Pheasant Wood Center

In the surveyor’s words

From the most serious findings on record at Pheasant Wood Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 16, 2026

  Based on interview and record review, the facility failed to follow hypoglycemia protocols resulting in a resident becoming unresponsive and requiring intervention and hospitalization in 1 of 3 residents reviewed for hospitalizations in a final sample of 18 residents. (Resident identifier is #4). Findings include:Review on 7/15/26 of Resident #4's provider note dated 2/5/26 revealed that the evening prior, Resident #4 was hospitalized when he/she was found unresponsive with a blood glucose (BG) in low 50's [milligrams per deciliter (mg/dl)].Review on 7/15/26 of Resident #4's February 2026 Medication Administration Record (MAR) for 2/4/26 revealed the following physician orders: Insulin Lispro 100 unit/ml inject per sliding scale: if 1-150 [mg/dl]= [is equal to]0. […]

• No harm, potential for more than minimal, patternF812Jun 27, 2024

  Based 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. Findings include: Interview on 6/25/24 at approximately 8:45 a.m. with Staff L (Dietary Manager) revealed that the facility utilized a high temperature dish machine to sanitize utensils and dishes. Observation and interview on 6/25/24 at approximately 8:45 a.m. during dishwashing in the kitchen revealed that Staff K (Dietary Aide) was washing food debris off dishes with water and lining them on a tray. The tray with dishes was then placed in the dish machine. During the rinse cycle, the rinse temperature was 170 degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, patternF925Jun 30, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to maintain an effective pest control and follow through with recommendations for pest control in the facility's main kitchen and on 1 out of 2 resident units (2nd floor unit). Findings Include: Observation on 6/28/22 between 9:45 a.m. to 10:15 a.m. of the facility's main kitchen with Staff C (Dietary Manager) revealed small fruit flies were in the dry storage area, box of potatoes in the dry storage area, cooking area, meal prep area, and the dishwashing room. Interview on 6/28/22 at approximately 9:45 a.m. with Staff C confirmed the above findings. Staff C stated that the fruit flies have been a problem for approximately a year. […]

• No harm, potential for more than minimal, isolatedF552Jul 16, 2026

  Based on interview and record review, the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifiers are #1, # 2, #5, and #12).Findings include: Resident #1 Review on 7/16/26 of Resident #1's current physician's orders revealed the following orders: Duloxetine HCL (hydrochloride) Oral Capsule Delayed Release Sprinkle 30 mg (milligram). Give 1 capsule by mouth 2 times a day for depression, start date 6/12/26 (antidepressant). Quetiapine Fumarate Oral Tablet 100 mg. […]

• No harm, potential for more than minimal, isolatedF584Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment in the facility with a census of 84 residents. Findings include:Resident #51Observation on 7/15/26 at approximately 10:00 a.m. of Resident #51's room revealed the baseboard heater was missing approximately four inches of the heater cover in the middle and the edges were sharp. Further observation revealed the baseboard heater cover was dirty, with dried brown substances adhered to it.Interview on 7/16/26 with Staff C (Licensed Practical Nurse) at approximately 10:05 a.m. confirmed the above findings. Resident #60 and Resident #61Observation on 7/15/26 at approximately 10:05 a.m. […]