The Hearth at Drexel.

“Glucometer readings were not accurately documented on medication administration records, and glucometers were calibrated with incorrect times. Specifically, one resident's glucometer reading was documented incorrectly, and two other residents' glucometers were calibrated with times that did not match the actual calibration times.”

“A prescription medication was found in the medication cart that had been open beyond the manufacturer's recommended discard date of six weeks, indicating improper storage and maintenance of medications.”

“An OTC or CAM medication bottle was found in the medication cart without proper labeling with the resident's name or room number.”

“A medication error occurred when a staff member administered medication to a resident without reviewing the medication administration record, glucose log, or physician's orders, resulting in a duplicate administration of the same medication within approximately 10 minutes.”

“Staff did not document narcotic medication administration on the correct narcotic sheets. Residents with standing orders every 8 hours and as-needed orders every 4 hours had all administrations incorrectly documented only on the 8-hour narcotic sheet.”

“Residents prescribed as-needed narcotic orders every 4 hours were administered medication more frequently than prescribed. One resident received doses on 2/16/25 at 9am, 12:13pm, 1:36pm, 4:30pm and on 2/18/25 at 5:00pm and 8:00pm. Another resident received doses at 2:30pm and 4:00pm without proper spacing.”

“Resident names and medications were identifiable on cellophane packets in the trash on the medication cart, violating confidentiality requirements. This was a repeat violation.”

“Carbon monoxide alarms were not installed within 15 feet of fossil-fuel burning devices as required by the Care Facility Carbon Monoxide Alarms Standards Act. The main kitchen lacked CO detectors near gas appliances, and gas dryers in the basement lacked CO detectors within required range. This was a repeat violation.”

“Privacy violations were identified: cameras were recording without proper signage to communicate video recording, and a camera captured the resident door of room #40. This was a repeat violation.”

“The residence's staff training plan for training year 2023 to 2024 did not include the name, title of staff, and location of the Relias training as required.”

“A bedside mobility device in room #W58 had an opening measuring 11"x13.5" that exceeds FDA requirements for zone 1 and was not covered.”

“Resident records were accessible, unattended, and unlocked in the nurse's station. Doors to the nurse's station on the first and second floors were open, making records easily accessible to unauthorized individuals.”

“Voice-controlled video devices were located in resident rooms with no notification posted indicating video and audio surveillance, violating resident privacy rights during bathing, dressing, changing, and medical procedures.”

“Poisonous materials (toothpaste tubes with poison control warnings) were unlocked, unattended, and accessible to residents, including residents not assessed as capable of safely using or avoiding poisonous materials.”

“Residents did not have access to their living units at all times. The home was locking resident unit doors to prevent another resident from entering and disrupting personal belongings, and residents unable to unlock rooms on their own without staff assistance.”

“The residence did not follow written Emergency Procedures during a utility emergency. Residents were not relocated to other rooms where heat was functioning; instead, portable heaters were provided.”

“Prescription medications were unlocked, unattended, and accessible in resident bathrooms. The residents were not assessed as capable of self-administering medications.”

“A resident who participated in development of their support plan did not sign and date the support plan as required.”

“Multiple residents did not have annual medical evaluations completed as required. The facility failed to ensure timely completion of required annual medical evaluations for residents.”

“A resident's annual written assessment was not completed on schedule. The facility failed to ensure timely completion of required annual assessments for residents.”