Peabody Health and Rehab

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one of one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 39 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS form 10123, Notice of Medicare Non-Coverage (NOMNC) for two residents, Resident (R) 1 and R23. The facility also failed to include the estimated cost to continue skilled services on CMS form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for the two residents, R1 and R23. This deficient practice placed the two residents at risk for uninformed decisions regarding skilled care.

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents, with two reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notice for facility-imitated transfer to the hospital for two residents, Resident (R) 4 and R19. This deficient practice placed the residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 39 residents. The sample included 12, with two reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide two residents, Resident (R) 4 and R19, with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed R4 and R19 at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents, with two reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R )25, who was admitted to hospice on 09/08/24, and R19, who was admitted on [DATE], which included a plan of care and a description of the services provided which included contact information, visit frequency, medications, and medical equipment. This deficient practice placed R25 and R19 at risk of not receiving needed care.

Inspectors wroteThe facility reported a census of 35 residents which included three residents sampled for appropriate treatment and services for mental disorders and safety. The facility failed to ensure staff provided appropriate supervision, monitoring, and interventions in response to Resident (R)1's suicidal ideation/actions and self-harm. At an unknown time on 03/10/24, R1, who suffered from delusions and hallucinations, jumped from an open window in her room, falling 12 feet to the sidewalk, and sustained multiple injuries that required hospitalization and surgery. Staff last saw R1 between 09:00 PM and 09:30 PM and found R1 on the sidewalk underneath her window at 10:54 PM. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility reported a census of 38 residents and identified one resident at risk for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)1, identified as a moderate risk for elopement. On 11/01/23 at 06:45 PM, R1 exited the north door, unsupervised, which triggered the door alarm. The responding staff silenced the door alarm without checking outside the door to determine who/what triggered the alarm. R1 ambulated down six crumbling cement steps, around the facility approximately 450 feet and through an unfenced, unsecured courtyard, where staff found R1 approximately 53 minutes later, trying to re-enter the facility through a locked door. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide nutritional support to prevent a significant weight loss of 10 lbs. or 6.36 percent in 21 days for Resident (R) 142. This failure placed the resident at ongoing risk for malnutrition and continued weight loss.

Inspectors wroteThe facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility' Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 40 residents, who reside in the facility.

Inspectors wroteThe facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident 142, who was left unattended and unassisted while dropping food down on the front of his shirt. This placed R142 at risk for impaired dignity and decreased psychosocial wellbeing.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to develop a comprehensive care plan for Remeron (an antidepressant medication), Lasix (a diuretic medication), and Eliquis (an anticoagulant medication), which required a Black Box Warning for one sampled resident, Resident (R) 29. This placed the resident at risk for adverse side effects.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with resident-centered interventions to prevent falls for two sampled residents, Resident (R) 7 and R18, and failed to notify and invite one sampled resident, R14 to her care plan meetings. This placed the affected residents at risk for uncommunicated and unmet care needs as well as decreased autonomy.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to identify and implement alternative communication methods for one sampled resident, Resident (R) 17, who had a diagnosis of cognitive communication deficit (difficulty with any aspect of communication that was affected by disruption of cognition) and spoke in Arabic. This placed the resident at risk for unmet needs, frustration, and loneliness. Findings Included: [...]

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed provide Resident (R) 5 assistance with toileting as requested and care planned and failed to provide R142 with meal assistance. This placed R5 and R142 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with one reviewed for Hospice (end of life) cares. Based on observation, record review, and interview, the facility failed to provide adequate end-of-life Hospice treatment and care for one resident, Resident (R)7, who was restless, hollering, and had the potential for skin breakdown. This placed the resident at risk for unmet needs and skin breakdown.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview the facility failed to reposition one sampled resident in a manner consistent with the standards of care and failed to provide a pressure reducing cushion for Resident (R) 7, who was at risk for impaired skin integrity. This placed the resident at risk for skin breakdown.

Inspectors wroteThe facility had a census of 40 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to implement care planned interventions for Resident (R)5 for toileting, and failed to identify and implement resident-centered interventions to prevent falls for R7 and R18 This palced the resident at risk for further falls and/or avoidable injuries.

Inspectors wroteThe facility had a census 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to obtain and replace Resident (R) 14's oxygen mask as physician ordered placing R14 at risk for respiratory infection.

Inspectors wroteThe facility reported a census of 41 residents. Based on observation and interview, the facility failed to ensure a clean and sanitary environment for the residents of the facility in five resident rooms, located in two of three resident halls.

Inspectors wroteThe facility reported a census of 41 residents with 13 residents sampled, including five residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to ensure three dependent residents had appropriate assistance with ADLs, including Resident (R)18, regarding appropriate nail care and R 20 and R 40, regarding lack of personal hygiene.

Inspectors wroteThe facility reported a census of 41 residents, with 13 residents sampled, including seven residents sampled for activities. Based on observation, interview and record review, the facility failed to provide activities for three Residents (R) 22, R11, and R28 to enhance their lives through activities of their choice.

Inspectors wroteThe facility reported a census of 41 residents with 13 selected for review which included two residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to implement measures for skin protection as advised by hospice for one resident (R)19 and failed to investigate and monitor the bruising and skin tear for R20.

Inspectors wroteThe facility reported a census of 41 residents with 13 residents sampled, including one resident reviewed for urinary incontinence (involuntary passage of urine) and Indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on interview, record review, and observation, the facility failed to care for the catheter in a clean manner to prevent infections for the one Resident (R)7 sampled.