Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 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with manufacturer instructions or facility policy requiring proper labeling, separation by route, and timely removal of outdated medications.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.
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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 Peterborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jaffrey Rehabilitation And Nursing Center | 8 mi | ★★★★★ | 8 | 0 |
| Crestwood Center | 14.6 mi | ★★★★★ | 3 | 0 |
| The Elms Center | 14.9 mi | ★★★★★ | 5 | 0 |
| Hillsboro House Nursing Home | 15.6 mi | ★★★★★ | 3 | 0 |
| Alpine Healthcare Center | 17.3 mi | ★★★★★ | 4 | 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.