Peabody Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 18, 2024

  Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R9) of 1 sampled resident. R9 fell during an EZ Stand transfer on 7/8/24. Following the fall, R9's care plan was updated with an intervention to transfer R9 with the assistance of two staff for all EZ Stand transfers. On 12/8/24, Certified Nursing Assistant (CNA)-G transferred R9 via EZ Stand without a second staff present. R9 fell during the transfer and sustained a right tibial plateau fracture. R9 was assessed by therapy and a recommendation was made to transfer R9 with two staff and a Hoyer lift. R9's care plan was not properly updated. […]

• No harm, potential for more than minimal, widespreadF812Jul 7, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 47 residents residing in the facility.The facility did not monitor and document refrigerator and freezer temperatures in units that held food for resident consumption. Findings include:On 7/7/25, Nursing Home Administrator (NHA)-A indicated the facility follows the Wisconsin Food Code.The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 49 out of 50 residents residing in the facility (one resident received nutrition via tube feeding). The facility did not monitor and document food cooling temperatures. The facility did not have a practice to ensure opened time/temperature control foods were labeled with open and use-by dates. The facility did not store food in a manner that protected it from contamination. Findings include: On [DATE], Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. […]

• No harm, potential for more than minimal, widespreadF812Oct 5, 2022

  Based on observation, staff interview, and record review, the facility did not serve foods under sanitary conditions. The practices had the potential to affect all 40 residents. Facility did not monitor Parts Per Million (PPM) of chemical sanitization warewashing (dishwashing) machine upon installation on 8/19/22 through time of investigation. Dietary Aide (DA)-F did not wear a hair restraint while serving food from steam table. Findings include: On 10/3/22 at 8:50 AM, Dietary Manager (DM)-E indicated the facility used Wisconsin (WI) Food Code as its standard of practice. Dishmachine Monitoring WI Food Code 2020 documents at 4-302.14 Sanitizing Solutions, Testing Devices. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2021

  Based on observation and interview, the facility did not serve food in accordance with professional standards for food service safety. The facility was not consistently monitoring dishwashing machine temperatures. Findings Include: The Food and Drug Administration (FDA) Food Code, 2017, states: 4-501.110 - Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (2) For a stationary rack, dual temperature machine, (150 F); 4-501.111-Manual Warewashing Equipment, Hot Water Sanitization Temperatures. If immersion in hot water is used for SANITIZING in a manual operation, the temperature of the water shall be maintained at 171F or above. […]