Inspection Reports for Exeter Center
8 Hampton Rd, Exeter, NH 03833, United States, NH, 03833
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
25 residents
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication labeling, and food storage safety at Exeter Center.
Findings
The facility failed to accurately code pressure ulcer assessments for residents, improperly labeled an open injectable medication vial, and did not store food in accordance with professional standards, including missing dates and spoiled items in the kitchen.
Deficiencies (3)
Failure to correctly code pressure ulcer section M0300 on Minimum Data Set assessments for 2 of 15 residents reviewed.
Open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) without an open date or expiration date in medication refrigerator.
Food stored without proper labeling or dating, presence of spoiled cucumbers, uncovered cooked potatoes, and thawed meats stored beyond recommended timeframes.
Report Facts
Residents reviewed for MDS assessments: 15
Residents affected by pressure ulcer coding deficiency: 2
Medication rooms observed: 1
Kitchen observed: 1
Number of thawed chicken breasts: 7
Number of cucumbers in leaking case: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | MDS Coordinator / MDS Nurse | Confirmed incorrect coding of pressure ulcer assessments for Residents #20 and #54 |
| Staff G | Licensed Practical Nurse | Confirmed unlabeled multi-dose vial in medication room |
| Staff A | Dietary Cook | Confirmed food storage deficiencies in kitchen |
| Staff B | Dietary Manager | Confirmed food storage policies and deficiencies |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Date: May 30, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide appropriate treatment and care according to physician orders for bowel management, and insufficient nursing staff to meet residents' needs.
Complaint Details
The complaint investigation found substantiated issues with bowel management protocols not being followed for 2 residents, leading to hospitalization of one resident. Staffing shortages were also substantiated with multiple shifts lacking adequate Licensed Nursing Assistants (LNAs), causing delays in care and resident dissatisfaction.
Findings
The facility failed to ensure residents received treatment and care in accordance with professional standards for bowel management, resulting in hospitalization of a resident. Additionally, the facility failed to provide sufficient nursing staff to meet residents' needs during April and May 2024, leading to long wait times and inadequate care.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resulting in actual harm to residents related to bowel management.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Residents reviewed for bowel management: 4
Shifts with insufficient LNA staffing: 28
Unit census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Nurse Practitioner | Notified late about resident's bowel movements; stated treatment changes would have been made if notified. |
| Staff C | Registered Nurse | Did not track bowel movements separately from LNAs; documented based on LNA reports. |
| Staff A | Director of Nursing | Confirmed findings regarding staffing shortages. |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, food service safety, and medical record accuracy at Exeter Center.
Findings
The facility failed to follow physician orders for wound care related to a resident's fall, did not ensure proper hair restraints were worn by kitchen staff, and had inaccuracies in medical records for wound care documentation.
Deficiencies (3)
Failed to follow physician orders for wound care for 1 of 3 residents reviewed for falls (Resident #18).
Failed to prepare food in accordance with professional standards and failed to ensure staff wore proper hair restraints in the kitchen.
Failed to ensure medical records were accurate for 1 of 2 residents reviewed for pressure ulcers (Resident #43).
Report Facts
Residents reviewed for falls: 3
Total residents in final sample: 16
Residents reviewed for pressure ulcers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Confirmed no documentation and no order for dressings for Resident #18 and confirmed wound evaluation findings for Resident #43 |
| Staff E | Cook | Observed serving food without facial hair restraint and confirmed not wearing facial hair restraint |
| Staff A | Registered Nurse | Confirmed treatment had not been added to the Treatment Administration Record for Resident #43 |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 4
Date: Mar 22, 2023
Visit Reason
The inspection was conducted based on complaints regarding medication administration errors, improper storage of expired medications, failure to administer influenza vaccine after consent, and inadequate call light system in resident bathrooms and bathing areas.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration errors, expired medication storage, vaccination administration, and call light system functionality. Substantiation status is not explicitly stated.
Findings
The facility failed to follow physicians' orders for medication administration, improperly stored expired medications on medication carts, did not administer influenza vaccine to a consenting resident, and had a call light system that did not adequately alert staff for two residents in a census of 51.
Deficiencies (4)
Failed to follow physicians' orders for 1 out of 28 medication administrations observed (Resident #102).
Failed to ensure proper storage of expired medications for 2 of 2 medication carts observed (Residents #25 and #38).
Failed to ensure that a resident received an influenza vaccine after obtaining consent (Resident #25).
Failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance for 2 residents (Residents #6 and #26).
Report Facts
Medication administrations observed: 28
Residents in census: 51
Medication carts observed: 2
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Named in medication administration error finding. |
| Staff C | Registered Nurse | Named in expired medication storage finding. |
| Staff D | Licensed Practical Nurse | Named in expired medication storage and call light system findings. |
| Staff A | Director of Nursing | Confirmed influenza vaccine administration finding. |
| Staff E | Licensed Nursing Assistant | Interviewed regarding call light system functionality. |
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