Peabody Manor

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Office of the State Long-Term Care Ombudsman was updated regarding hospital transfers and/or discharges for 4 residents (R) (R6, R43, R55, and R62) of 4 sampled residents. R6 was transferred to hospital on 1/7/26. Long-Term Care Ombudsman (LTCO)-C was not updated regarding R6's hospital transfer. R43 was trasferred to the hospital on [DATE] and 11/9/25. LTCO-C was not updated regarding R43's hospital transfers. R55 was transferred to the hospital on 9/28/25. LTCO-C was not updated regarding R55's hospital transfer. R62 discharged from the facility on 1/31/26. LTCO-C was not updated regarding R62's discharge.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menus met the nutritional needs of residents in accordance with established national guidelines. This practice had the potential to affect more than 4 of the 58 residents residing in the facility. The facility did not implement a menu that delineated portion sizes for residents.

Inspectors wroteBased on observation and staff interview, the facility did not ensure food was stored, prepared, or served under sanitary conditions. This practice had the potential to affect more than 4 of the 58 residents residing in the facility. Multiple food items were undated, expired, and/or not sealed properly.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse consequences of psychotropic medication was provided for 1 resident (R) (R7) of 5 sampled residents. R7 had orders for buspirone (an antipsychotic medication) and olanzapine (an antipsychotic medication). The facility did not complete quarterly Abnormal Involuntary Movement Scale (AIMS) assessments (used to monitor patients on long-term antipsychotic medications for involuntary muscle movements associated with tardive dyskinesia) for R7.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R63) of 2 sampled residents received care and treatment to prevent accidents. R63 was observed smoking outside the facility. R63's medical record did not contain a smoking assessment to ensure R63 was safe to smoke independently and/or without supervision.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R52) of 1 sampled resident received the necessary care and services to prevent or monitor weight loss. R52 had significant weight loss. R52's weight was not monitored as ordered. In addition, appropriate follow-up was not completed, including timely notification of the physician.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During observations of medication administration, 2 errors occurred during 30 opportunities which resulted in a 6.67% medication error rate that affected 1 resident (R) (R32) of 4 residents observed during medication administration. R32 had an order for pantoprazole (used to treat acid reflux). The order stated to give the medication on an empty stomach. On 3/18/26, staff administered pantoprazole to R32 after R32 started eating breakfast. In addition, R32 had an order for isosorbide (used to prevent/treat chest pain). The order indicated not to crush the medication. Staff crushed the medication prior to administration.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R2 and R6) of 2 sampled residents. During wound care for R2, Registered Nurse (RN)-J did not appropriately change gloves and cleanse hands. In addition, RN-J applied Medi-honey to R2's wound bed with a soiled glove. Staff did not comply with enhanced barrier precautions (EBP) during wound care for R6.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 47 residents residing in the facility. The facility did not monitor and document refrigerator and freezer temperatures in units that held food for resident consumption.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 2 sampled residents. The facility did not ensure R1's oxygen orders were consistently followed. R1's plan of care did not indicate R1 received oxygen therapy and did not include respiratory care, goals, or interventions related to respiratory disease. In addition, R1's primary diagnoses list did not include a chronic obstructive pulmonary disorder (COPD).

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R9) of 1 sampled resident. R9 fell during an EZ Stand transfer on 7/8/24. Following the fall, R9's care plan was updated with an intervention to transfer R9 with the assistance of two staff for all EZ Stand transfers. On 12/8/24, Certified Nursing Assistant (CNA)-G transferred R9 via EZ Stand without a second staff present. R9 fell during the transfer and sustained a right tibial plateau fracture. R9 was assessed by therapy and a recommendation was made to transfer R9 with two staff and a Hoyer lift. R9's care plan was not properly updated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written transfer notice was provided for 1 resident (R) (R36) of 2 residents reviewed for hospitalization. The facility did not provide R36's Guardian with a written transfer notice or notify the Ombudsman when R36 was transferred to the hospital on 6/8/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R36) of 2 sampled residents reviewed for hospitalization received the required written information of the duration of the bed hold, the reserve bed hold payment rate, and the right of the resident to return to the facility. R36 was transferred to the hospital on 6/8/24. R36's Guardian was not provided a written bed hold notice.

Inspectors wroteBased on staff and interview and record review, the facility did not ensure 1 resident (R) (R311) of 1 resident received appropriate dialysis care and services. R311 received dialysis services. R311 did not have a dialysis care plan and staff did not complete pre- and post-dialysis assessments. In addition, staff did not assess and monitor R311's fistula site.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R22, R15, and R30) of 4 residents observed during the provision of cares. During an observation of wound, incontinence, and catheter care for R22 on 12/17/24, Registered Nurse (RN)-J, Certified Nursing Assistant (CNA)-K, and CNA-L did not wash or sanitize hands between glove changes. During an observation of peri-rectal care for R15 on 12/17/24, CNA-C did not wash or sanitize hands between glove changes. R30 was on enhanced barrier precautions (EBP). During an observation on 12/18/24, RN-I did not don a gown prior to administering R30's tube feeding.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the Nursing Home Administrator (NHA) and State Agency (SA) for 2 residents (R) (R2 and R3) of 5 sampled residents. On 4/23/24, R3 and R2 had an altercation. Following the altercation, R2 stated to staff that R2 was fearful of R3. Staff did not report the incident to NHA-A or the SA in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R2 and R3) of 5 sampled residents. After a resident-to-resident altercation on 4/23/24, R2 expressed to staff that R2 was fearful of R3. The facility did not thoroughly investigate the incident.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 49 out of 50 residents residing in the facility (one resident received nutrition via tube feeding). The facility did not monitor and document food cooling temperatures. The facility did not have a practice to ensure opened time/temperature control foods were labeled with open and use-by dates. The facility did not store food in a manner that protected it from contamination.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a legal representative was informed in advance or provided updated consents outlining the risks and benefits of prescribed psychotropic medications for 1 Resident (R) (R10) of 5 sampled residents. R10 was prescribed Seroquel (an antipsychotic medication), Effexor (an antidepressant medication), Wellbutrin (an antidepressant medication), Zyprexa (an antipsychotic medication) and lorazepam (a sedative/benzodiazapine medication). The facility did not obtain consent or updated consent forms for the medications.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pharmacy recommendations were acted on by a physician for 1 Resident (R11) of 5 residents reviewed for unnecessary medications. Three pharmacy recommendation reports were not acknowledged by R11's physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R3, R10, and R11) of 5 sampled residents were monitored for adverse reactions to high-risk medications. R3 was prescribed apixaban (an anticoagulant medication) and was not monitored for adverse reactions to the high-risk medication. R11 was prescribed furosemide (a diuretic medication) and was not monitored for adverse reactions to the high-risk medication. R10 was prescribed apixaban and was not monitored for adverse reactions to the high-risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the medical record contained complete and accurate documentation for 1 Resident (R) (R152) of 19 sampled residents. R152 had a peripherally inserted central catheter (PICC) (vascular access device). R152's medical record did not contain evidence of PICC assessments from 3/18/23 through 3/26/23.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R28) of 3 residents observed during the provision of care. Certified Nursing Assistant (CNA)-G did not appropriately cleanse hands during the provision of perineal care for R28.