Exeter Center

In the surveyor’s words

From the most serious findings on record at Exeter Center, in the surveyor’s own words.

• Actual harm, isolatedF684May 30, 2024

  Based on interview and record review, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 out of 4 residents reviewed for bowel management. A resident required hospitalization when his/her ordered bowel protocol was not followed (Resident Identifiers are #1 and #2). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. […]

• No harm, potential for more than minimal, patternF725May 30, 2024

  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. […]

• No harm, potential for more than minimal, patternF761May 5, 2022

  Based on observation, interview, record review, manufacturer's instruction review, and policy review, it was determined that the facility failed to label opened medications with an opening date/open expiration date and failed to discard expired medications on 1 out of 3 medication carts, 1 out of 2 medication rooms, and 1 out of 1 refrigerator observed. Findings include: [NAME] Unit Observation on 5/4/22 at approximately 12:24 p.m. of the medication cart on [NAME] unit named Front revealed the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #10's [MEDICATION(S)] Solution, date of opening 3/21/22, use by date 4/18/22. Resident #25's Wixela inhaler, no date of opening, no use by date. […]

• No harm, potential for more than minimal, isolatedF658Apr 30, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF759Apr 30, 2026

  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. […]