A list of the most recent deficiencies for Peabody Manor. 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? |
|---|---|---|---|---|
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-09-11 | 2023-10-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-13 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-13 | 2023-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-06 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-09-11 | 2023-10-06 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Establish methods for sharing information. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-11 | 2023-10-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-13 | 2023-10-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-13 | 2023-10-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-13 | 2023-09-29 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-09-11 | 2023-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-12-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-05 | 2022-12-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-05 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-05 | 2022-10-31 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-05 | 2022-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-10-31 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-10-05 | 2022-10-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-05 | 2022-10-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-10-06 | 2022-10-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-06 | 2022-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-06 | 2022-10-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-06 | 2022-10-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-06 | 2022-10-07 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-08-16 | 2021-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-18 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-18 | 2021-09-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-09-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-16 | 2021-09-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-08-16 | 2021-09-03 | N |
