Inspection Reports for
Wolfeboro Bay Center

The visit was complaint-related, triggered by concerns about medication administration errors and pain management. The report documents substantiated findings of medication errors and failure to provide prescribed pain medication.

The facility failed to meet professional standards in medication administration for 1 of 4 nursing staff observed and 1 of 2 residents reviewed for pain management. Medication errors were frequent, including failure to rinse mouth after inhaler use, unavailability of prescribed pain medication, and a high medication error rate of 31.43%.

The complaint investigation focused on Resident #111's decline on 8/12/23, where staff failed to promptly assess and intervene after noticing changes in condition. The resident was transferred to the hospital and later died. The investigation also included staffing shortages and food safety concerns.

The facility failed to ensure timely assessment and intervention for Resident #111's change in condition, resulting in hospitalization and death. Additionally, the facility did not provide sufficient nursing staff to meet residents' needs on multiple days, leading to delayed responses to call bells. The facility also failed to monitor food temperatures properly, with no documentation of meal temperature monitoring since August 2023.

The complaint investigation was substantiated with findings of failure to timely address a resident's change in condition resulting in hospitalization and death, failure to provide required transfer/discharge notices, failure to ensure physician visits, staffing shortages, incomplete nurse aide reviews, medication regimen issues, medication and food storage monitoring failures, incomplete resident records, and inadequate nurse aide training.

The facility was found deficient in multiple areas including failure to timely assess and intervene for a resident's change in condition resulting in hospitalization and death, failure to provide required written notices of transfer/discharge, failure to ensure physician face-to-face visits at required intervals, insufficient nursing assistant staffing leading to delayed care, lack of annual performance reviews for nurse aides, failure to act on medication regimen review recommendations, inadequate monitoring of medication refrigerator temperatures, failure to monitor food temperatures, incomplete and inaccurate resident records, and failure to provide required nurse aide in-service training.

The complaint investigation found that Resident #1 was unable to access petty cash when needed, particularly when the staff person responsible was not working, leading to frustration and inability to purchase cigarettes. The investigation also revealed that the MDS assessments for Residents #1, #2, #3, and #4 were incorrectly coded as non-smokers despite evidence they were smokers. Interviews with staff confirmed the coding errors.

The facility failed to ensure that residents had access to their funds on an ongoing basis for 1 of 4 residents reviewed, causing frustration and inability to purchase cigarettes. Additionally, the facility failed to accurately reflect the smoking status of 4 residents in their MDS assessments, with all four residents incorrectly coded as non-smokers despite evidence and interviews confirming they were smokers.

The visit was complaint-related involving allegations of abuse and medication misappropriation for Residents #1 and #5. The facility failed to fully report investigation results and failed to implement corrective actions for the misappropriation.

The facility failed to timely report an alleged medication misappropriation and did not fully report the results of abuse investigations to the State Survey Agency. Additionally, the facility failed to implement corrective actions regarding narcotic management and failed to maintain proper narcotic inventory controls and medication security.

The facility was found deficient in multiple areas including failure to provide Medicare Non-Coverage notices to residents, privacy breaches of electronic medical records, unsafe and unsanitary resident environment, failure to address pharmacist medication recommendations, improper medication storage and labeling, inadequate Quality Assurance committee attendance, lack of antibiotic stewardship monitoring, absence of a qualified Infection Preventionist, and failure to maintain patient care equipment safely.