Autumn Care of Drexel

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan in the area of anticoagulant (blood thinner) medication use for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe or complete paralysis of one side of the body) following a cerebral infarction (a blocked or narrowed blood vessel that cuts off blood flow to a part of the brain) and chronic atrial fibrillation (a sustained irregular heart rhythm). A review of the active medication orders for Resident #8 revealed an order for rivaroxaban (an anticoagulant medication) 20 milligrams (mg) by mouth; take daily with evening meal for history of cerebral infarction. The medication had a start date of 12/30/2025. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #8 dated 04/21/2026 indicated Resident #8 was receiving an anticoagulant. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility failed to implement their Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) when the Wound Nurse and Nurse Aide (NA) #1 failed to wear a gown while providing wound care to Resident #12. Resident #12 was admitted to the facility with a chronic heel wound with drainage. This deficient practice occurred for 2 of 8 staff observed for infection control practices (Wound Nurse and NA #1).The findings included:Review of the Enhanced Barrier Precautions policy and procedure which is part of the Infection Control policies and procedures last revised on 04/15/26 revealed the following:Policy: Enhanced Barrier Precautions (EBP) are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk resident during high contact activities.High risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and traches) and for all those colonized or infected with a MDRO…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure ready to use dishware was cleaned and dried before being stored, food was dated/labeled in the walk-in freezer, walk-in cooler, and dry goods storage area. This occurred for 1 of 2 kitchen observations. This had the potential to affect food served and distributed to 88 of 88 residents who received an oral diet. The findings included: The initial tour of the kitchen occurred on 04/21/25 at 9:30 AM with the Dietary Manager. The initial observation of the dishware storage area revealed the following: a. Dishware that was ready for use was put away and stacked wet. -4 out of 4 metal serving bins were stacked flat upside down visibly wet with pooled water on the sides and water pooled around the rim. -22 small plastic bowls stacked right side up. 3 out of 22 bowls were observed with small amount of pooled water in the base of the bowls. -2 of 8 clear small plastic dessert bowls were stacked right side up with small amount of pooled water in base of the bowls. b. Dishware that was ready for use was put away/or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident, staff, family, and physician interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #86). This deficient practice occurred for 1 of 3 residents reviewed for respiratory care and services. Findings included: Resident #86 was admitted to the facility on [DATE]. Resident #86 had diagnoses which included myoneural disorder (a neuromuscular disorder which leads to progressive muscle weakness and paralysis which affects breathing). Review of the Electronic Medical Record (EMR) revealed a physician order for Resident #86 dated 04/17/2025 at 10:17 AM for oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia. Review of the baseline care plan dated 04/17/2025 revealed Resident #86 was receiving oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia. Resident #86's 5-Day Minimum Data Set (MDS) assessment was in progress and not yet completed. Review of the Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interviews and staff interviews the facility failed to have systems in place for providing evening snacks to residents for 5 of 5 halls. The deficient practice had the potential to affect all residents requesting an evening snack. The findings included: An interview conducted on 02/13/24 at 6:30 AM with Nurse Aide (NA) #2 revealed she worked second shift and residents during second shift (3:00 PM to 11:00 PM) had not received a bedtime snack on multiple days because staff were unable to get into the nourishment room on either floor. NA #2 further revealed the nourishment rooms had a code that was not provided to them, and the kitchen was locked. The NA indicated she had reported this to a Nurse on duty over the past few months but could not recall which Nurse. An interview conducted with Nurse #1 on 02/13/24 at 7:20 AM revealed nursing staff were often unable to access the kitchen and nourishment rooms at night to retrieve snacks because the doors had a code that had not been provided to her. The Nurse further revealed she had reported these concerns and was told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and failed to remove expired food items in 1of 1 walk-in cooler and 1 of 2 nourishment rooms (First Floor). These practices had the potential to affect food served to residents. Findings included: a. An observation and interview were conducted on 2/11/23 at 9:15 AM with Dietary [NAME] #1 in the walk-in cooler revealed eleven sandwiches, six grilled cheese sandwiches, tomato soup in a container with saran wrap on top, and four cups of lima beans which were unlabeled and not dated. The Dietary [NAME] believed the sandwiches and grilled cheese sandwiches were made the day prior but was unsure when they had been prepared and needed to be discarded. The Dietary [NAME] was unable to determine when the other items had been prepared. Observations further revealed leftover roasted potatoes with the expiration/discard date of 02/09/23. Dietary [NAME] #1 stated the dietary staff member that puts the food item in the walk in the cooler was responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with residents, staff and the Nurse Practitioner, the facility failed to assess the ability of a resident to self-administer for 1 of 4 residents observed (Resident#88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses of allergies. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was cognitively intact and needed supervision with most activities of daily living. A review of Resident #88's medical record indicated no documentation that Resident #88 was assessed for self-administration of medications. Resident #88 did not have a physician's order for self-administration of medications. A review of Resident #88's order summary for February 2024 indicated an active physician's order for Fluticasone Propionate Nasal Suspension 50 micrograms - two sprays both nostrils in morning for allergies and instructions to shake well. During an initial observation of a medication pass for Resident #88…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident with mental health diagnoses upon admission for 1 of 3 residents reviewed for PASRR (Resident #47). The findings include: Review of Resident #47's medical record revealed a PASRR level I screening had been completed on 08/08/2018. No further PASRR documentation was discovered in Resident #47's medical record. Resident #47 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and dementia with mood disorder. During an interview on 02/14/24 at 1:20 PM with the Social Worker (SW), she revealed she had been employed as the facility SW for the past 36 years and was responsible for completing PASRR referrals upon resident admission. She revealed she would review a resident's diagnoses once they were admitted to see if they would require a level II PASRR referral to be completed. The SW stated Resident #47 had been admitted from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff, and Hospice Nurse Aide interviews, the facility failed to provide incontinence care to prevent a resident (Resident #45) from having urinary incontinence through her brief, pants, lift pad and onto her wheelchair pad for 1 of 3 residents reviewed for activities of daily living for dependent residents. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included hemiplegia following a stroke, dysphagia, muscle weakness and dementia. Review of Resident #45's care plan dated 12/07/23 revealed a focus area for the resident having an activities of daily living (ADL) self-care deficit due to stroke with left hemiparesis and resident required extensive to total assistance with ADL. Resident #45 was also at risk for further unavoidable declines related to diagnosis of dementia. The interventions included assist with activities of daily living (ADL), dressing, grooming, toileting, promote independence and dignity, and provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities resulting in a medication error rate of 6.25% for 2 of 4 residents (Resident #26 and Resident #76) observed during medication administration observation. The findings included: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN). A Physician order dated 05/13/12 revealed Resident #26 was to receive Metoprolol Tartrate 25 mg (milligrams) one tablet by mouth twice a day for hypertension. Instructions on the physician orders read to hold medication for systolic pressure less than 100 or a heart rate less than 60. During medication pass observation 02/14/24 at 8:15 AM Nurse #2 prepared medications for Resident #26. Nurse #2 was observed taking a Metoprolol Tartrate 25mg tablet out of a blister package and placing it in a medicine cup. The label on the blister package included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 07/07/22 and follow-up and complaint investigation survey that occurred on 09/21/22. This was for one deficiency cited in July 2022 in the area of infection control and one deficiency cited in September 2022 in the area of maintain a medication error rate of 5% or less and both were subsequently cited on the current recertification and complaint investigation survey of 02/14/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F880: Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure and did not doff her gloves, sanitize her hands, and don clean gloves after cleansing the hip wound and before applying the treatment to the wound for a resident (Resident #55). The Treatment Nurse only doffed her right glove, sanitized her right hand, and donned a clean glove on her right hand after removing the soiled dressing from the resident's hip wound, did not doff her gloves after cleansing the wound, did not sanitize her hands, and did not don clean gloves before proceeding to apply the treatment to the hip wound and covering the wound with a clean border gauze dressing. This occurred for 1 of 3 residents reviewed for wound care. The findings included: The facility's policy entitled Hand Hygiene/Handwashing Policy which is part of their Infection Control Policies and Procedures last revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.