Peabody Retirement Community

Inspectors wroteBased on interview and record review, the facility failed to ensure hospital discharge orders were accurately transcribed to ensure continuation of treatment for 2 of 3 residents reviewed for new admissions. (Resident B and Resident D)

Inspectors wroteBased on record review and interview, the facility failed to complete a required Preadmission Screening and Record Review (PASRR) Level I screening assessment to determine if a Level II assessment was required when a resident received a new major mental illness diagnosis for 3 of 3 residents reviewed for PASRR (Resident 2, Resident 6, and Resident 160).

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify targeted behaviors and individualized interventions to clinically support the use of an antipsychotic medication for 2 of 2 residents reviewed for chemical restraints. (Residents 2 and 3) 1. During an observation on 5/12/26 at 10:02 a.m., Resident 2 was asleep in his wheelchair and the television was on. On 5/14/26 at 11:18 a.m., Resident 2 was sitting in his wheelchair in his room talking with a visitor. He laughed intermittently and waved to staff passing by. On 5/18/26 at 10:45 a.m., Resident 2 was up and dressed, sitting in his wheelchair in the living area, watching television. He was quiet and slept intermittently. Resident 2's clinical record was reviewed on 5/14/26 at 10:05 a.m. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure insulin pen needles were primed prior to administration according to manufacturer's instructions and professional standards to ensure the full dosage was received for 1 of 14 residents reviewed for medication administration. (Resident 17)

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 4 residents reviewed for falls (Resident 45). B. Based on interview, observation, and record review, the facility failed to provide safe bed mobility assistance for a dependent resident which resulted in the resident being rolled out of the bed and onto the floor by staff for 1 of 4 residents reviewed for falls (Resident 7).

Inspectors wroteBased on observation and interview, the facility failed to prepare and distribute food in a safe and sanitary manner. This deficient practice has the potential to affect 46 of 46 residents who receive meals from the Transitional Care Unit and Tulip Place kitchenette.

Inspectors wroteA6. During an observation on 4/2/25 at 4:52 p.m., CNA 15 approached Resident 153's room, where a droplet isolation sign was in place at the door. The droplet isolation sign indicated everyone was required to perform hand hygiene before entering and when leaving the room. A face shield or goggles was required. The face protection was required to be removed prior to exiting the room. She donned a gown and gloves, and entered the resident's room. CNA 15 already had a surgical mask in place when she approached the resident's room. The mask was not changed when she entered the room and delivered a cup of water to the resident. She wore regular eyeglasses. Eye protection was not worn during the observation. CNA 15 doffed her gown and gloves and exited the room at 4:54 p.m., without removing her surgical mask. She continued to deliver water to random residents' rooms on the Cedar Ridge Unit. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote resident dignity by failing to provide prompt care for bowel incontinence for 1 of 1 resident reviewed for dignity. (Resident 71)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who self-administered medications were assessed for safety for 2 of 2 residents reviewed for medication self-administration. (Residents 31 and 14)

Inspectors wroteBased on interview and record review, the facility failed to monitor bowel movements and initiate the facility's bowel protocol for a resident with constipation for 1 of 1 resident reviewed for constipation. (Resident 40)

Inspectors wroteA. Based on observation, record review, and interview, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 71) B. Based on observation, record review, and interview, the facility failed to utilize infection prevention and control strategies to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 153)

Inspectors wroteBased on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies.

Inspectors wroteBased on record review and interview, the facility failed to prevent staff-to-resident verbal abuse of a dependent resident (Resident D) and neglect of a resident (Resident E) from a staff member, CNA 1, for 2 of 3 residents reviewed for abuse. The deficient practice was corrected on [DATE], prior to the date of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. This deficient practice resulted in the resident eloping from the facility and being unaccounted for overnight for 1 of 3 residents reviewed for elopements. (Resident B) The Immediate Jeopardy began on 5/23/24 when the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. The resident eloped from the facility on 5/23/24 at 10:34 p.m. and being unaccounted for overnight until 5/24/24 at 7:09 a.m. when he was found in a local park approximately one-half mile from the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to report accurate information regarding an elopement for 1 of 1 facility reported incidents reviewed for elopement (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps (for swelling) for 2 of 26 residents reviewed for following physician orders. (Residents 90 and 82)

Inspectors wrote2. During an observation, on 4/25/24 at 11:06 a.m., Resident 120 was seated in his recliner with his legs elevated. He had a dressing to his left heel and wore non-slip socks. During an observation, on 4/26/24 at 9:56 a.m., Resident 120 was fully dressed. He was seated in his recliner with non slip socks to bilateral feet. During an observation, on 4/29/24 at 10:08 a.m., Resident 120 was seated in his recliner with non slip socks on his bilateral feet. A pair of pressure relief boots were on the top of the dresser. Two handwritten signs were taped to the dresser doors in his room and indicated the following: Wear pressure relief boots to bed. Left boot at all times. During a catheter care observation, on 4/29/24 at 2:27 p.m., QMA 23 and CNA 24 indicated Resident 120 did not have his offloading boot on his left foot. His left foot dressing was dated 4/28/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a system of individualized behavior monitoring and management that provided information for assessment to develop individualized interventions to prevent recurrence of behavior expressions for 1 of 4 residents reviewed for dementia services (Resident 85).

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labeled with resident identifiers and directions for 2 of 5 medication carts reviewed. (Rehabilitation Cart 1 and Rehabilitation Cart 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care for 2 of 3 residents reviewed for skin conditions. (Residents 154 and 467)

Inspectors wroteBased on observation, interview, and record review, the facility failed to make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an LPN employed to work in the facility in the nursing department had a valid Indiana nursing license or an active out of state license valid through an interstate compact agreement (LPN 3). This deficient practice had the potential to impact 164 of 164 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services for effective supervision were provided to ensure a pencil sharpener was not left unattended and within the reach of a cognitively impaired resident with dementia for 1 of 3 residents reviewed for dementia care. This deficient practice resulted in Resident B ingesting the sharpener blade and required hospitalization for surgical removal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify effective, individualized interventions to prevent the elopement of a cognitively impaired resident with known elopement risk from a secured unit's bedroom window for 1 of 3 residents reviewed for elopement risk. (Resident C) The deficient practice was corrected on 3/26/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's narcotic medication was free from diversion for 1 of 1 resident reviewed for misappropriation of medication (Resident B). The deficient practice was corrected on 10/10/23, prior to the start of the survey, and was therefore past noncompliance.