Pheasant Wood Center

Inspectors wroteBased on interview and record review it was determined that the facility failed to follow its grievance policy for grievances for 2 out of 5 residents reviewed for grievances (Resident Identifiers are #67 and #80).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days for 1 of 1 residents reviewed for medication side effects in a final sample of 18 residents. (Resident identifier is #8.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the physician was notified of a weight change for 2 of 2 residents reviewed for notification of changes in a final sample of 18 residents. (Resident identifiers are #85 and #143.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents on the 2nd floor with a census of 47 residents. (Resident identifiers are #8, #33,#67, and #80

Inspectors wroteBased on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 5 residents reviewed for choices in a final sample of 18 residents. (Resident identifier is #8.)

Inspectors wroteBased on interview, observation and record review it was determined that the facility failed to follow currently accepted professional principles for labeling and/or storing drugs and biologicals in 2 of 3 medications carts observed. (Resident identifiers are #16 and #41.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the resident and/or resident representative a Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 3 of 3 residents reviewed for beneficiary notices. (Resident identifiers are #69, #145 and #146.)

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to ensure that dishes were sanitized according to manufacturer's instruction for food services safety in the main kitchen.

Inspectors wroteBased on interview, record review, and policy review, it was determined that the facility failed to act upon the Medication Regimen Review (MRR) recommendations for 1 of 5 residents reviewed for unnecessary medications in a final sample size of 23 residents (Resident Identifier #59).

Inspectors wroteBased on observation, interview and facility policy review, it was determined that the facility failed to have a secondary lock secured for a controlled medication in 1 of 2 medication rooms (Resident Identifier #76).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain wheelchairs and tubefeeding pumps according to manufacturer's instructions for 3 of 5 residents reviewed for physical environment in a final sample of 23 residents (Resident Identifiers are #2, #3, and #65).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident's Minimum Data Set (MDS) accurately reflected the resident's status for 3 of 23 residents reviewed for MDS in a final sample of 23 residents (Resident Identifiers are #22, #29 and #56).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to fully thoroughly investigate neglect after a resident fall in 1 of 4 residents reviewed for falls (Resident Identifier is #1).

Inspectors wroteBased on interview and record review it was determined that the facility failed to thoroughly assess a resident for injury (diagnosed with a fractured right hip) after a fall prior to mechanically transferring the resident back to bed in 1 of 4 residents reviewed for falls (Resident Identifier is #1).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for accidents in a final sample of 23 residents. (Resident identifier is #68).

Inspectors wroteBased on interview, resident council interviews, and record review, it was determined that the facility failed to provide sufficient staff to meet the resident's needs on the Skilled Nursing Unit (Resident identifiers are #2, #24, #40, and #182).

Inspectors wroteBased on observation, interview, review of manufacturer's instructions, and review of the facility's policy and procedure it was determined that the facility failed to label an opened insulin vial and opened insulin pen with an expiration date on 1 of 2 medication carts observed (3-North Medication Cart) (Resident identifier is #29).

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to follow manufacturer's instructions for cleaning the Hydrocollator in physical therapy and maintaining equipment for multi patient use. (Resident identifier is #27.)

Inspectors wroteBased on interview and policy review, it was determined the facility failed to ensure residents received their mail promptly.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a homelike environment in 2 of 2 resident units (Resident Identifiers are #2, #11, and #19).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that residents with a mental disorder received a Level I Pre-admission Screening and Resident Review (PASRR) for 2 of 3 residents reviewed for PASRR in a final survey sample of 23 residents (Resident identifiers are #45 and #74).