Pheasant Wood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Peterborough, New Hampshire.
- Location
- 50 Pheasant Road, Peterborough, New Hampshire 03458
- CMS Provider Number
- 305059
- Inspections on file
- 16
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pheasant Wood Center during CMS and state inspections, most recent first.
Two residents reported grievances regarding delayed call bell responses and prolonged periods in soiled briefs, but staff failed to document these concerns or follow the facility's grievance policy. As a result, the grievances were not logged, investigated, or resolved according to established procedures.
A resident received PRN Lorazepam for anxiety without a required 14-day stop date, and the order remained active beyond the policy limit. The DON confirmed that the order lacked a stop date and was not extended by a physician, contrary to facility policy.
The facility did not notify the provider of significant weight changes or missed daily weights for two residents with CHF, despite physician orders requiring notification for specific weight gains. Documentation and staff interviews confirmed that the provider was not informed as required.
The facility did not provide enough nursing staff on one floor to meet residents' needs, leading to long call bell wait times, episodes of incontinence, and missed opportunities for activities and outdoor time. Multiple residents and staff reported that delays were worse during certain shifts and on weekends, with some residents left in soiled briefs or unable to get assistance for basic needs.
A resident received incorrect doses of Hydromorphone on multiple occasions, and staff failed to accurately document the receipt and administration of controlled drugs. The facility did not follow its policy for reporting and investigating discrepancies in controlled substance records, as confirmed by the DON.
Surveyors found that two medication carts contained improperly labeled and stored medications, including open eye drops and inhalers without open or expiration dates, and ear drops stored with eye drops. LPNs confirmed these findings, which were not in accordance with manufacturer instructions or facility policy requiring proper labeling, separation by route, and timely removal of outdated medications.
The facility did not provide the required Medicare beneficiary notices, such as the NOMNC and SNF ABN, to three residents whose Medicare Part A coverage ended while they still had benefit days remaining. This deficiency was confirmed by the administrator, who was unable to produce the necessary documentation for these residents.
The facility failed to sanitize dishes according to the manufacturer's instructions, as staff did not check the dish machine's temperature gauge during operation. The rinse temperatures recorded were inconsistent with the required minimum of 180°F, violating both the FDA Food Code and facility policy.
A resident's medication regimen was not adjusted according to the pharmacy's recommendation for a Gradual Dose Reduction of Benzotropine, despite the provider's acceptance of the recommendation. The medication order remained unchanged, as confirmed by the DON, contrary to the facility's policy on acting upon MRR recommendations.
The facility failed to maintain cleanliness of wheelchairs and tube feeding pumps for three residents. A resident's wheelchair had dried food-like substances, another's had built-up dust, and a third's tube feeding pump was covered in dried substances. Staff confirmed that cleaning schedules were not followed, and the facility's policies and manufacturer's instructions for regular maintenance and cleaning were not adhered to.
A facility failed to ensure controlled medications were stored under double lock as required. An inspection revealed that a medication refrigerator was not locked, containing a bottle of Lorazepam labeled for a resident. This was confirmed by an LPN and the DON, despite the facility's policy mandating double lock storage for controlled substances.
The facility failed to ensure accurate MDS assessments for three residents. One resident's MDS incorrectly listed multiple treatments not received, another's inaccurately noted restraint use, and a third's omitted anticoagulant medication use. These errors were confirmed by staff interviews.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to follow its established grievance policy for two residents who reported concerns regarding their care. According to the facility's policy, staff are required to initiate a Grievance/Concern Form upon receipt of a grievance, document it on the Grievance Concern Log, investigate the grievance, take corrective action if needed, and notify the person filing the grievance in a timely manner. However, interviews and record reviews revealed that grievances reported by two residents were not documented or processed according to this policy. One resident reported filing multiple grievances about excessive wait times for call bell responses and issues with an LNA's attitude, but these grievances were not found on the facility's grievance log, and staff confirmed they had not completed the required documentation. The resident's care plan note did mention grievances and weekly check-ins with the Unit Manager, but no formal grievance forms were completed. Another resident reported having filed multiple grievances since admission, including an incident where the resident waited over two hours in a soiled brief and reported this to an LNA. The LNA stated that the grievance was reported to the Unit Manager, but again, there was no documentation of this grievance on the facility's grievance log. The Administrator confirmed that these grievances were not forwarded or documented as required by policy. As a result, the facility did not make prompt efforts to resolve the grievances or ensure the residents' rights to voice concerns without discrimination or reprisal.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, as required by policy, for one resident. Record review showed that a resident had an active PRN order for Lorazepam 0.5 mg to be given every 4 hours as needed for increased anxiety, starting from 5/9/25, with no stop date indicated. The medication administration record confirmed that the resident received doses of Lorazepam beyond the 14-day limit without a documented stop date or physician extension. The Director of Nursing confirmed these findings during an interview. Facility policy requires PRN psychotropic medication orders, excluding antipsychotics, to be limited to 14 days unless extended by the prescribing practitioner.
Failure to Notify Provider of Significant Weight Changes in Residents with CHF
Penalty
Summary
The facility failed to ensure that physicians were notified of significant weight changes for two residents with orders for daily weights related to congestive heart failure (CHF). For one resident, the treatment administration record showed a physician's order to notify the provider if there was a weight gain of more than 2 pounds in one day or 5 pounds in a week. Documentation revealed that on one occasion, the resident's weight increased by 11.8 pounds over two days, but there was no evidence that the provider was notified as required. Additionally, there were missing weight entries on certain days, and no documentation indicated that the provider was informed of these omissions. For the second resident, the record indicated a similar physician's order for daily weights with notification parameters for weight gain. However, weights were not obtained or were refused on multiple consecutive days, and again, there was no documentation that the provider was notified of the missed weights or refusals. Interviews with the Director of Nursing and the Nurse Practitioner confirmed that the provider was not notified of these findings as ordered.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on the 2nd floor, as determined by their own facility assessment, to meet the needs of 47 residents. Multiple residents reported excessive wait times for call bell responses, with one resident stating they waited up to 30 minutes for assistance to use the bathroom, resulting in episodes of incontinence. Another resident expressed concern about not being able to go outside to smoke, particularly on weekends when staffing was lower. Staff interviews confirmed that there were not enough staff to meet residents' needs, leading to delays in care, including residents being left in soiled briefs for up to two hours and not being able to attend activities due to lack of assistance. Resident Council meeting minutes and interviews with both residents and staff indicated that the issue was more pronounced during the 3-11 and 11-7 shifts, as well as on weekends, when staffing levels were reduced. Residents reported being put to bed in their day clothes or left up until the next shift due to insufficient staff. The care plan review for one resident showed interventions for bowel incontinence, but the resident still experienced long waits for assistance. Overall, the deficiency was evidenced by consistent reports and documentation of unmet care needs and delayed responses due to inadequate staffing.
Failure to Accurately Record and Reconcile Controlled Drug Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically Hydromorphone, for one resident. The resident expressed concern about receiving the wrong dose of pain medication. Review of the Medication Administration Records (MAR) and Individual Patient's Narcotic Records revealed multiple instances where the resident was administered an incorrect dose of Hydromorphone, including full 2 mg tablets instead of the prescribed 1 mg (0.5 tablet) dose. These errors were confirmed by the Director of Nursing during interviews. Additionally, there was a documented discrepancy in the quantity of Hydromorphone tablets received, with conflicting documentation by two nurses regarding the number of tablets accepted by the facility. The facility did not follow its own policy for managing controlled substances when the discrepancy was identified. The nursing supervisor was not notified, a Controlled Drug Discrepancy Investigation Form was not completed, and no investigation into the discrepancy was initiated. The facility's policy requires that any discrepancies in controlled drug receipt or administration be reported and investigated immediately, but this process was not followed in this case.
Failure to Properly Label and Store Medications in Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to follow accepted professional principles for labeling and storing drugs and biologicals in two of three medication carts reviewed. Specifically, an open bottle of Brimodine eye drops was found without an open date, expiration date, or resident identifier. A box of Cipro ear drops labeled with an expiration date of 6/6 was stored in the medication cart alongside eye drops, contrary to facility policy requiring separation of medications by route of administration. Additionally, an open Breyna inhaler and an open Incruse Ellipta inhaler were found without open dates or open expiration dates. These findings were confirmed by interviews with LPNs responsible for the medication carts. Review of manufacturer instructions and facility policy indicated that these medications require labeling with open dates and must be discarded after specific periods post-opening. The facility's policy also mandates that eye and ear medications be stored separately and that outdated medications be immediately removed from stock. The observed deficiencies demonstrate non-compliance with both professional standards and facility policy regarding medication labeling and storage.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to three residents who either remained in the facility or were discharged home after their last covered day of Medicare Part A services. Specifically, for each of the three residents reviewed, the facility could not produce the Notice of Medicare Non-Coverage (NOMNC) and, where applicable, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). Documentation reviewed indicated that these residents had benefit days remaining at the time their Medicare coverage ended, yet the necessary notifications regarding coverage termination and potential financial liability were not given. This was confirmed during an interview with the facility administrator, who acknowledged the absence of the required notices.
Failure to Sanitize Dishes According to Manufacturer's Instructions
Penalty
Summary
The facility failed to ensure that dishes were sanitized according to the manufacturer's instructions for food service safety in the main kitchen. During an observation and interview with the Dietary Manager and Dietary Aide, it was revealed that the facility used a high-temperature dish machine to sanitize utensils and dishes. However, the staff did not check the wash and rinse temperature gauge on the dish machine while it was running. The rinse temperatures recorded during multiple cycles were 170, 175, 176, 178, and 180 degrees Fahrenheit, which did not consistently meet the required minimum temperature of 180 degrees Fahrenheit as specified by the manufacturer's instructions and the FDA Food Code 2017. The facility's policy on machine warewashing and sanitizing, effective from May 1, 2023, requires that the final rinse temperature for a high-temperature machine be a minimum of 180 degrees Fahrenheit. If temperatures fall below the standard, the Director of Dining Services or Maintenance Department should be notified immediately, and warewashing should be discontinued until the issue is corrected. Despite these guidelines, the staff continued to use the dish machine without verifying the temperatures, leading to a failure in maintaining proper sanitization standards.
Failure to Implement Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act upon the Medication Regimen Review (MRR) recommendations for a resident who was receiving an anticholinergic medication, Benzotropine, three times a day. The pharmacy consultation report recommended a Gradual Dose Reduction (GDR) of Benzotropine to two times a day with the goal of eventual discontinuation. This recommendation was accepted by the provider on a specified date. However, upon review of the resident's active physician orders, it was found that the Benzotropine medication order remained at three times a day, contrary to the pharmacy's recommendation. This discrepancy was confirmed during an interview with the Director of Nursing. The facility's policy on Medication Regimen Review emphasizes the importance of acting upon recommendations, yet in this instance, the necessary changes were not implemented.
Failure to Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to maintain wheelchairs and tube feeding pumps according to the manufacturer's instructions for three residents. Resident #65 was observed sitting in a wheelchair with yellow dried liquid splatters and clumps of dried yellow food-like substance on various parts of the wheelchair. Staff confirmed that wheelchairs were supposed to be cleaned weekly on residents' shower days, but there was no current schedule for cleaning wheelchairs. The facility's protocol indicated that Resident #65's wheelchair should have been cleaned on a specific day, but it was not. Resident #3's wheelchair was found to have built-up dust and a dark substance. The resident reported having asked for the wheelchair to be cleaned, but the LNA only cleaned the seat. The facility's policy required wheelchairs to be sprayed down and dried during shower times, but this was not done for Resident #3. The manufacturer's instructions emphasized the importance of regular maintenance and cleaning to prevent wear and damage. Resident #2 was observed with a tube feed kangaroo pump that had a dried off-white substance covering the top and screen, and a dried brown substance in the grooves. The facility's policy required cleaning and disinfecting of frequently touched items and surfaces, following the manufacturer's recommendations. The manufacturer's manual for the pump recommended cleaning after each feeding set use to prevent bacterial contamination, which was not adhered to in this case.
Controlled Medication Storage Deficiency
Penalty
Summary
The facility failed to comply with the requirement to store controlled medications under double lock, as observed in one of the medication rooms. During an inspection, it was found that a medication refrigerator on the second floor was not locked, and it contained a 30 ml bottle of Lorazepam, a controlled substance, labeled with a resident's name. This was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that controlled substances should be double locked. The Director of Nursing (DON) also confirmed the finding. The facility's policy, last revised on April 1, 2022, mandates that all controlled substances must be stored under double lock, separate from other medications.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents as reflected in their Minimum Data Set (MDS) evaluations. For one resident, the MDS inaccurately indicated that the resident was receiving multiple special treatments, including chemotherapy and IV therapy, despite no documentation supporting these treatments during the assessment period. This error was confirmed by the Director of Nursing during an interview. Another resident's MDS incorrectly noted the use of a trunk restraint, which was not used at any time during the resident's stay, as confirmed by both a Licensed Practical Nurse and the Assistant MDS Coordinator. Additionally, a third resident's MDS failed to document the use of an anticoagulant medication, Apixaban, which was prescribed and administered during the assessment period. This oversight was confirmed by the Director of Nursing, who acknowledged that the anticoagulant use should have been recorded in the MDS. These inaccuracies in the MDS assessments highlight a failure in the facility's processes to ensure that residents' statuses are accurately documented.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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