Autumn Care of Drexel

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during Resident Council meetings for twelve of thirteen months reviewed (May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, March 2026, April 2026, and May 2026).

Inspectors wroteBased on record review, staff, Medical Director and Consulting Pharmacist interviews, the facility failed to prevent a significant medication error when Nurse #1 administered 30 units of insulin glargine (a long acting insulin that lasts for 24 hours and does not have a peak of onset) intended for Resident #31 to Resident #16. Resident #16 did not have a diagnosis of diabetes or a physician's order for insulin. Resident #16 was assessed by the Nurse Practitioner (NP) and immediately started on intravenous (IV) dextrose (a solution that contains sugar) fluids for 24 hours. The NP also ordered finger stick blood sugars every hour for 24 hours with instructions to notify the provider if Resident #16's blood sugar was below 90 (Normal range is between 70-99). [...]

Inspectors wroteBased on observations, record review, Medical Director, resident and staff interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #34) with left side weakness and vascular dementia with incontinent care. The resident was rolled onto her left side then left in her bed unattended with the side rails down. Resident #34 was unable to hold herself up and she fell off the side of the bed onto the floor. The resident sustained a laceration to her nose, bruises to her face, and was transferred to the hospital for treatment. She received medical glue to the laceration on her nose, and a hospital CT (computed tomography) scan revealed the resident had suffered a fractured nose due to the fall. The resident was discharged back to the facility on 4/12/25. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain daily posted staffing sheets for 134 of 385 days (9/21/2024-12/31/2024, 1/4/2025, 1/5/2025, 1/11/2025, 1/12/2025, 1/18/2025, 1/19/2025, 1/25/2025, 1/26/2025, 2/1/2025, 2/2/2025, 2/8/2025, 2/9/2025, 2/15/2025, 2/16/2025, 2/22/2025, 2/23/2025, 3/1/2025, 3/2/2025, 3/8/2025, 3/9/2025, 3/15/2025, 3/16/2025, 3/22/2025, 3/23,2025, 3/29/205, 3/30/2025, 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/19/2025, 4/20/2025) reviewed for daily posted staffing information.

Inspectors wroteBased on observations, record review, and Nurse Practitioner (NP) and staff interviews, the facility failed to prevent an accident when staff was assisting a resident with advanced Parkinson's disease (disorder of the central nervous system that affects movement) to the dining room in her wheelchair without the use of foot pedals. The resident was unable to keep her feet up while in her wheelchair without the assistance of her foot pedals which allowed her foot to drop, causing her shoe to fall off and her shoe to become stuck underneath the wheel of the wheelchair. This caused the wheelchair to stop abruptly and the resident to fall forward out of the wheelchair and hit her head on the floor. The resident sustained a large gash above her left eye and was transferred to the hospital for treatment. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]