A list of the most recent deficiencies for Peabody Retirement Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-01-19 | 2023-10-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-23 | 2023-09-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-13 | 2023-05-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-13 | 2023-05-13 | N |
| Develop a communication plan. | Fire Safety | 2023-04-13 | 2023-05-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-13 | 2023-05-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-13 | 2023-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-28 | 2023-04-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-28 | 2023-04-27 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-03-28 | 2023-04-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-28 | 2023-04-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-04-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-28 | 2023-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-28 | 2023-04-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-28 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-28 | 2023-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-04-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-04-26 | 2023-04-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-19 | 2022-08-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-19 | 2022-08-08 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-20 | 2022-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-20 | 2022-06-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-20 | 2022-06-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-05 | 2022-05-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-17 | 2022-05-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-17 | 2022-04-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-17 | 2022-04-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-17 | 2022-04-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-17 | 2022-04-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-17 | 2022-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-17 | 2022-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-17 | 2022-04-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-17 | 2022-04-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-17 | 2022-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-17 | 2022-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-16 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-17 | 2022-04-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-17 | 2022-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-16 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-17 | 2022-04-16 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-03-17 | 2022-04-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-03-17 | 2022-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-17 | 2022-04-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-17 | 2022-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-09-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-06 | 2021-08-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-06 | 2021-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-06 | 2021-08-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-06 | 2021-08-30 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-07-01 | 2021-07-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-19 | 2021-05-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-19 | 2021-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-19 | 2021-05-06 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-08-18 | 2020-09-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-08-18 | 2020-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-08-18 | 2020-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-08-18 | 2020-09-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-27 | 2020-07-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-27 | 2020-07-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-27 | 2020-07-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-27 | 2020-07-03 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-27 | 2020-07-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-27 | 2020-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-27 | 2020-07-03 | N |
| Post nurse staffing information every day. | Health | 2020-02-27 | 2020-07-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-27 | 2020-07-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-27 | 2020-07-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-27 | 2020-07-03 | N |
