Exeter Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards for medication administration for 1 of 5 residents observed for medication administration, follow physician's order for 1 of 5 residents reviewed for unnecessary medications, and obtain wound dressing orders for 1 of 1 resident reviewed for skin condition. (Resident identifiers are #8, #13, and #45.)Findings include:[NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier.Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. Resident #13 Observation on 4/28/26 at approximately 9:37 a.m. of Resident #13 revealed that Resident #13's was in bed and his/her right hand had red drainage (blood-like) on the fingers. Further observation revealed that the red drainage (blood-like) came from an area on his/her right medial leg and that there was…

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 observation, interview, and record review, the facility failed to ensure that medication error rate remained below 5 percent for 4 of 34 opportunities of medication administration observed. (Resident identifiers are #41 and #46.)Findings include: Resident #46 Observation on 4/29/26 at approximately 8:45 a.m. with Staff A (Licensed Practical Nurse) during Resident #46's medication administration revealed that Staff A prepared Resident #46' scheduled morning medication and placed the oral medications in a medication cup that included one Over-The-Counter (OTC) Calcium with Vitamin D 600 mg-200 unit tablet, one Metoprolol Tartrate 12.5 milligram (mg) dose tablet, and one Digoxin 125 microgram (mcg) tablet. After preparing the medications, Staff A brought the medication cup, a 4% Lidocaine patch, and a cup of water to Resident #46's room. Staff A then obtained Resident #46's blood pressure and heart rate using a wrist blood pressure monitor, which showed a blood pressure of 117/65 and a heart rate of 59.…

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 observation, interview, and record review, the facility failed to obtain laboratory services as ordered for 1 of 1 residents reviewed for anticoagulant in a final sample of 18 residents. (Resident identifier is #5.)Findings include:Review on 4/28/26 of Resident #5's medical record revealed a physician's orders for an International Normalized Ratio (INR) to be drawn on 4/27/26. Further review of the medical record under laboratory (lab) results revealed that there was no INR laboratory report on 4/27/26.Review on 4/29/26 of Resident #5's After-Hours Telehealth Consult note, dated 4/26/26, revealed that Resident #5's INR was subtherapeutic from lab results for 4/26/26 and that the provider ordered a repeat INR for 4/27/26.Interview on 4/29/26 at approximately 1:42 p.m. with Staff A (Licensed Practical Nurse) confirmed the above findings and that the INR was not completed as ordered.

Based on observation, interview, and record review, the facility failed to follow infection control policies and professional standards for hand hygiene, disinfection of equipment, enhanced barrier precaution (EBP), and urinary catheter maintenance for 1 of 1 resident reviewed for Transmission Based Precaution (TBP) and 2 of 2 residents reviewed for urinary catheter. (Resident identifiers are #8, #13, and #41.)Findings inclcude:Resident #8 Observation on 4/28/26 at approximately 9:48 a.m. of Resident #8 in his/her bed revealed that there was an urinary catheter bag on the floor next to the bed. Observation on 4/30/26 at approximately 8:19 a.m. of Resident #8 in his/her bed revealed that the urinary catheter bag was touching the edge of cushioned fall mat that was on the floor by Resident #8's bed. Interview on 4/30/26 at approximately 8:20 a.m. with Staff D (Licensed Nursing Assistant (LNA)) confirmed the above findings and further revealed that the urinary catheter bag should not be touching the fall mat or the floor. Observation on 4/30/26 at approximately 8:45 a.m. of Resident #8…

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 observation, interview, and record review, it was determined that the facility failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 1 medication room observed. Findings Include: Observation on 4/21/25 at approximately 8:30 a.m. with Staff G (Licensed Practical Nurse) in the Chase Unit Medication Room revealed an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) without an open date or an open expiration date in the medication refrigerator. Interview on 4/21/25 at approximately 8:30 a.m. of Staff G confirmed the above findings. Review on 4/21/25 of the Tuberculin Purified Protein Derivative (Mantoux) manufacturer instructions revealed A vial .which has been entered and in use for 30 days should be discarded . Review on 4/21/25 of the facility policy titled Medications and Medication Labels dated 1/25 revealed PROCEDURES .2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications .Nursing staff should document the date opened on…

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 observation, interview and policy review, it was determined that the facility failed to ensure that food is stored in accordance with professional standards for food service safety for 1 out of 1 kitchen observed. Finding Include: Observation on 4/21/25 at approximately 8:20 a.m. in the kitchen with Staff A (Dietary Cook) revealed the following: A small dish of salad covered in plastic wrap without a preparation or use by date in the refrigerator; a clear container with tuna fish covered with plastic wrap, labeled tuna fish with a date of 4/14 (preparation date) in the refrigerator; a clear container with chicken salad covered in plastic wrap, labeled chicken salad with date of 4/13 (preparation date) in the refrigerator; a stainless steel bowl containing cubes of cooked potatoes uncovered without a preparation date; a plastic bag containing 7 thawed chicken breasts dated 4/15 (date pulled from the freezer) in the walk-in refrigerator; a case of cucumbers with 6 cucumbers that is leaking fluid, had black spots, and soft to touch in the walk-in refrigerator; a stainless…

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 interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs in April 2024 and May 2024. Findings include: Review on 5/30/24 of the Facility Assessment revealed Consider the overall needs of your resident population based on your Facility Assessment, MDS [Minimum Data Set], Resident Population Profile and any additional source when indicating the number, average, range or ratio needed. Further review of the Facility Assessment revealed the following staffing levels for direct care staff: [NAME] - 1 Nurse [Registered Nurse (RN)/Licensed Practical Nurse (LPN)], 2 LNAs [Licensed Nurse Aide] day and eves, 1 Nurse, 1 LNA nights. [NAME] - 1 Nurse, 2 LNAs days and eves, 1 Nurse, 1 LNA nights. Review on 5/30/24 of the Daily Staffing Sheets from April 23, 2024 to May 30, 2024, revealed the following 6 shifts (over 4 days) in April and 22 shifts (over 16 days) in May with LNA/Certified Nursing Assistant (CNA) staffing that does not meet levels…

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 observation and interview, it was determined that the facility failed to prepare food in accordance with professional standards for food service safety and failed to ensure that staff were wearing proper hair restraints in the main kitchen. Findings include: Observation on 4/23/24 at 08:20 a.m., during the initial tour of the kitchen, revealed Staff E (Cook) serving scrambled eggs onto plates. Further observation revealed Staff E had facial hair and was not wearing a facial hair restraint. Interview on 04/23/24 at approximately 8:25 a.m. with Staff E confirmed that he/she did not wear a facial hair restraints when serving food. Review on 04/25/24 of the facility policy titled Staff Attire undated, revealed Procedures .1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review on 04/25/24 of Chapter 2 of the FDA (Food and Drug Administration) food code 2022 Management and Personnel document section 2-402 Hair Restraints 2-402.11 Effectiveness (A) Except as provided in ¶ (B) of this section, FOOD…

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.