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 Wolfeboro Bay Center during CMS and state inspections, most recent first.
A resident with vascular dementia and agitation had a PRN Olanzapine order written for 60 days, and the resident received multiple PRN doses while the order remained active beyond the 14-day limit. A med regimen review noted the order exceeded CMS guidance, the prescriber disagreed, and staff confirmed the order was still in place despite the facility policy limiting PRN antipsychotic orders to 14 days with no exceptions.
A resident with DM2 had a physician order for NovoLog 20 units before meals, to be held if BS was under 110. MAR review showed multiple insulin doses were given when BS readings were below the hold parameter, and one MAR entry was left blank with no BS documented and no indication whether insulin was given or held. The Unit Manager confirmed the findings, and the facility policy stated insulin must be administered in accordance with physician orders.
A facility failed to maintain a medication error rate below 5% when an LPN prepared 11 medications for a resident but attempted to administer them to another resident. The error was caught by a surveyor before administration. This incident resulted in a medication error rate of 31.43%, violating the facility's policy on ensuring the right resident receives the correct medication.
The facility failed to follow professional standards in medication administration for a resident by not instructing them to rinse their mouth after using an inhaler. Additionally, another resident did not receive their prescribed Oxycodone for chronic pain due to unavailability, leading to missed and incorrect dosages. The Nurse Practitioner was unaware of these issues, and the resident's pain management goals were not met.
PRN Antipsychotic Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN order for an antipsychotic medication was limited to 14 days for one resident reviewed for unnecessary medications. Resident #11 had an order for Olanzapine 5 mg by mouth every 12 hours as needed for vascular dementia with agitation for 60 days, starting 2/26/26. The record showed the resident received PRN doses on 4/1/26, 4/3/26, 4/4/26, 4/6/26, 4/14/26, and 4/15/26. The Medication Regime Review dated 3/12/26 noted the active PRN Olanzapine order had a duration of 60 days and stated CMS guidelines do not allow PRN antipsychotic orders to remain on medication profiles for more than 14 days; the prescriber responded, "disagree, already documented need for over 14 days." Staff C confirmed the order during interview, and the facility policy stated PRN antipsychotic orders shall be limited to 14 days with no exceptions.
Insulin Administered Outside Ordered Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for Resident #33, who had an order dated 1/16/26 for NovoLog Flex Pen 100 unit/ml, 20 units subcutaneously before meals for DM2, with instructions to hold for blood sugar under 110. Review of the MAR showed multiple instances in which insulin was given when the resident’s blood sugar was below the ordered hold parameter, including readings of 96, 99, 99, 106, 103, 109, 109, 97, 91, and 72. One MAR entry on 2/12/26 was left blank with no blood sugar documented and no indication whether insulin was administered or held. During interview, the Unit Manager confirmed the findings. The facility policy titled Timely Administration of Insulin stated that all insulin will be administered in accordance with physician’s orders.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who prepared 11 medications for a resident but mistakenly attempted to administer them to another resident. This error was observed during a medication administration round, where the LPN entered the wrong resident's room and was prepared to give the medications to the incorrect resident. The surveyor intervened before the medications were administered. The facility's policy on medication administration, which includes ensuring the right resident receives the correct medication, was not followed. This incident resulted in a medication error rate of 31.43%, significantly exceeding the acceptable threshold.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident, as observed when a Medication Nursing Assistant (MNA) did not instruct a resident to rinse their mouth after administering Fluticasone Propionate Diskus Inhalation Powder. This oversight was confirmed by the MNA during an interview. The manufacturer's instructions for the medication clearly state that rinsing the mouth is a necessary step after inhalation, and the facility's policy mandates that medications be administered according to manufacturer specifications. Additionally, the facility did not ensure the availability and proper administration of pain medication for another resident. The resident, who was prescribed Oxycodone for chronic pain, reported that the facility had run out of the medication. A review of the resident's Medication Administration Record (MAR) showed missed doses and incorrect dosages administered on specific dates. Nursing notes indicated that the medication was unavailable or awaiting delivery from the pharmacy. The Nurse Practitioner was unaware of these issues, and the resident's pain care plan included a goal for achieving acceptable pain control, which was not met due to these deficiencies.
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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.
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Nursing homes near Wolfeboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Community | 8.2 mi | ★★★★★ | 3 | 0 |
| Belknap County Nursing Home | 14.2 mi | ★★★★★ | 14 | 0 |
| Golden View Health Care Center | 14.2 mi | ★★★★★ | 3 | 0 |
| Laconia Rehabilitation Center | 14.4 mi | ★★★★★ | 0 | 0 |
| Saint Francis Rehabilitation And Nursing Center | 14.5 mi | ★★★★★ | 0 | 0 |
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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.