Riverwoods at Exeter

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 2, 2021

  Based on interview and medical record review, it was determined that the facility failed to employ interventions for dysphagia that resulted in actual harm that is not immediate in which the resident was hospitalized for aspiration pneumonia for 1 resident out of a final sample size of 16 residents. (Resident identifier is #9.) Findings include: Review on 4/2/21 of Resident #9's diet order with start date 1/12/21 revealed a diet of Puree (all solid foods), extra side of gravys and sauces with special instruction to discontinue lip plate and resident to be assisted with all meals and no sandwiches. Review on 4/2/21 of Resident #9's Nursing to Rehab Communication form dated 1/17/21 revealed that Resident #9 has been recently coughing with thin liquids. […]

• No harm, potential for more than minimal, widespreadF880Mar 18, 2026

  Based on interview, and record review, the facility failed to implement water management control measures, potentially exposing a census of 3 residents to waterborne pathogens. Findings include:Review on 3/18/26 of the facility Water Management Plan for Legionella Control, reviewed on 9/26/25, revealed .Protocol for Flushing Unoccupied Resident Rooms and Daily Use Outlets: Maximum number of days a resident room is allowed to be vacant without action: 3 days. Protocols for resident rooms recently vacated: Open every fixture in room on maximum hot setting for 1 minute. Open every fixture in room on maximum cold setting for 1 minute. Flush toilet times 1. Clean and disinfect faucets, showerheads, and jets. Document activity. […]

• No harm, potential for more than minimal, patternF756Feb 24, 2023

  Based on interview and record review, it was determined that the facility failed to ensure that the irregularities identified by the pharmacist during the monthly review were documented in the residents medical record for 3 out of 5 residents reviewed for unnecessary medications (Resident Identifiers are #4, #6, and #9). Findings include: Resident #9: Review on 2/24/23 of Resident #9's medical record revealed a progress note dated 12/27/22 documenting that a medication regimen review was performed with one new irregularity found. Further review revealed no pharmacy consultation report to identify the irregularities from 12/27/22. Interview on 2/23/23 at approximately 2:00 p.m. […]

• No harm, potential for more than minimal, patternF881Feb 24, 2023

  Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to tracking of antibiotics prescribed and the appropriate use of antibiotics for 3 out of 3 months reviewed for antibiotic use (Resident identifiers are #5, #11, #12, #21). Findings include: Review on 2/24/23 of the facility infection surveillance line list for December 2022 through February 2023 revealed the following: - December 2022 - no entries for antibiotic use; - January 2023 - Resident #5 was treated for a urinary tract infection with antibiotics from 1/4/23 through 1/11/23, McGeers Criteria was not met as urgency and pain were only symptoms and the urinalysis obtained was negative with no culture and sensitivity completed; - February 2023 - no entries for… […]

• No harm, potential for more than minimal, patternF812Apr 19, 2022

  Based on observation and interview, the facility failed to maintain the dishwasher rinse temperature to manufacturer's instructions to ensure sanitary conditions in 1 of 2 kitchens observed. Findings include: Observation on 4/18/22 at approximately 9:20 a.m. of dishwasher in main kitchen revealed a rinse cycle temperature reading of 170°F (degrees Fahrenheit). Interview on 4/18/22 at approximately 9:22 a.m. with Staff A (Kitchen Operations Manager) confirmed above findings. Review on 4/18/22 of The Ridge-Main Dish Machine Log revealed .all items run through the machine .a final rinse temp of at least 180° . […]