Exeter Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Exeter, New Hampshire.
- Location
- 8 Hampton Road, Exeter, New Hampshire 03833
- CMS Provider Number
- 305064
- Inspections on file
- 17
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Exeter Center during CMS and state inspections, most recent first.
An LPN was observed storing an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) in the medication refrigerator without documenting the open date or expiration date, contrary to manufacturer instructions and facility policy requiring such labeling for product integrity.
Surveyors found that food items in the kitchen were not stored according to professional standards, with several items lacking proper labeling, dating, or covering, and some foods being kept beyond recommended timeframes. The facility's own policies and the FDA Food Code require proper storage, labeling, and timely use or disposal of food, but these procedures were not followed, as confirmed by dietary staff.
Two residents with documented Stage 2 pressure ulcers present on admission were incorrectly coded on their MDS assessments, with one not marked as having a pressure ulcer and the other not identified as having the ulcer on admission. These errors were confirmed by facility staff.
The facility failed to follow bowel management protocols for two residents, leading to one requiring hospitalization. A resident with hepatic failure and cirrhosis did not receive prescribed Lactulose, resulting in unresponsiveness and hospitalization. Another resident with cirrhosis did not meet bowel movement goals, and staff failed to notify the provider. Staff interviews revealed communication lapses in tracking bowel movements.
The facility failed to maintain adequate staffing levels, as outlined in their Facility Assessment, during April and May 2024. Interviews with staff and residents revealed that the shortage of LNAs led to long wait times for assistance, particularly during mealtimes and when residents required lifts. Residents reported waits of up to 45 minutes and instances of soiling themselves due to delayed responses. Staff expressed that the administration considered only the census, not the acuity of residents, when scheduling, leading to overworked LNAs and insufficient care.
The facility failed to ensure that staff were wearing proper hair restraints in the main kitchen. A cook was observed serving scrambled eggs without a facial hair restraint, despite having facial hair. The cook confirmed this practice, which is against the facility's policy and FDA food code requirements.
The facility failed to follow physician orders and document a resident's injury after a fall. An observation revealed a gauze border dressing on the resident's right elbow without a date, and there was no documentation or order for the dressing. Interviews confirmed the lack of documentation, violating the facility's policy on skin integrity and wound management.
The facility failed to ensure accurate medical records for a resident's wound care, with discrepancies in treatment documentation and wound location evaluations confirmed by staff.
Failure to Label Open Multi-Dose Injectable Medication
Penalty
Summary
During an observation in the Chase Unit medication room, an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) was found in the medication refrigerator without an open date or an open expiration date. This was confirmed by an LPN present at the time. Review of the manufacturer's instructions indicated that a vial in use for 30 days should be discarded, and the facility's own policy required multi-dose vials to be labeled with the date opened to ensure product integrity. The lack of labeling on the vial was not in accordance with both manufacturer instructions and facility policy.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen. Items found included a small dish of salad covered in plastic wrap without a preparation or use by date, a container of tuna fish labeled with a preparation date, a container of chicken salad with a preparation date, and a bowl of cooked potatoes that was uncovered and undated. Additionally, thawed chicken breasts, cucumbers that were leaking fluid and had black spots, and thawed sliced deli meats with dates indicating they had been pulled from the freezer well beyond recommended timeframes were found in the walk-in refrigerator. These findings were confirmed by the dietary cook during the survey. A review of the facility's food storage policies revealed requirements for all foods to be wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination. The policies also specified storage timeframes for ready-to-eat and raw foods. The FDA Food Code was also referenced, which outlines standards for date marking, storage, and discarding of foods to prevent contamination. The facility failed to follow these professional standards and its own policies, resulting in the cited deficiency.
Incorrect MDS Coding for Pressure Ulcers on Admission
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to pressure ulcers. For one resident, documentation showed a pressure area was present on admission, and the 5-day MDS assessment indicated one Stage 2 pressure ulcer. However, the section indicating whether the Stage 2 ulcer was present on admission was incorrectly coded as zero. The resident's care plan also confirmed the presence of a pressure area on the coccyx upon admission, and the MDS nurse acknowledged the coding error during an interview. For another resident, both the hospital discharge summary and the facility's admission note documented a Stage 2 pressure injury on the right heel at the time of admission. Despite this, the 5-day MDS assessment did not code the resident as having a pressure ulcer or being at risk, and the section for unhealed pressure ulcers was marked as zero. The MDS Coordinator confirmed in an interview that this was an incorrect coding, as the resident did have a Stage 2 pressure ulcer present on admission.
Failure in Bowel Management Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for bowel management. For one resident, the Medication Administration Record (MAR) indicated that the prescribed Lactulose was not administered as needed when the resident did not have the required three bowel movements daily. This oversight led to the resident becoming unresponsive and requiring hospitalization due to concerns of encephalopathy, as the resident had a history of hepatic failure and alcoholic cirrhosis. Another resident also did not receive the necessary bowel management as per the physician's orders. The MAR showed that the resident did not achieve the goal of three bowel movements on multiple days, and the staff failed to notify the provider as required. This resident had a diagnosis of alcoholic cirrhosis. Interviews with staff revealed a lack of communication and tracking of bowel movements, contributing to the failure in following the prescribed bowel management protocols.
Staffing Deficiency in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents during April and May 2024. The Facility Assessment outlined specific staffing levels required for direct care staff, including one nurse and two LNAs during the day and evening shifts, and one nurse and one LNA during the night shift. However, a review of the Daily Staffing Sheets revealed multiple instances where these staffing levels were not met, with significant shortages in LNA staffing across several shifts. This deficiency was confirmed by the Director of Nursing during an interview. Interviews with staff members highlighted the challenges faced due to inadequate staffing. Staff reported that LNAs were overworked, often unable to take breaks, and that nurses had to assist LNAs despite having their own responsibilities. The lack of sufficient LNAs led to long wait times for residents, particularly during mealtimes and when residents required assistance with lifts, which necessitated two staff members. Staff expressed that the administration seemed to consider only the census and not the acuity of residents when scheduling staff. Residents also reported negative experiences due to the staffing shortages. They described long wait times for assistance, with some residents experiencing waits of up to 45 minutes. One resident mentioned instances of soiling themselves due to delayed responses to call bells. Another resident expressed concerns about safety when being changed in bed by only one aide. The Resident Council meetings also highlighted chronic staffing issues, with reports of staff turnover exacerbating the problem. Overall, the deficiency in staffing levels significantly impacted the quality of care provided to residents.
Failure to Ensure Proper Hair Restraints in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety and did not ensure that staff were wearing proper hair restraints in the main kitchen. During an observation, a cook was seen serving scrambled eggs without wearing a facial hair restraint, despite having facial hair. The cook confirmed that he/she did not wear a facial hair restraint when serving food. The facility's policy requires all staff to have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. This policy aligns with the FDA food code, which mandates that food employees wear hair restraints to prevent hair from contacting exposed food and clean equipment.
Failure to Follow Physician Orders and Document Resident Injury
Penalty
Summary
The facility failed to follow physician orders for a resident who was reviewed for falls. An observation revealed that the resident had a gauze border dressing on their right elbow without a date. The resident indicated that the injury might have been a result of a recent fall. However, a review of the resident's orders, skin/wound assessments, change in condition report, treatment records, care plans, and progress notes showed no documentation of the right elbow injury. This indicates a lack of proper documentation and adherence to physician orders regarding the resident's care following the fall. Interviews with the Director of Nursing confirmed that there was no documentation or order for the dressings on the resident's right elbow. Additionally, the facility's policy on skin integrity and wound management requires nursing assistants to observe and report skin changes to the nurse, and for the nurse to evaluate and document any skin changes or wounds. The failure to document and follow up on the resident's injury represents a deficiency in meeting professional standards of quality care.
Inaccurate Medical Records for Wound Care
Penalty
Summary
The facility failed to ensure medical records were accurate for one resident reviewed for pressure ulcers. Specifically, a review of the resident's current orders revealed a wound care order dated 4/8/24 for the left posterior thigh, which was not documented in the April 2024 Treatment Administration Record (TAR). An interview with a Registered Nurse confirmed that the treatment had not been added to the TAR. Additionally, the resident's wound evaluations incorrectly listed the location as the rear right thigh instead of the left posterior thigh. The Director of Nursing confirmed these findings and the error in the wound evaluations.
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Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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