Celebration Villa of Exeter.

“Resident assessment did not include a response to "Sensory Limitations, Section F, 1-6" on page 6 of the Home's approved Assessment Form.”

“A resident in the secure dementia unit refused showering assistance, and staff person A responded by saying 'We can do this the easy way or the hard way.' After the resident chose 'the hard way,' staff person A poured a cup of soapy water over the resident's head, failing to treat the resident with dignity and respect.”

“Two resident bedrooms did not have operable lighting at the bedside. One room had a lamp with a blown light bulb, and another room had a lamp plugged into an outlet controlled by a wall switch that was turned off, making the light inaccessible from the bed.”

“A resident had a prescribed as-needed medication ordered every six hours, but the medication was not available in the medication cart for administration. Upon review, the medication had expired and been removed from the cart, and the pharmacy had not yet obtained authorization for a new prescription.”

“The facility failed to provide immediate access to requested medication administration training records upon departmental request. Records were requested at 10:15 a.m., 12:00 p.m., and 3:00 p.m., but were not provided until approximately 3:30 p.m. due to a misunderstanding of the request.”

“The facility failed to report two incidents within the required 24-hour timeframe. One resident death incident was not reported until 4/3/25, and one smoke detector activation and evacuation event was not reported until 5/12/25.”

“Resident records were left unsecured and accessible to unauthorized persons. At approximately 9:40 a.m., the computer on the medication cart was unlocked and unattended with access to resident medical records. At approximately 1:30 p.m., two white binders with resident information were left on top of the medication cart, unlocked, unattended and accessible.”

“Two staff members were hired without required FBI fingerprint background checks. Staff person A, hired without having lived in Pennsylvania for the past 2 years, did not have an FBI fingerprint background check completed. Staff person B, hired without having lived in Pennsylvania for the past 2 years, did not have an FBI fingerprint background check completed prior to employment.”

“Resident #1's Resident Assessment and Support Plan did not include documentation of the specific need for the Halo Safety Ring device, intended use, risks, resident's ability to use it safely, the specific device details, or FDA guideline compliance requirements.”

“Direct care staff person A was hired without documentation of a U.S. high school diploma or GED. The staff member had a high school diploma from a non-U.S. country, which was not accepted as meeting the qualification requirement.”

“Refrigerators in the 200 commons and 300 commons areas contained unlabeled and undated food items, including a covered cup with unknown liquid and a bag with creamy white substance, in violation of leftover food labeling requirements.”

“The ice cream freezer temperature was 15 degrees Fahrenheit, exceeding the maximum allowable temperature of 0 degrees Fahrenheit for frozen food storage.”

“A walker was observed blocking the emergency exit to the courtyard, and the exit door in the 200 hallway would not open without excessive force, both preventing immediate egress in case of emergency.”

“A dose of PRN morphine was administered to Resident #2 but was not documented on the Medication Administration Record (MAR) at the time of administration.”

“A resident's Medical Evaluation (DME) did not include an indication of mobility need, with the section left blank. The regulation requires documentation of mobility assessment within 60 days prior to admission or within 30 days after admission.”

“The facility failed to follow a prescriber's orders for medication administration. A resident with orders for medication three times daily with meals and a sliding scale order did not receive the medication as ordered on a specified date, and blood sugar was not tested in the morning as required.”

“Medical evaluation documentation for residents in the secure dementia care unit did not include a diagnosis of Alzheimer's disease or other dementia as required. The forms indicated diagnoses of cognitive impairment or other forms of dementia, but did not use the specific terms 'dementia' or 'Alzheimer's disease' required by regulation.”

“Staff person A did not have annual training in the required topic of Resident Rights for the 2022 training year.”

“In the main kitchen's freezer there was a plastic bag of frozen chicken that was not sealed properly.”

“Resident #1 requires daily monitoring. The 8am reading was documented incorrectly on the Medication Administration Record.”

“Resident #2 has an order for medication to be held based on specific parameters. Although the medication was held as required, the med tech failed to document this action accurately on the Medication Administration Record.”