Inspection Reports for Peabody Retirement Community
400 W 7th St, North Manchester, IN 46962, United States, IN, 46962
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2025, found Peabody Retirement Community in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies cited. Prior inspections showed a pattern of deficiencies primarily related to emergency preparedness, life safety code compliance, and quality of care issues including medication management, infection control, and resident supervision. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved staff-to-resident verbal abuse, medication diversion, and inadequate supervision of cognitively impaired residents, with corrective actions implemented each time. Enforcement actions included an immediate jeopardy finding in June 2024 related to elopement and failure to provide adequate supervision, which was resolved after corrective measures; fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest survey showing compliance following earlier citations and complaint-related deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
229% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
91% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 174
Capacity: 192
Deficiencies: 0
Jun 12, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/06/25 by the Indiana Department of Health.
Findings
At this PSR survey, Peabody Retirement Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers, including 42 CFR 483.73 and 42 CFR Subpart 483.90(a).
Report Facts
Certified beds: 192
Census: 174
Inspection Report
Complaint Investigation
Census: 156
Capacity: 176
Deficiencies: 0
May 28, 2025
Visit Reason
The visit was conducted for the investigation of Complaint IN00458816 and in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on 2025-04-09.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00458816 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 156
Total Capacity: 176
Medicare Census: 5
Medicaid Census: 114
Other Payor Census: 57
Inspection Report
Re-Inspection
Census: 176
Capacity: 176
Deficiencies: 0
May 28, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2025-04-09, conducted in conjunction with the Investigation of Complaint IN00458816.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations during this revisit.
Complaint Details
Complaint IN00458816 was investigated and no deficiencies related to the allegations were found.
Report Facts
Census SNF/NF beds: 176
Total census: 176
Medicare census: 5
Medicaid census: 114
Other payor census: 57
Inspection Report
Life Safety
Census: 174
Capacity: 192
Deficiencies: 6
May 6, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Emergency Preparedness and Life Safety Code requirements, including failure to conduct annual emergency preparedness training and failure to maintain sprinkler system fire pump gauges as required. Additionally, egress doors in Building 04 were not readily accessible to residents without specialized security needs.
Severity Breakdown
SS=F: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program (EPP). | SS=F |
| Failed to ensure 1 of 2 sprinkler system fire pump gauges were replaced or tested every 5 years by comparison with a calibrated gauge in Building 02. | SS=F |
| Failed to ensure 1 of 2 sprinkler system fire pump gauges were replaced or tested every 5 years by comparison with a calibrated gauge in Building 03. | SS=F |
| Failed to ensure 1 of 2 sprinkler system fire pump gauges were replaced or tested every 5 years by comparison with a calibrated gauge in Building 04. | SS=F |
| Failed to ensure the means of egress through 9 of 15 exit doors for Building 04 were readily accessible for residents without a clinical diagnosis requiring specialized security measures. | SS=E |
| Failed to ensure 1 of 2 sprinkler system fire pump gauges were replaced or tested every 5 years by comparison with a calibrated gauge in Building 06. | SS=F |
Report Facts
Certified beds: 192
Census: 174
Exit doors with accessibility issues: 9
Exit doors total: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed the report and involved in exit conference |
| Facilities Manager | Interviewed regarding deficiencies and findings | |
| Director of Facility Operations | Re-educated on NFPA 25 requirements and responsible for audits |
Inspection Report
Annual Inspection
Census: 227
Deficiencies: 8
Apr 9, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted over April 2, 3, 4, 7, 8, and 9, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide prompt incontinence care, failure to assess residents for safe medication self-administration, failure to monitor and treat constipation, failure to promote healing and prevent infection of pressure injuries, failure to maintain sanitary food handling practices, failure to maintain an effective QAPI program, and failure to follow infection prevention and control practices including droplet precautions.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide prompt care for bowel incontinence for Resident 71. | SS=D |
| Failure to ensure residents who self-administer medications were assessed for safety (Residents 31 and 14). | SS=D |
| Failure to monitor bowel movements and initiate bowel protocol for Resident 40 with constipation. | SS=D |
| Failure to implement interventions to promote healing and prevent infection of pressure injuries for Residents 71 and 153. | SS=D |
| Failure to prepare and distribute food in a safe and sanitary manner affecting 46 residents. | SS=E |
| Failure to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. | SS=D |
| Failure to utilize infection prevention and control practices for residents on droplet precautions and during dining services. | SS=E |
| Failure to ensure medications were administered safely and appropriately for Resident 48. | — |
Report Facts
Survey dates: 6
Census SNF/NF beds: 175
Census Residential beds: 52
Total census: 227
Residents on droplet precautions: 38
Residents affected by food handling deficiency: 46
Residents with pressure ulcer dressing orders: 10
Residents reviewed for medication administration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed report and involved in plan of correction |
| LPN 2 | Licensed Practical Nurse | Observed leaving medication at bedside for Resident 48 without proper assessment |
| CNA 10 | Certified Nursing Assistant | Observed improper hand hygiene and food handling during dining assistance |
| Dietary Cook 8 | Dietary Cook | Observed improper glove use and food handling practices |
| QMA 11 | Qualified Medication Aide | Interviewed regarding Resident 71 incontinence care |
| CNA 12 | Certified Nursing Assistant | Interviewed and observed regarding Resident 71 incontinence care |
| Unit Manager 4 | Unit Manager | Interviewed regarding Resident 71 incontinence care and infection control |
| RN 16 | Registered Nurse | Interviewed regarding incontinence care and bowel management |
| QMA 25 | Qualified Medication Aide | Interviewed regarding medication administration for Resident 31 |
| RN 23 | Registered Nurse | Observed wound care with improper infection control practices |
| CNA 15 | Certified Nursing Assistant | Observed failure to wear eye protection during droplet precautions |
| CNA 20 | Certified Nursing Assistant | Observed failure to perform hand hygiene and wear eye protection during droplet precautions |
| CNA 21 | Certified Nursing Assistant | Observed failure to perform hand hygiene and wear eye protection during droplet precautions |
| Dietary Aide 22 | Dietary Aide | Observed failure to perform hand hygiene and wear eye protection during droplet precautions |
| CNA 6 | Certified Nursing Assistant | Observed failure to wear required face shield during droplet precautions |
| QMA 7 | Qualified Medication Aide | Interviewed regarding droplet precautions and PPE use |
| CNA 25 | Certified Nursing Assistant | Interviewed regarding PPE use for droplet precautions |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 226
Deficiencies: 0
Feb 24, 2025
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00454058.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00454058 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 174
Census Residential: 52
Total Capacity: 226
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 111
Census Payor Type Other: 56
Inspection Report
Complaint Investigation
Census: 170
Capacity: 170
Deficiencies: 0
Jan 14, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448038 and IN00448648.
Findings
No deficiencies related to the allegations in complaints IN00448038 and IN00448648 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00448038 - No deficiencies related to the allegations are cited. Complaint IN00448648 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 170
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 106
Census Payor Type - Other: 54
Inspection Report
Complaint Investigation
Census: 223
Deficiencies: 1
Nov 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00444013 and IN00447236. Complaint IN00444013 resulted in federal/state deficiencies related to abuse and neglect, while complaint IN00447236 had no deficiencies cited.
Findings
The facility failed to prevent staff-to-resident verbal abuse and neglect involving two residents by a staff member (CNA 1). The deficient practice was corrected prior to the survey date. The facility implemented a systemic plan including resident assessments, corrective action for the CNA involved, staff re-education, and audits for neglect concerns.
Complaint Details
Complaint IN00444013 was substantiated with federal/state deficiencies cited at F600 related to abuse and neglect. Complaint IN00447236 was not substantiated with any deficiencies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prevent staff-to-resident verbal abuse of a dependent resident and neglect of another resident by a staff member. | SS=D |
Report Facts
Census: 223
SNF/NF beds: 164
Residential beds: 59
Medicare residents: 9
Medicaid residents: 106
Other payor residents: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in findings related to verbal abuse and neglect of residents |
| CNA 2 | Certified Nursing Assistant | Provided statements regarding abuse and neglect incidents |
| DON | Director of Nursing | Provided facility investigation details and interview regarding the abuse incidents |
Inspection Report
Original Licensing
Census: 165
Capacity: 192
Deficiencies: 3
Sep 23, 2024
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Preoccupancy Survey for remodeling and renovation of resident rooms into a dialysis treatment area and licensed beds, to assess compliance with regulatory requirements including emergency preparedness and facility modifications.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and had deficiencies related to the emergency preparedness plan not addressing persons at-risk and dialysis services, means of egress obstructions in the dialysis treatment area, and sprinkler system clearance issues with privacy curtains not meeting NFPA standards.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Emergency preparedness plan failed to address resident population including persons at-risk and services provided in the dialysis treatment area. | SS=E |
| Means of egress in the dialysis treatment area was not continuously maintained free of obstructions due to ceiling mounted televisions being too low. | SS=E |
| Clearance of at least 18 inches was not maintained below sprinkler deflectors in 3 rooms due to privacy curtains not meeting NFPA standards. | SS=E |
Report Facts
Certified beds: 192
Census: 165
Dialysis treatment stations: 9
Rooms remodeled: 3
Licensed comprehensive beds: 2
Privacy curtains affected rooms: 3
Ceiling mounted televisions: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed the report |
| Director of Facility Services | Interviewed regarding emergency preparedness plan and dialysis treatment area deficiencies | |
| Assistant Administrator | Interviewed regarding emergency preparedness plan and dialysis treatment area deficiencies | |
| Facility Operations Director | Educated on deficiencies and responsible for audits and corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Sep 23, 2024
Visit Reason
The visit was conducted to assess compliance with Emergency Preparedness and Life Safety Code requirements for Medicare and Medicaid participating providers and suppliers.
Findings
Peabody Retirement Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements as per the surveys conducted on 09/23/2024.
Inspection Report
Complaint Investigation
Census: 156
Capacity: 156
Deficiencies: 0
Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438871.
Findings
No deficiency related to the complaint allegation was cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00438871 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Medicare census: 4
Medicaid census: 94
Other payor census: 58
Inspection Report
Follow-Up
Census: 166
Capacity: 192
Deficiencies: 0
Jul 29, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/23/24 was performed by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Peabody Retirement Community was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 192
Census: 166
Inspection Report
Complaint Investigation
Census: 162
Capacity: 162
Deficiencies: 0
Jul 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437522.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00437522 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 10
Medicaid census: 88
Other payor census: 64
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 21, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00435415 completed on June 7, 2024.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00435415 completed on June 7, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 159
Capacity: 159
Deficiencies: 2
Jun 7, 2024
Visit Reason
This visit was for the investigation of complaints IN00434570, IN00434656, and IN00435415, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility failed to report accurate information regarding an elopement incident involving Resident B and failed to ensure adequate observation and care checks for a cognitively impaired resident at risk for elopement, resulting in the resident eloping and being unaccounted for overnight. Immediate Jeopardy was identified but removed after corrective actions were implemented.
Complaint Details
Complaint IN00434570 and IN00434656 had no deficiencies related to the allegations. Complaint IN00435415 was substantiated with federal/state deficiencies cited at F689 and F609 related to elopement and failure to provide adequate supervision.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to report accurate information regarding an elopement incident for Resident B. | SS=D |
| Failed to ensure a cognitively impaired resident at risk for elopement was observed overnight and provided with care checks, resulting in elopement and being unaccounted for overnight. | SS=J |
Report Facts
Census: 159
Total Capacity: 159
Survey Dates: 3
Medicare Census: 5
Medicaid Census: 93
Other Payor Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nursing Assistant | Reported Resident B missing during morning rounds and participated in search |
| LPN 16 | Licensed Practical Nurse | Last saw Resident B ambulating without walker before elopement; responsible for reporting incident |
| CNA 6 | Certified Nursing Assistant | Assigned to Resident B during night of elopement; failed to check on resident |
| Maintenance Employee 25 | Maintenance Employee | Located Resident B at local park and returned him to facility |
| Floor Technician 34 | Floor Technician | Assisted in locating Resident B at local park |
| Agency Nurse 15 | Agency Nurse | On duty night of elopement; unaware Resident B was elopement risk |
| Nurse Manager 52 | Nurse Manager | Interviewed regarding elopement incident and staff responsibilities |
| Administrator | Facility Administrator | Oversaw investigation and corrective actions related to elopement incident |
| DON | Director of Nursing | Reviewed video footage of elopement and participated in interviews |
Inspection Report
Follow-Up
Census: 161
Capacity: 161
Deficiencies: 0
May 31, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00431817 completed on April 18, 2024, conducted in conjunction with a PSR to the Recertification and State Licensure Survey completed on May 1, 2024.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey. The complaint IN00431817 was corrected.
Complaint Details
Complaint IN00431817 was investigated and found to be corrected as of this visit.
Report Facts
Census SNF/NF beds: 161
Census Medicare residents: 7
Census Medicaid residents: 105
Census Other residents: 49
Inspection Report
Re-Inspection
Census: 161
Capacity: 161
Deficiencies: 0
May 31, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 1, 2024, conducted in conjunction with a PSR to the Investigation of Complaint IN00431817 completed on April 18, 2024.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey. The complaint IN00431817 was corrected.
Complaint Details
Complaint IN00431817 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 161
Census Medicare residents: 7
Census Medicaid residents: 105
Census Other residents: 49
Inspection Report
Life Safety
Census: 166
Capacity: 192
Deficiencies: 6
May 23, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 05/23/2024.
Findings
The facility was found not in compliance with Life Safety Code requirements including sprinkler system obstructions, incomplete smoke barriers in multiple buildings, and improper use of power strips in patient care areas. These deficiencies could affect residents and staff in several buildings.
Severity Breakdown
SS=E: 4
SS=F: 2
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Sprinkler spray pattern obstructed by a drop ceiling in the egress of the Evergreen Park neighborhood, affecting 30 residents and staff. | SS=E |
| Incomplete smoke barriers for 2 of 2 smoke compartments in Building 002 larger than 22,500 square feet, affecting all staff and residents in Building 002. | SS=F |
| Power strip of unknown UL rating used in patient care vicinity in Healthcare North room 122, affecting 1 resident. | SS=D |
| Incomplete smoke barriers for 1 of 1 smoke compartments in Building 003 larger than 22,500 square feet, affecting all staff and residents in Building 003. | SS=F |
| Three power strips of unknown UL rating used in patient care vicinity in Healthcare South room 122, affecting 1 resident and 20 staff/residents. | SS=E |
| Power strip used to power a refrigerator (high power draw equipment) in Social Services office, improper use of power strips. | SS=E |
Report Facts
Certified beds: 192
Census: 166
Residents affected: 30
Residents affected: 20
Power strips of unknown UL rating: 4
Smoke compartment size: 36645
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Named as facility administrator signing the report |
| Director of Facility Services | Interviewed and involved in observations related to sprinkler obstruction, smoke barriers, and power strip deficiencies |
Inspection Report
Renewal
Census: 56
Capacity: 220
Deficiencies: 7
May 1, 2024
Visit Reason
This visit was for a State Residential Licensure Survey and Recertification. The survey was conducted over multiple days from April 24 to May 1, 2024.
Findings
The facility was found in compliance with no deficiencies cited for the State Residential Licensure Survey. However, deficiencies were cited in areas including quality of care related to following physician orders, pressure ulcer treatment, nurse staffing information posting, labeling of drugs, staff licensing, infection prevention and control, and dementia care behavior monitoring.
Severity Breakdown
SS=D: 5
SS=C: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps for 2 of 26 residents reviewed. | SS=D |
| Failed to provide monitoring and implement interventions to promote healing of pressure injuries for 2 of 3 residents reviewed. | SS=D |
| Failed to post nurse staffing data in a prominent, accessible location for residents and visitors. | SS=C |
| Failed to develop and implement individualized behavior monitoring and management for a resident with dementia. | SS=D |
| Failed to ensure medications were labeled with resident identifiers and directions for use on two medication carts. | SS=D |
| Employed an LPN without a valid Indiana nursing license or active out-of-state license through an interstate compact agreement. | SS=C |
| Failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care for 2 of 3 residents reviewed. | SS=D |
Report Facts
Survey dates: 6
Census SNF/NF: 164
Census Residential: 56
Total Capacity: 220
Residents receiving diabetic services: 22
Residents receiving ace wrap treatments: 11
Residents with ordered dressing changes: 29
Residents with behavior monitoring: 138
Residents in facility: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed the report and involved in interviews |
| LPN 3 | LPN Supervisor | Observed providing wound care; found to lack valid Indiana nursing license |
| QMA 20 | Observed medication cart with unlabeled morphine and other medications | |
| LPN 16 | Observed performing wound care with contamination risk | |
| DON | Director of Nursing | Provided multiple interviews regarding findings and policies |
| Unit Manager 11 | Provided interviews regarding wound care and staffing postings | |
| QMA 4 | Provided interview regarding resident behavior | |
| Activity Assistant 5 | Provided interview regarding resident behavior | |
| CNA 6 | Provided interview regarding resident behavior | |
| LPN 7 | Provided interview regarding resident behavior |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 165
Deficiencies: 1
Apr 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00427809, IN00431274, and IN00431817. The investigation focused on allegations related to dementia care and resident safety.
Findings
The facility failed to ensure effective supervision for a cognitively impaired resident with dementia, resulting in the resident ingesting a pencil sharpener blade that required hospitalization and surgical removal. The facility conducted environmental sweeps, re-educated staff, and implemented ongoing audits to prevent recurrence.
Complaint Details
Complaint IN00427809 - No deficiencies related to the allegations are cited. Complaint IN00431274 - Federal/State deficiencies related to the allegations are cited at F689. Complaint IN00431817 - Federal/State deficiencies related to the allegations are cited at F744. The citation relates to Complaint IN00431817.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure services for effective supervision to prevent a cognitively impaired resident from ingesting a pencil sharpener blade. | SS=G |
Report Facts
Census SNF/NF: 165
Medicare Census: 6
Medicaid Census: 99
Other Payor Census: 60
Length of blade: 2.3
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed the report and plan of correction |
| LPN 21 | Nurse involved in the incident response and interview regarding the pencil sharpener ingestion | |
| CNA 8 | Certified Nursing Assistant who discovered the resident chewing on the pencil sharpener and assisted in the response | |
| CNA 4 | Interviewed regarding knowledge of pencil sharpeners and resident supervision | |
| CNA 11 | Agency CNA present during the incident | |
| Activity Assistant 15 | Interviewed regarding supervision and activities involving the resident | |
| DON | Director of Nursing | Interviewed regarding the incident, environmental sweeps, and audits |
| Nurse Practitioner (NP) | Assessed the resident and ordered x-rays and hospital evaluation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 167
Deficiencies: 1
Jan 19, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00419428, IN00420619, IN00420827, IN00423217, IN00423753, IN00424683, and IN00419835).
Findings
The facility was found deficient related to misappropriation of a resident's narcotic medication for 1 of 1 residents reviewed (Resident B). The deficient practice involved missing controlled medication records and suspected diversion by a licensed practical nurse (LPN 6). The issue was corrected prior to the survey date with systemic actions including audits, staff education, and monitoring.
Complaint Details
Complaint IN00419428 was substantiated with federal/state deficiencies cited at F602 related to misappropriation of medication. Other complaints investigated were not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's narcotic medication was free from diversion, with missing controlled drug record sheets and discrepancies in medication counts. | SS=D |
Report Facts
Census: 167
Total Capacity: 167
Medicare Census: 9
Medicaid Census: 95
Other Census: 63
Medication doses documented: 6
Medication pills missing: 9
Controlled substance count sheets: 13
Controlled substance count sheets: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in medication diversion finding; last nurse documented giving medication before missing punch card; agency nurse not allowed to return. |
| QMA 17 | Qualified Medication Aide | Discovered missing narcotic medication punch card and initiated investigation. |
| RN 3 | Registered Nurse | Provided typed statement regarding discovery of missing medication record sheets. |
| DON | Director of Nursing | Interviewed regarding investigation and corrective actions. |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 169
Deficiencies: 0
Oct 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417908 at Peabody Retirement Community.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaint IN00417908 found no deficiencies related to the allegations.
Report Facts
Census: 169
Total Capacity: 169
Medicare Census: 7
Medicaid Census: 101
Other Payor Census: 61
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 22, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00415238 completed on August 23, 2023.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00415238 completed on August 23, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 169
Capacity: 169
Deficiencies: 0
Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416889 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and COVID-19 survey.
Complaint Details
Complaint IN00416889 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 169
Census total residents: 169
Census Medicare residents: 5
Census Medicaid residents: 100
Census other payor residents: 64
Inspection Report
Complaint Investigation
Census: 161
Capacity: 222
Deficiencies: 1
Aug 23, 2023
Visit Reason
The visit was conducted for the investigation of three complaints (IN00414874, IN00415238, and IN00415053). Deficiencies related to complaint IN00415238 were cited, while no deficiencies were found related to the other two complaints.
Findings
The facility failed to ensure the resident call light system was fully operational, specifically the call pendants worn by residents were not consistently transmitting alerts to staff pagers, although the centralized staff work area monitors continued to function. The issue was addressed with technician intervention, installation of a signal booster, and ongoing 15-minute rounding until full functionality was restored.
Complaint Details
Complaint IN00415238 was substantiated with federal/state deficiencies cited related to the call light system. Complaints IN00414874 and IN00415053 were not substantiated with no deficiencies cited.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the call light system was operational, specifically the resident call pendants were not consistently transmitting alerts to staff pagers. | SS=F |
Report Facts
Residents affected: 161
Residents capable of using pendants: 87
Census SNF/NF beds: 161
Census Residential beds: 61
Total licensed capacity: 222
Medicare residents: 9
Medicaid residents: 96
Other payor residents: 56
Inspection Report
Complaint Investigation
Census: 156
Capacity: 156
Deficiencies: 0
Aug 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413800, IN00413170, and IN00412923.
Findings
No deficiencies related to the allegations in complaints IN00413800, IN00413170, and IN00412923 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00413800, IN00413170, and IN00412923 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 156
Total Capacity: 156
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 95
Census Payor Type - Other: 54
Inspection Report
Follow-Up
Census: 134
Capacity: 199
Deficiencies: 0
May 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on March 28, 2023, including a PSR to the State Residential Licensure Survey.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
SNF/NF Census: 134
Residential Census: 65
Total Capacity: 199
Medicare Census: 5
Medicaid Census: 83
Other Payor Census: 46
Inspection Report
Follow-Up
Deficiencies: 0
May 17, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 04/13/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73.
Findings
At this PSR survey, Peabody Retirement Community was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73.
Inspection Report
Complaint Investigation
Census: 140
Capacity: 140
Deficiencies: 0
May 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407840.
Findings
No deficiencies related to the allegations in Complaint IN00407840 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00407840 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 140
Total Capacity: 140
Medicare Census: 13
Medicaid Census: 92
Other Payor Census: 35
Inspection Report
Complaint Investigation
Census: 137
Capacity: 137
Deficiencies: 1
Apr 26, 2023
Visit Reason
This visit was for the investigation of complaints IN00407085 and IN00406426. Complaint IN00407085 resulted in federal/state deficiencies related to the allegations cited at F744, while complaint IN00406426 had no deficiencies cited.
Findings
The facility failed to provide appropriate interventions related to dementia behavioral care for one resident (Resident B), resulting in a physical altercation with staff, police involvement, and the resident being handcuffed. The resident exhibited aggressive behaviors including hitting, pinching, and kicking staff, and the incident was captured on security video. The facility revised the resident's care plan and interventions following the incident.
Complaint Details
Complaint IN00407085 was substantiated with federal/state deficiencies cited at F744 related to dementia care. Complaint IN00406426 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and services to a resident with dementia to maintain highest practicable physical, mental, and psychosocial well-being, resulting in an altercation with staff and police involvement. | SS=G |
Report Facts
Census Bed Type: 137
Medicare Census: 5
Medicaid Census: 83
Other Payor Census: 49
Discoloration measurement: 20
Discoloration measurement: 9
Discoloration measurement: 10
Discoloration measurement: 8
Discoloration measurement: 13
Discoloration measurement: 8
Discoloration measurement: 12
Discoloration measurement: 7
Inspection Report
Routine
Census: 136
Capacity: 192
Deficiencies: 5
Apr 13, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, specifically failing to review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing Program at least annually. The facility also failed to conduct required emergency preparedness exercises at least twice per year. The Life Safety Code survey found the facility in compliance with applicable fire safety regulations.
Severity Breakdown
SS=F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Policies and Procedures at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Communication Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Training and Testing Program at least annually. | SS=F |
| Failed to conduct emergency preparedness exercises at least twice per year, including unannounced staff drills. | SS=F |
Report Facts
Certified beds: 192
Census: 136
Deficiency completion date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed report and involved in exit conference |
Inspection Report
Census: 62
Deficiencies: 13
Mar 28, 2023
Visit Reason
This visit was for a State Residential Licensure Survey and Investigation of Complaint IN00402752, including a Recertification and State Licensure Survey.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, honoring resident preferences, notification of changes, communication with hospice providers, wound care, fall prevention, respiratory care, medication labeling, food handling, infection control, catheter care, and staff training. Complaint allegations were not substantiated.
Complaint Details
Complaint IN00402752 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 10
SS=E: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility staff failed to serve residents in a dignified manner during dining services, including seating residents alone and delayed meal service. | SS=D |
| Facility failed to honor resident preferences for wake times and meal choices. | SS=D |
| Facility failed to provide Long Term Care Ombudsman contact information to Resident Council upon request. | SS=E |
| Facility failed to timely notify physician and family of significant change in condition for a resident with respiratory decline and failed to notify physician of dietary recommendations for weight loss. | SS=D |
| Facility failed to ensure communication between hospice company and facility staff for residents receiving end of life services. | SS=D |
| Facility failed to complete routine assessments of stage IV pressure ulcer and failed to ensure wound care was provided in a sanitary manner. | SS=D |
| Facility failed to implement fall interventions to prevent further falls for a resident with repeated falls. | SS=D |
| Facility failed to ensure respiratory equipment was stored in a sanitary manner. | SS=D |
| Facility failed to ensure insulin pens were labeled with dates opened and expiration dates on medication carts. | SS=D |
| Facility failed to ensure foods were handled in a sanitary manner during meal preparation. | SS=D |
| Facility failed to handle catheter drainage bag in a sanitary manner to prevent infection. | SS=D |
| Facility failed to ensure a minimum of one awake staff member certified in CPR was on site for multiple shifts. | — |
| Facility failed to ensure required annual dementia education was completed for some staff. | — |
Report Facts
Survey dates: 6
Census: 62
Residents served by staff identified: 2
Shifts lacking CPR certified staff: 14
Insulin pen expiration days: 28
Pressure ulcer size: 5
Pressure ulcer size width: 3.4
Pressure ulcer size depth: 2
Bruise size length: 17
Bruise size width: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Robinson | Administrator | Signed report |
| Pam Bennett | Infection Control Assessor | Conducted Infection Control Assessment and Response (ICAR) on 4/6/2023 |
| Cindy Nanavaty | FNP, CWOCN | VA wound care provider for Resident 98 |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Jan 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00395053 and IN00397974.
Findings
Both complaints IN00395053 and IN00397974 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395053 - Unsubstantiated due to lack of evidence. Complaint IN00397974 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 123
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 41
Inspection Report
Complaint Investigation
Census: 133
Capacity: 133
Deficiencies: 0
Sep 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386982.
Findings
The complaint IN00386982 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00386982 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Medicare census: 12
Medicaid census: 72
Other payor census: 49
Inspection Report
Re-Inspection
Census: 129
Capacity: 129
Deficiencies: 0
Sep 7, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00385095 completed on July 19, 2022.
Findings
Peabody Retirement Community was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00385095.
Complaint Details
Complaint IN00385095 - Corrected.
Report Facts
Census Bed Type: 129
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 42
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