Peabody Retirement Community

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 17, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision and immediate individualized interventions to prevent falls. This deficient practice resulted in 4 of 8 residents reviewed for falls sustaining fractures (Residents 79, 179, 125, and 18). The immediate jeopardy began on 1/24/22, when Resident 79 fell and sustained a right femur fracture and immediate interventions to prevent falls were not put into place, resulting in additional falls. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. Findings include: 1. On 3/8/22 at 2:16 p.m., Resident 79 was seated in her wheelchair at a table in the unit common area. Activity Aide 31 was seated next to her. […]

• Immediate jeopardy, isolatedF689Jun 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. This deficient practice resulted in the resident eloping from the facility and being unaccounted for overnight for 1 of 3 residents reviewed for elopements. (Resident B) The Immediate Jeopardy began on 5/23/24 when the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. The resident eloped from the facility on 5/23/24 at 10:34 p.m. and being unaccounted for overnight until 5/24/24 at 7:09 a.m. when he was found in a local park approximately one-half mile from the facility. […]

• Immediate jeopardy, isolatedF600Mar 17, 2022

  Based on observation, interview, and record review the facility failed to provide adequate supervision and intervention to prevent resident to resident abuse for 4 of 7 residents reviewed for resident to resident abuse. (Resident 117, Resident 93, Resident 107, and Resident 108) This deficiency resulted in Resident 117 grabbing Resident 65 resulting in Resident 117 falling and fracturing her left hand. The immediate jeopardy began on 2/9/22, when Resident 117 grabbed Resident 65 and had a fall that resulted in a left hand fracture. […]

• Immediate jeopardy, isolatedF725Mar 17, 2022

  Based on observation, interview and record review, the facility failed to ensure staffing levels were adequate related to falls, abuse prevention, meal timing and call lights for 12 of 46 residents reviewed for staffing, (Residents 179, 125, 18, 93, 117, 65, 108, 14, 86, 91 and Resident B). The immediate jeopardy began on 12/3/21, when the facility failed to ensure staffing levels were adequate to allow supervision of residents to prevent frequent falls resulting in major injury of cognitively impaired residents and resident to resident abuse and altercations. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. […]

• Immediate jeopardy, isolatedF744Mar 17, 2022

  Based on observation, interview, and record review the facility failed to provide adequate supervision, failed to implement behavior interventions, and failed to provide adequate dementia care to prevent resident to resident altercations for 4 of 7 cognitively impaired residents reviewed for abuse (Resident 45, Resident 93, Resident 117, and Resident 120) and failed to identify and implement individualized, non-pharmacological interventions for 2 of 10 residents reviewed for dementia care (Resident 1 and Resident 79). The immediate jeopardy began on 10/23/21, when Resident 45 pushed a chair out from under Resident 93. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. […]