed the miconazole powder or zinc protective cream, a physician's order was required.
345165 02/26/2026
Autumn Care of Marion 1264 Airport Road Marion, NC 28752
#74's wound but the IP had told the Wound Care Nurse and the Director of Nursing (DON) that she was
#74.An interview with the Director of Nursing (DON) revealed he would have expected Resident #74 to
incontinence care and wound care to the resident.