Peabody Health and Rehab

In the surveyor’s words

From the most serious findings on record at Peabody Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF742Mar 18, 2024

  The facility reported a census of 35 residents which included three residents sampled for appropriate treatment and services for mental disorders and safety. The facility failed to ensure staff provided appropriate supervision, monitoring, and interventions in response to Resident (R)1's suicidal ideation/actions and self-harm. At an unknown time on 03/10/24, R1, who suffered from delusions and hallucinations, jumped from an open window in her room, falling 12 feet to the sidewalk, and sustained multiple injuries that required hospitalization and surgery. Staff last saw R1 between 09:00 PM and 09:30 PM and found R1 on the sidewalk underneath her window at 10:54 PM. This deficient practice placed R1 in immediate jeopardy. […]

• Immediate jeopardy, isolatedF689Nov 7, 2023

  The facility reported a census of 38 residents and identified one resident at risk for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)1, identified as a moderate risk for elopement. On 11/01/23 at 06:45 PM, R1 exited the north door, unsupervised, which triggered the door alarm. The responding staff silenced the door alarm without checking outside the door to determine who/what triggered the alarm. R1 ambulated down six crumbling cement steps, around the facility approximately 450 feet and through an unfenced, unsecured courtyard, where staff found R1 approximately 53 minutes later, trying to re-enter the facility through a locked door. […]

• Actual harm, isolatedF692Feb 27, 2023

  The facility had a census of 40 residents. The sample included 12 residents, with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide nutritional support to prevent a significant weight loss of 10 lbs. or 6.36 percent in 21 days for Resident (R) 142. This failure placed the resident at ongoing risk for malnutrition and continued weight loss. Findings included: - R142's Electronic Medical Record (EMR) recorded he admitted to the facility on [DATE] with the only diagnosis of Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder) disease. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2025

  The facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one of one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 01/28/25 at 07:42 AM, In a three-door refrigerator, an unsealed plastic bag of yellow shredded cheese, an unlabeled updated 1 1/2-pound (lb.) plastic bag with white cheese, and an unlabeled, undated zip-lock plastic bag with two round slices of meat. […]

• No harm, potential for more than minimal, widespreadF867Feb 27, 2023

  The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility' Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 40 residents, who reside in the facility. Findings included: -Based on observation, record review, and interview, the facility failed to provide Resident (R) 142 with dignified dining. Refer to F550. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to include R29's Black Box Warning medications. […]