Inspection Reports for
Pheasant Wood Center
50 PHEASANT ROAD, PETERBOROUGH, NH, 03458
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 47
Deficiencies: 7
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including Medicare/Medicaid beneficiary notices, grievance policies, medication management, nursing staffing, and pharmaceutical services.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare Non-Coverage notices, failure to follow grievance policies, improper use of psychotropic medication orders, failure to notify physicians of significant weight changes, insufficient nursing staff to meet resident needs, discrepancies in controlled drug records, and improper labeling and storage of medications.
Deficiencies (7)
Failed to provide Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 3 residents.
Failed to follow grievance policy for 2 residents; grievances were not documented or forwarded.
Failed to limit as needed psychotropic medication orders to 14 days for 1 resident.
Failed to notify physician of significant weight changes for 2 residents.
Failed to provide sufficient nursing staff on 2nd floor to meet resident needs for 47 residents.
Failed to maintain accurate records and investigate discrepancies in controlled drug records for 1 resident.
Failed to properly label and store medications on medication carts for 3 medications observed.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 47
Residents affected: 1
Medications carts observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Administrator | Confirmed inability to provide NOMNC and SNF ABN notices; confirmed grievances were not forwarded |
| Staff K | Unit Manager | Failed to document grievances for Resident #67 |
| Staff I | Licensed Nursing Assistant | Reported grievance of Resident #80 to Staff K |
| Staff C | Director of Nursing | Confirmed findings related to psychotropic medication orders, failure to notify physician, and controlled drug discrepancies |
| Staff D | Nurse Practitioner | Confirmed not being notified of weight changes as ordered |
| Staff A | Licensed Practical Nurse | Confirmed medication labeling and storage deficiencies on 2nd Floor Medication Cart |
| Staff B | Licensed Practical Nurse | Confirmed medication labeling deficiency on Celtics Court Medication Cart |
| Staff F | Anonymous | Reported insufficient staffing on 2nd floor |
| Staff M | Anonymous | Reported residents often not up or dressed due to staffing issues |
| Staff N | Anonymous | Reported resident complaints about long wait times and staffing shortages |
Inspection Report
Deficiencies: 1
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring controlled drugs are stored with appropriate security measures.
Findings
The facility failed to secure a secondary lock for a controlled medication in one of two medication rooms, specifically a medication refrigerator containing Lorazepam was not locked as required by facility policy.
Deficiencies (1)
Failure to have a secondary lock secured for a controlled medication in one of two medication rooms.
Report Facts
Medication rooms inspected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse | Confirmed medication refrigerator was not locked and controlled substances should be double locked |
| Staff A | Director of Nursing | Confirmed the finding regarding medication storage |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication regimen reviews, medication storage, food safety, equipment maintenance, and infection control at the nursing facility.
Findings
The facility was found deficient in accurately coding resident Minimum Data Sets (MDS), acting on pharmacist medication regimen review recommendations, securing controlled medications with secondary locks, sanitizing dishes according to manufacturer instructions, and maintaining wheelchairs and tube feeding pumps according to manufacturer guidelines. Several residents' records and observations revealed errors or lapses in these areas.
Deficiencies (5)
Failure to ensure resident's Minimum Data Set (MDS) accurately reflected resident status for 3 of 23 residents.
Failure to act upon Medication Regimen Review recommendations for unnecessary medications for 1 of 5 residents reviewed.
Failure to have a secondary lock secured for a controlled medication in 1 of 2 medication rooms.
Failure to ensure dishes were sanitized according to manufacturer's instructions for food services safety in the main kitchen.
Failure to maintain wheelchairs and tube feeding pumps according to manufacturer's instructions for 3 of 5 residents reviewed.
Report Facts
Residents reviewed for MDS accuracy: 23
Residents with inaccurate MDS: 3
Residents reviewed for unnecessary medications: 5
Residents with unacted medication recommendations: 1
Medication rooms inspected: 2
Medication rooms with lock deficiency: 1
Residents reviewed for equipment maintenance: 5
Residents with equipment maintenance issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Confirmed findings related to inaccurate MDS coding and medication regimen review |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding restraint use and tube feed kangaroo pump cleanliness |
| Staff G | Assistant MDS Coordinator | Confirmed incorrect MDS coding for restraint |
| Staff D | Licensed Practical Nurse | Confirmed medication room lock deficiency |
| Staff L | Dietary Manager | Interviewed regarding dishwashing procedures and observations |
| Staff K | Dietary Aide | Observed and interviewed regarding dishwashing and sanitizing practices |
| Staff H | Unit Manager | Confirmed wheelchair cleanliness findings |
| Staff I | Licensed Nursing Assistant | Interviewed about wheelchair cleaning schedule |
| Staff F | Infection Control/Infection Preventionist | Confirmed findings related to tube feeding pump cleanliness and wheelchair maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 7, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to thoroughly investigate neglect after a resident fall and to assess the adequacy of post-fall injury assessment and documentation for Resident #1.
Complaint Details
The complaint investigation found that Resident #1 was not fully assessed for injury after a fall, was mechanically transferred without proper range of motion assessment, and the fall was not properly documented or discussed in the weekly Fall Committee Meeting. The resident was not asked to provide a statement regarding the fall.
Findings
The facility failed to fully investigate neglect after a resident fall and did not thoroughly assess a resident for injury (fractured right hip) prior to mechanically transferring the resident back to bed. Documentation was incomplete and did not follow facility policy, and the resident was not asked for a statement regarding the fall.
Deficiencies (2)
Failed to fully investigate neglect after a resident fall in 1 of 4 residents reviewed for falls.
Failed to thoroughly assess a resident for injury (fractured right hip) after a fall prior to mechanically transferring the resident back to bed.
Report Facts
Residents reviewed for falls: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Responded to Resident #1's fall, documented progress note, did not fully document all facts and assessment |
| Staff B | Licensed Nursing Assistant | Assisted in transferring Resident #1 with mechanical lift |
| Staff C | Nurse Practitioner | Assessed Resident #1 after fall, called for emergency department evaluation |
| Staff D | Unit Manager | Reviewed fall documentation, identified policy not followed |
| Staff E | Reported Resident #1 was not discussed at weekly Fall Committee Meeting |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Pheasant Wood Center.
Findings
The facility was found deficient in multiple areas including timely mail delivery to residents, maintaining a homelike environment, PASARR screening for residents with mental disorders, accident hazard prevention, adequate nursing staffing, medication labeling, and equipment cleanliness and maintenance.
Deficiencies (7)
Failure to ensure residents received their mail promptly, including on Saturdays.
Failure to ensure a homelike environment in 2 of 2 resident units, including unrepaired wall holes, clutter, missing floorboards, and debris in dining area.
Failure to ensure residents with mental disorders received required Level I PASARR screening and review.
Failure to ensure resident environment free from accident hazards; resident found with acrylic paint in mouth due to unsecured supplies.
Failure to provide sufficient nursing staff to meet resident needs, resulting in delayed responses and missed showers.
Failure to label opened insulin vials and pens with expiration dates on medication cart.
Failure to follow manufacturer's cleaning instructions for Hydrocollator and maintain cleanliness of multi-patient equipment.
Report Facts
Residents reviewed for PASARR: 23
Residents affected by PASARR deficiency: 2
Residents reviewed for accidents: 23
Residents affected by accident hazard deficiency: 1
Day shifts with at least three LNAs scheduled: 13
Day shifts with multiple LNAs scheduled: 1
Evening shifts with at least three LNAs scheduled: 9
Evening shifts with two LNAs scheduled plus additional LNA: 6
Residents with missed showers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Activities Director | Interviewed regarding mail delivery and accident hazard involving acrylic paint |
| Staff J | Maintenance Director | Interviewed and confirmed unrepaired wall holes |
| Staff D | Director of Nursing | Interviewed regarding resident belongings, accident hazard, and staffing issues |
| Staff G | Unit Manager | Confirmed maintenance requests and equipment cleanliness findings |
| Staff N | Director of Social Services | Interviewed regarding PASARR screening |
| Staff E | Licensed Nursing Assistant | Reported acrylic paint incident |
| Staff L | Administrator | Interviewed regarding staffing and environment |
| Staff M | Licensed Nursing Assistant | Interviewed regarding staffing shortages |
| Staff B | Medication Nursing Assistant | Confirmed medication labeling deficiencies |
| Staff F | Director of Therapy | Interviewed regarding Hydrocollator cleaning |
| Staff H | Infection Preventionist | Confirmed equipment cleanliness issues |
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