Inspection Reports for
Laconia Rehabilitation Center
175 BLUEBERRY LANE, LACONIA, NH, 03246
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 2
Date: May 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to timely reporting of injuries of unknown origin and the adequacy of care plan meetings for residents.
Findings
The facility failed to timely report an injury of unknown source for one resident and failed to hold routine interdisciplinary care plan meetings and revise care plans for 11 of 24 residents reviewed.
Deficiencies (2)
Failed to timely report an injury of unknown source to the State Survey Agency for 1 of 2 residents reviewed for accidents.
Failed to develop and hold routine interdisciplinary care plan meetings and revise care plans for 11 of 24 residents reviewed.
Report Facts
Residents reviewed for accidents: 24
Residents reviewed for care planning: 24
Residents affected by care plan deficiencies: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding failure to report injury of unknown source and care plan meeting documentation | |
| Regional Nurse | Interviewed confirming no evidence of quarterly care plan meetings after 11/27/24 | |
| Unit Manager | Interviewed confirming no documentation of care plan meeting for Resident #94 prior to 4/23/25 | |
| Registered Nurse | Interviewed regarding Resident #85's eating behaviors and care plan deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services regulations, including the management and storage of controlled drugs and medications.
Findings
The facility failed to maintain accurate records of receipt and disposition of controlled drugs for 3 of 7 residents reviewed, and failed to maintain locked storage of medications in 1 of 3 medication carts. These deficiencies were confirmed through record reviews, observations, and staff interviews.
Deficiencies (2)
Failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable accurate reconciliation for 3 residents.
Failed to maintain locked storage of medications and biologicals in 1 of 3 medication carts.
Report Facts
Residents reviewed for controlled drugs: 7
Residents affected by controlled drug record deficiency: 3
Medication carts observed: 3
Medication carts with locked storage deficiency: 1
Tablets discrepancy example Resident #7 Diazepam: 1
Tablets discrepancy example Resident #6 Clonazepam: 1
Incorrect count entries Resident #2 Oxycodone: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Staff A confirmed medication count discrepancies and unlocked medication cart | |
| Licensed Practice Nurse | Staff C confirmed medication count discrepancy and failure to document administration | |
| Director of Nursing | Staff B confirmed medication record discrepancies |
Inspection Report
Deficiencies: 3
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, activity provision, and infection prevention and control practices at Laconia Rehabilitation Center.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments for residents, providing activities that meet residents' needs and preferences, and maintaining proper infection control practices during wound care, specifically the failure to disinfect scissors between dressing changes.
Deficiencies (3)
Failure to ensure the Minimum Data Set (MDS) assessment accurately reflected residents' status for 3 of 23 residents reviewed.
Failure to provide activities to support residents based on their choices and care plans for 1 of 1 resident reviewed for activities.
Failure to maintain infection control practices in regards to cleaning equipment during wound care in 1 of 1 observations of pressure ulcer care.
Report Facts
Residents reviewed for MDS: 23
Residents with inaccurate MDS: 3
Residents reviewed for activities: 23
Residents with activity deficiencies: 1
Residents observed for wound care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Reimbursement Coordinator | Confirmed findings related to inaccurate MDS assessments |
| Staff F | Director of Activities | Confirmed findings related to failure to provide activities per resident preferences |
| Staff G | Activity Aid | Confirmed not asking Resident #106 to attend live music activity |
| Staff H | Licensed Nursing Assistant | Confirmed Resident #106 was not asked to attend group activities |
| Staff B | Licensed Practical Nurse | Observed and confirmed failure to disinfect scissors during wound care |
| Staff D | Director of Nursing | Confirmed expectation that scissors be cleaned between dressing changes |
Inspection Report
Deficiencies: 1
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety and accident prevention protocols following an incident involving a resident who was injured during transportation in a facility wheelchair van.
Findings
The facility failed to properly assess Resident #1 after a fall during transportation, resulting in actual harm with multiple injuries. The investigation revealed inadequate use of safety restraints and delayed emergency response contrary to facility policies.
Deficiencies (1)
Failure to properly assess Resident #1 after a fall during transportation in the facility van.
Report Facts
New diagnoses due to van incident: 7
BIMS score: 15
Anticoagulant dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unit Clerk/Scheduler | Received call from Staff D about incident and directed return to facility. |
| Staff B | Nurse Practitioner | Notified upon Resident #1's return and sent resident to hospital for evaluation. |
| Staff C | Licensed Practical Nurse | Notified on-call provider and obtained hospital evaluation order for Resident #1. |
| Staff D | Wheelchair Van Driver | Transported Resident #1 during incident, failed to use shoulder belt, and called facility after incident. |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to pressure ulcer care and medication administration in the facility.
Findings
The facility failed to ensure weekly wound assessments with proper measurements and descriptions for 2 of 5 residents with pressure ulcers, and failed to prevent a significant medication error for 1 of 5 residents reviewed.
Deficiencies (2)
Failed to ensure residents with pressure ulcers had documentation of weekly assessments containing measurements and descriptions for 2 of 5 residents reviewed.
Failed to prevent a significant medication error for 1 of 5 residents reviewed for medication errors.
Report Facts
Weeks missing wound documentation: 8
Weeks missing wound documentation: 2
Residents reviewed for pressure ulcers: 5
Residents reviewed for medication errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Confirmed missing wound documentation for Residents #2 and #3 |
| Staff A | Registered Nurse | Discontinued medication order without physician's order |
| Staff C | Nurse Practitioner | Documented progress note revealing medication order details for Resident #1 |
Inspection Report
Routine
Deficiencies: 11
Date: May 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, physician visits, equipment maintenance, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to assess residents' ability to self-administer medications, failure to follow grievance policies, incomplete care plans for residents with PTSD, failure to update care plans after falls and medication changes, failure to follow physician orders for weights and medication administration times, failure to identify causes of resident falls, ineffective pain management, failure to ensure required physician visits, improper medication labeling and storage, unsanitary ice machines, and unclean oxygen equipment.
Deficiencies (11)
Failed to assess a resident's ability to self-administer medications.
Failed to follow grievance policy for prompt resolution of missing items.
Failed to develop comprehensive care plans addressing PTSD and discharge planning.
Failed to update care plans timely for falls and psychotropic medication side effects.
Failed to follow physician orders for resident weights and medication administration times.
Failed to identify causes of resident falls to prevent future accidents.
Failed to ensure effective pain management for a resident.
Failed to ensure residents were seen by physicians at required intervals.
Failed to ensure medications were labeled with open/use by dates and expired medications removed.
Failed to maintain ice machines in sanitary condition.
Failed to maintain oxygen equipment (filters and tubing) in clean and sanitary condition.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 4
Falls: 11
Medication doses administered: 22
Medication doses administered: 30
Medication doses administered: 18
Medication doses administered: 23
Physician visits overdue: 5
Medication carts observed: 3
Ice machines observed: 2
Residents with oxygen equipment issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Licensed Practical Nurse | Confirmed medication on Resident #21's over-bed table without physician order |
| Staff A | Unit Manager | Aware of missing outfit grievance for Resident #58 |
| Staff B | Director of Social Services | Confirmed discharge care plan missing for Resident #103 |
| Staff N | Unit Manager | Confirmed no PTSD triggers documented in Resident #29's care plan |
| Staff D | Director of Nursing | Confirmed care plan updates missing for Residents #3 and #55 |
| Staff C | Nurse Practitioner | Unaware of amount of pain medication administered to Resident #112 |
| Staff G | Registered Nurse | Confirmed expired medication on Opechee Unit medication cart |
| Staff H | Registered Nurse | Confirmed expired medication on Winnisquam Unit medication cart |
| Staff F | Licensed Practical Nurse | Confirmed expired and unlabeled medications on Lakeport Unit medication cart |
| Staff I | Cook | Confirmed unsanitary ice scoop holder in Main Kitchen |
| Staff J | Maintenance | Confirmed does not clean ice scoop holder or ice machine |
| Staff M | Licensed Nursing Assistant | Confirmed unclean oxygen filter and tubing for Residents #71 and #98 |
| Staff K | Administrator | Revealed facility not tracking physician visits for compliance |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 17, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control practices during a COVID-19 outbreak, including staff adherence to PPE use and hand hygiene, and to evaluate the facility's reporting of COVID-19 cases to residents' representatives and families.
Findings
The facility failed to ensure staff consistently wore appropriate PPE, including eye protection, and properly performed hand hygiene during a COVID-19 outbreak across multiple units. Additionally, the facility did not notify residents' representatives and families by 5:00 p.m. the next calendar day following confirmed COVID-19 infections on several dates.
Deficiencies (2)
Failure to ensure staff wore appropriate PPE (N95 mask and eye protection) and used proper hand hygiene during a COVID-19 outbreak on 4 out of 6 units observed.
Failure to report COVID-19 data to residents' representatives and families by 5:00 p.m. the next calendar day following confirmed infections.
Report Facts
Confirmed positive COVID-19 cases: 3
Confirmed positive COVID-19 cases: 3
Confirmed positive COVID-19 cases: 3
Confirmed positive COVID-19 cases: 4
Confirmed positive COVID-19 cases: 6
Confirmed positive COVID-19 cases: 9
Confirmed positive COVID-19 cases: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nurses | Interviewed regarding facility policy on PPE use and COVID-19 outbreak |
| Staff C | Infection Preventionist | Interviewed and observed staff PPE use and infection control practices during outbreak |
| Staff D | Housekeeper | Observed not wearing eye protection and improper doffing of PPE |
| Staff F | Medication Nursing Assistant | Observed not wearing eye protection while exiting resident room |
| Staff G | Licensed Nursing Assistant | Observed handling trash without gloves and not performing hand hygiene |
| Staff I | Housekeeper | Observed not wearing eye protection while cleaning resident bathroom |
| Staff A | Administrator | Interviewed regarding notification of residents' representatives and families about COVID-19 cases |
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