Care One at Peabody

In the surveyor’s words

From the most serious findings on record at Care One at Peabody, in the surveyor’s own words.

• Actual harm, isolatedF740Feb 1, 2023

  Based on record review and interview, the facility failed to provide behavioral health services to 2 Residents (#209 and #206), after verbalizing suicidal ideation, out of a total sample of 33 residents. Findings include: Review of the facility policy, titled Behavioral Assessment, Intervention, and Monitoring, dated February 2019, indicated the following: -The facility will provide and residents will receive the behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. 1. […]

• No harm, potential for more than minimal, widespreadF725Apr 10, 2024

  Based on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs. Findings include: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report, submitted by the facility for Fiscal Year (FY) Quarter 1 2024 (October 1, 2023 - December 31, 2023), was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the facility assessment indicated the following: - Based on the above information and programming goals, a staffing plan has been developed to meet the professional, technical and administrative needs of the center. […]

• No harm, potential for more than minimal, patternF761Mar 27, 2025

  Based on observation and interview the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles on three of three units. Specifically, 1. The facility failed to secure drugs and biologicals on three of three units when two treatment carts and one medication room were accessible to the surveyor unsupervised. 2. The facility failed to properly label and store medications in medication carts on two of three units. 3. The facility failed to secure medications in a resident room for one (Resident #90) of 28 sampled residents. […]

• No harm, potential for more than minimal, patternF550Apr 10, 2024

  Based on observation, interview and policy review, the facility failed to provide a dignified dining experience on the second and third floor units. Findings include: Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; avoiding the use of labels when referring to residents (e.g., feeders). Review of the facility policy titled Dignity, dated February 2021, indicated the following: - When assisting with care, residents are supported in exercising their rights. […]

• No harm, potential for more than minimal, patternF677Apr 10, 2024

  Based on observations, record review, policy review and interviews, the facility failed to provide assistance for Activities of Daily Living (ADLs) for five Residents (#414, #100, #19, #95, and #61) out of a total sample of 28 residents. Specifically, 1.) For Residents #414, #100, and #19, the facility failed to provide showers, 2.) For Resident #95, the facility failed to provide supervision during meals, and 3.) For Resident #61, the facility failed to provide incontinence care. Findings include: 1.) Review of the facility policy titled Bath, Shower/Tub, dated 2001, indicated the following: - The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. […]