Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Care Of Drexel during CMS and state inspections, most recent first.
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A nurse administered 30 units of insulin glargine to a non-diabetic, severely cognitively impaired resident after failing to verify the resident's identity and giving the medication in the dining room instead of the resident's room. The error was immediately recognized and reported, and the resident was closely monitored for hypoglycemia, requiring interventions including IV dextrose and glucagon. Staff interviews confirmed the error resulted from not following proper medication administration protocols.
A resident with left-sided weakness and vascular dementia, dependent on staff for all ADLs and requiring bed rails, was left unattended on her side during incontinence care without bed rails raised or the bed locked. The resident fell from the bed, sustaining a nasal laceration, facial bruising, and a fractured nose, requiring hospital treatment. Staff and therapy interviews confirmed the resident was left in an unsafe position without necessary assistive devices, leading to the fall.
Surveyors found that dishware was stored while still wet and sometimes with food debris or dead insects present. Additionally, opened food items in the freezer, cooler, and dry storage areas were not labeled or dated as required. These deficiencies had the potential to affect all residents receiving an oral diet.
A resident with a neuromuscular disorder requiring continuous oxygen therapy did not consistently receive oxygen at the physician-ordered flow rate. Observations showed the oxygen was set below the prescribed 3 LPM on multiple occasions, and staff interviews revealed confusion and inconsistency regarding who was responsible for setting and adjusting oxygen flow rates. Although leadership stated that only licensed nurses should manage oxygen settings, nursing assistants were sometimes performing this task, resulting in the deficiency.
The facility did not maintain or post daily nurse staffing sheets for numerous days, including entire months and multiple weekends, due to a lack of awareness and designated responsibility among staff. The scheduler was unaware of the requirement to complete and retain these records on weekends, and the DON and Administrator confirmed the absence of a designated weekend process, leading to missing documentation.
A resident with advanced Parkinson's disease fell from her wheelchair and sustained injuries because staff failed to use foot pedals during transport. The resident's foot dropped, causing her shoe to get stuck under the wheel, leading to an abrupt stop and a fall. The incident resulted in a head injury and a small subarachnoid hemorrhage, requiring hospital treatment. Staff interviews revealed a lack of consistent application of foot pedals, contributing to the accident.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Significant Medication Error: Insulin Administered to Non-Diabetic Resident
Penalty
Summary
A significant medication error occurred when a nurse administered 30 units of insulin glargine, intended for a diabetic resident, to another resident who did not have a diagnosis of diabetes and no physician's order for insulin. The error took place in the dining room, where two residents were seated together, and the nurse failed to verify the correct identity of the resident prior to administration. The nurse immediately recognized the mistake after administering the insulin and reported it to the appropriate medical staff and the resident's family. The resident who received the insulin in error was severely cognitively impaired and unable to communicate that she was not supposed to receive insulin. She was closely monitored following the incident, with hourly blood sugar checks and intravenous dextrose administered as ordered by the nurse practitioner. During the monitoring period, the resident's blood sugar dropped to 61, prompting further intervention, including administration of orange juice, a snack, and glucagon as ordered by the on-call provider. The resident remained alert and did not display signs of hypoglycemia during the observed period. Interviews with nursing staff, the medical director, and the consulting pharmacist confirmed that administering a high dose of long-acting insulin to a non-diabetic resident could result in hypoglycemic events. The nurse involved stated that she was working on a hall she was not normally assigned to and attributed the error to failing to follow proper medication administration protocols, specifically not verifying the resident's identity and administering medication outside of the resident's room. The director of nursing and administrator both stated their expectation that staff follow the six rights of medication administration, which were not adhered to in this incident.
Removal Plan
- Nurse #1 was suspended pending investigation.
- The Director of Nursing contacted the Board of Nursing regarding the medication error.
- The Provider immediately assessed Resident #16 and gave orders for hourly blood sugar checks, IV dextrose, and monitoring for hypoglycemia.
- Resident #16's Responsible Party was notified of the medication error.
- The Director of Nursing and/or Designee reviewed finger stick blood glucose levels of all residents requiring glucose monitoring to ensure no signs of hypoglycemia.
- The Director of Nursing and/or Designee audited residents with active orders for blood glucose monitoring and insulin to ensure insulin was administered per orders.
- The Director of Nursing interviewed cognitively intact residents and assessed cognitively impaired residents for signs of hypoglycemia.
- Education was started for all Licensed Nurses and Medication Aides (including agency staff) on not administering medications in the dining room and to follow the 6 rights of medication administration, including verifying resident identity using the electronic health record picture.
- Licensed Nurses and Medication Aides not currently working were educated via phone or in person and will not be allowed to work until they have received this education.
- Any Nurse on leave or paid time off will be provided the education prior to working their next shift.
- Education will be provided in new hire orientation for all Licensed Nurses and Medication Aides.
- Agency credentialing/education specialists were contacted and provided the facility-specific plan of correction education packet; agency staff must receive this education before working in the facility.
- The Director of Nursing educated the Scheduler on ensuring continuity of staff assignments to prevent medication errors.
- The Director of Nursing and/or Designee will observe 3 medication passes for Licensed Nurses and/or Medication Aides weekly for 8 weeks, then monthly for 1 month, to ensure medications are administered as ordered.
- The Director of Nursing and/or Designee will observe 5 residents in the Dining Room weekly for 8 weeks, then monthly for 1 month, to ensure no medications are being passed in the dining room.
- An ADHOC QAPI meeting was held to discuss the incident and educate the team on interventions.
- The Medical Director was notified of the medication error and interventions.
- The Interdisciplinary team will review and provide recommendations on audit results during QAPI meetings for the next 3 months to ensure sustained compliance.
- If noncompliance is identified, immediate correction, re-education, and an ADHOC QAPI meeting will be held to address and adjust the plan.
- The Administrator and Director of Nursing will ensure the corrective action plan is implemented.
Resident Fall Due to Unattended Incontinence Care and Failure to Use Assistive Devices
Penalty
Summary
Staff failed to provide safe care to a resident with left-sided weakness and vascular dementia during incontinence care. The resident, who was cognitively intact but dependent on staff for all activities of daily living and required bed rails for mobility, was rolled onto her left side in bed and left unattended by a nursing assistant. The bed rails were not raised, and the bed was not locked at the time. While the nursing assistant left the bedside to retrieve a clean gown, the resident, unable to support herself due to her hemiplegia and hemiparesis, rolled off the bed and fell to the floor. As a result of the fall, the resident sustained a laceration to the bridge of her nose, facial bruising, and a fractured nasal bridge. She was assessed by nursing staff, and emergency services were called. The resident was transferred to the hospital, where she received medical treatment including glue for the laceration and pain management. Imaging confirmed the nasal fracture, but no other injuries were found. The resident was discharged back to the facility the same day. Interviews and documentation confirmed that the resident was left alone on her weaker side without the use of required assistive devices, and the bed was not secured. Staff involved acknowledged the oversight, and the incident was attributed to human error. The resident, staff, and therapy personnel all indicated that leaving a resident with significant mobility impairment unattended in such a position without proper safety measures directly contributed to the fall and resulting injuries.
Improper Dishware Storage and Inadequate Food Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to the cleaning, drying, and storage of dishware, as well as the labeling and dating of food items. During the initial kitchen tour, dishware that was considered ready for use was found stacked while still wet, with pooled water present in and around several metal serving bins and plastic bowls. Some dishware was also observed with food debris, sticky substances, and even dead insects present. Specifically, one metal serving bin had dried red food debris, two plastic bins had a brown sticky substance, and one dessert bowl contained two dead gnats in pooled water. Additionally, food storage practices were found to be lacking. Several opened boxes of frozen food items in the walk-in freezer, such as green beans, diced green peppers, French bread, cookie dough, and biscuit dough, were not labeled with dates. In the dry goods storage area, opened bottles of chocolate syrup and cereal bags were not labeled with opened or use-by dates. The walk-in cooler also contained a box of strawberries with no date. Interviews with the Dietary Manager and Administrator confirmed that the facility's expectation was for dishware to be thoroughly cleaned, dried, and stored properly, and for all food items to be labeled and dated when opened.
Failure to Provide Oxygen at Prescribed Flow Rate
Penalty
Summary
The facility failed to ensure that a resident with a myoneural disorder requiring continuous oxygen therapy received oxygen at the prescribed flow rate as ordered by the physician. The physician's order specified oxygen at 3 liters per minute (LPM) via nasal cannula continuously to relieve hypoxia. However, multiple observations over several days revealed that the resident's oxygen was set below the prescribed rate, ranging from 1.5 to 2 LPM on both the oxygen concentrator and portable oxygen tank. The resident was observed in various settings, including in bed and in a wheelchair, with the oxygen flow rate consistently set lower than ordered, although the resident was not in visible distress during these observations. Interviews with the resident confirmed that she did not adjust her own oxygen settings and relied on nursing staff for this task. Nursing assistants (NAs) and nurses provided conflicting accounts regarding responsibility for setting and adjusting the oxygen flow rate. Some NAs reported that they set the flow rate on portable tanks when transferring the resident, while others stated that only licensed nurses should perform this task. Nurses acknowledged that the flow rate should match the physician's order but admitted to not always checking the settings during their rounds. Leadership staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, all stated that only licensed nurses should set or adjust oxygen flow rates and that NAs should not be responsible for this task. Despite these expectations, the practice observed and described by staff interviews indicated that NAs were sometimes adjusting oxygen flow rates, leading to the resident not consistently receiving oxygen at the prescribed rate.
Failure to Maintain and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to maintain and post daily nurse staffing information as required, with missing records for 134 out of 385 days reviewed. Specifically, there were no available daily posted staffing sheets for the entire months of September through December 2024, and for multiple weekend days in January through April 2025. Record review confirmed these gaps, and staff interviews revealed that the scheduler, who began in January 2025, was unaware that staffing sheets needed to be completed on weekends and retained for 18 months. The scheduler also could not locate any staffing sheets for the months of September through December 2024. Further interviews with the DON and Administrator confirmed that the scheduler was responsible for completing and maintaining the daily posted staffing sheets, but there was no designated staff member to handle this task on weekends. The DON was aware of the requirement to complete and retain the sheets daily, but the process was not consistently followed, particularly on weekends and for several months, resulting in the deficiency.
Failure to Prevent Accident Due to Lack of Wheelchair Foot Pedals
Penalty
Summary
The facility failed to prevent an accident involving a resident with advanced Parkinson's disease who was being transported to the dining room in a wheelchair without foot pedals. The resident, who was unable to keep her feet up without assistance, had her foot drop, causing her shoe to fall off and become stuck under the wheelchair wheel. This led to the wheelchair stopping abruptly, resulting in the resident falling forward and hitting her head on the floor. The incident caused a large gash above her left eye and a small subarachnoid hemorrhage, requiring hospital treatment. The resident was admitted to the facility with diagnoses including Parkinson's disease, muscle weakness, and a history of falling. She was assessed as being dependent on staff for all activities of daily living and required a wheelchair for mobility. On the day of the incident, a nursing assistant was transporting the resident without foot pedals and asked her to hold her feet up. The assistant did not notice when the resident's foot dropped and her shoe fell off, leading to the accident. Interviews with staff revealed that the nursing assistant had seen the resident transported without foot pedals before and did not think to apply them. The nurse on duty responded to the incident by calling emergency services and providing first aid. The facility's Director of Nursing and Administrator were notified and began investigating the incident. The Director of Therapy confirmed that prior to the fall, there was no requirement for the resident to have foot pedals applied at all times, as her capability varied depending on her condition.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Morganton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grace Heights Health & Rehabilitation | 3.6 mi | ★★★★★ | 2 | 0 |
| College Pines Health And Rehabilitation | 4.6 mi | ★★★★★ | 2 | 0 |
| Magnolia Lane Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 11 | 0 |
| Shaire Nursing Center | 7.6 mi | ★★★★★ | 5 | 0 |
| Carolina Rehab Center Of Burke | 8 mi | ★★★★★ | 4 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.