Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Exeter Center during CMS and state inspections, most recent first.
Medication administration and wound care deficiencies were identified for multiple residents. An LPN gave a medication via G-tube without verifying tube placement or patency, an opioid was administered outside the ordered pain parameters, and a resident with a bleeding leg wound and a history of skin picking had no documented wound dressing order despite the open area being observed and confirmed by staff.
Medication administration errors exceeded the allowed rate when an LPN gave a resident morning meds despite hold parameters tied to BP and HR, and an RN documented a second resident’s meds in the EMAR before obtaining cetirizine. The observed errors, along with additional medication administration discrepancies, resulted in an 11.76% error rate.
A resident receiving anticoagulant monitoring had an INR ordered as a repeat test after a subtherapeutic result, but the lab was not completed as ordered. Record review showed no INR report for the ordered draw, and an LPN confirmed the test was not done.
Infection control practices were not followed for a resident with a urinary catheter, a resident on EBP, and a resident on contact precautions for Cryptosporidium. A catheter bag was observed on the floor and touching a fall mat, staff repositioned a resident on EBP while wearing gloves only instead of gown and gloves, and staff caring for the resident on contact precautions used ABHR instead of soap and water, carried a blood draw case out of the room without disinfecting it, and disinfected a vital signs monitor with an inappropriate wipe after leaving the room.
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.
Medication Administration and Wound Care Deficiencies
Penalty
Summary
The facility failed to follow professional standards for medication administration for a resident with a gastrostomy tube. During observation, an LPN flushed the resident’s G-tube with water, administered 60 mL of Lactulose mixed with water, and then completed a post-medication water flush without first checking or verifying tube placement or patency. The LPN later confirmed that the G-tube placement and patency were not checked before the medication was given. The resident’s MAR showed an order for Lactulose 10 gm/15 mL, 60 mL via G-tube four times daily, and the care plan directed staff to check patency and placement daily and before administering feedings and medications. The facility also failed to follow the physician’s order for an opioid medication for a resident receiving pain management. The resident had an order for Oxycodone HCl 5 mg by mouth every 4 hours as needed for pain level 8-10 for 14 days. Review of the MAR showed the medication was administered on multiple occasions when the documented pain levels were below the ordered range, including pain levels of 4, 7, 3, 6, and 5. The DON confirmed these findings during interview. In addition, the facility failed to obtain a wound dressing order for a resident with an open area on the right medial leg. Observation showed red, blood-like drainage on the resident’s fingers and from the right medial leg, with a dressing peeled back over the area. Staff confirmed the resident was actively bleeding and had a history of skin picking. The medical record showed a diagnosis of excoriation and a care plan for risk of picking with wound care as ordered, but there was no wound dressing order documented for the leg wound. Staff interviews confirmed the wound was not documented in the record, the provider had not been notified for dressing orders, and the facility policy required newly identified skin or wound impairments to be documented and the physician or APP notified.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with 4 of 34 observed medication administration opportunities not completed in accordance with physician orders, resulting in an error rate of 11.76 percent. During observation of Resident #46’s morning medication pass, a LPN prepared and administered oral medications including calcium with vitamin D, metoprolol tartrate 12.5 mg, and digoxin 125 mcg, along with a lidocaine patch. The resident’s blood pressure was 117/65 and heart rate was 59 at the time of administration. The EMAR showed orders for calcium with vitamin D 600-400 mg-unit daily, digoxin 125 mcg by mouth on Monday, Wednesday, and Saturday with a hold parameter for heart rate less than 60, and metoprolol tartrate 12.5 mg by mouth every morning and at bedtime with hold parameters for SBP less than 100 mmHg and heart rate less than 60. Staff later confirmed the metoprolol order and its hold parameters were to be interpreted based on both blood pressure and heart rate values. During observation of Resident #41’s medication pass, an RN prepared the morning medications and documented administration in the EMAR before obtaining the cetirizine HCl 10 mg tablet. The RN locked the medication cart and proceeded to the resident’s room without first placing the cetirizine in the medication cup. The RN later confirmed that the cetirizine tablet had not been obtained before clicking yes and completing the EMAR documentation for the morning medications, including cetirizine. The facility policy stated that medications are to be administered in accordance with written prescriber orders, and the cited standard emphasized verifying each medication against the order and not giving a medication until the seven rights of medication administration can be followed.
Missed INR Lab Order for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one resident who was being monitored for anticoagulant therapy. Resident #5 had a physician order for an INR to be drawn on 4/27/26, but review of the medical record showed no INR laboratory report for that date. An After-Hours Telehealth Consult note dated 4/26/26 documented that the resident’s INR was subtherapeutic based on lab results from 4/26/26, and the provider ordered a repeat INR for 4/27/26. During interview on 4/29/26, an LPN confirmed that the INR was not completed as ordered.
Infection Control Failures with Catheter Care, EBP, and Contact Precautions
Penalty
Summary
The facility failed to follow infection control policies and professional standards for hand hygiene, disinfection of equipment, enhanced barrier precautions, and urinary catheter maintenance for residents on transmission-based precautions and residents with urinary catheters. One resident with an indwelling urinary catheter was observed with the catheter bag on the floor next to the bed and later touching the edge of a cushioned fall mat on the floor. Staff confirmed that the bag should not be touching the fall mat or the floor, and CDC guidance reviewed in the record stated that the collecting bag should be kept below the level of the bladder and not rest on the floor. A second resident had a physician’s order for a urinary catheter and a care plan that included enhanced barrier precautions. A sign outside the room indicated gown and gloves were required for high-contact activities, but two staff entered the room and repositioned the resident while wearing gloves only and no gown. Staff later confirmed that the resident was on EBP and that repositioning in bed required both gown and gloves. A third resident had contact precautions for acute infection and a positive Cryptosporidium antigen. Staff entered the room wearing gloves and a mask, later donned a gown, and then removed PPE and performed hand hygiene with alcohol-based hand rub before exiting while carrying a blood draw supply case without disinfecting it. Another staff member entered the room for medication administration and vital signs, wore gown and gloves, then exited with the vital signs monitor and disinfected it afterward with CaviWipes1. The infection preventionist stated that soap and water was the correct hand hygiene for Cryptosporidium and that CaviWipes1 was not an appropriate disinfectant for the monitor; the facility policy and CDC guidance reviewed in the record addressed contact precautions, gown and glove use, soap-and-water handwashing for Cryptosporidium, and appropriate disinfection of equipment.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 337 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Exeter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverwoods At Exeter | 3.7 mi | ★★★★★ | 2 | 0 |
| Oceanside Skilled Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 6 | 0 |
| Webster At Rye | 6.8 mi | ★★★★★ | 14 | 0 |
| Rockingham County Nursing Home | 7.5 mi | ★★★★★ | 10 | 0 |
| Mill Town Health And Rehabilitation | 8.4 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Exeter Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.