Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Peabody during CMS and state inspections, most recent first.
The facility failed to secure and properly label medications across three units, leaving treatment carts unlocked and a medication room unsupervised. Unopened insulin was improperly stored, and medication carts were found with spills and unlabeled items. A resident's medications were left unsecured on the floor. Staff interviews confirmed these practices were against facility policies.
A resident with a history of stroke and dysphagia was not provided with built-up utensils during meals, despite physician orders and care plans indicating their necessity. Observations showed the resident eating without assistance, and staff interviews revealed a lack of awareness about the resident's current needs. The care plan and documentation were not updated to reflect the resident's actual level of care, leading to a deficiency.
A resident with heart failure experienced a significant weight gain of 11.4 pounds over four days, but the facility failed to notify the physician as required by the physician's order. Interviews revealed that staff were unaware of the need to notify the physician, highlighting a lapse in communication and documentation.
A facility failed to ensure proper communication and implementation of care for a resident requiring dialysis. The resident had elevated phosphorus levels, but the recommended calcium acetate was not ordered or administered. The responsibility to check the dialysis communication book was not fulfilled, leading to a lack of necessary medication orders. The DON confirmed the need for updating physicians on dialysis center recommendations, which was not done.
The facility failed to maintain sufficient staffing levels to meet residents' personal and cognitive care needs. The CASPER PBJ Staffing Data Report indicated low weekend staffing, and daily schedules from October 2023 to April 2024 showed that most shifts were below expected PPD levels. Interviews with CNAs and a nurse revealed that they were unable to provide timely care due to staffing shortages. The Administrator acknowledged staffing challenges but believed improvements had been made through recruitment efforts.
The facility failed to provide a dignified dining experience on the second and third floor units. Staff were observed referring to residents as 'feeders' and standing while feeding residents, contrary to facility policies. Interviews with the Staff Development Coordinator and DON confirmed these practices were inappropriate.
The facility failed to provide scheduled showers for three residents, supervision during meals for a resident with dysphagia, and timely incontinence care for a resident with severe cognitive impairment. Observations and interviews confirmed these deficiencies, highlighting lapses in care and documentation.
The facility failed to store and prepare food in accordance with professional standards for food service safety. Observations included a staff member without a hair restraint, dented cans, and multiple containers of food that were undated, unlabeled, or past their use-by dates. The Food Service Director confirmed these practices were against policy.
The facility failed to maintain accurate medical records for four residents, including incomplete ADL documentation, incorrect air mattress records, false wound care documentation, and an error in documenting a physician's plan of care for liquid protein supplements.
The facility failed to meet professional standards of quality by not transcribing and implementing physician's orders for wound care and suture removal for three residents. This led to the worsening of a pressure wound, lack of dressing on an arterial wound, and failure to remove sutures as ordered.
The facility failed to provide appropriate hearing treatment and services for two residents. Despite referrals and requests for audiological consultations, neither resident was seen by an audiologist or provided with assistive hearing devices. Staff were unaware of why referrals were not followed up, and the facility's contracted audiology services had not been consistently available.
The facility failed to ensure proper pressure ulcer care and prevention for two residents. One resident did not have a physician's order to discontinue a dressing and air mattress, leading to multiple small open wounds. Another resident's air mattress was not set to the correct settings as ordered, compromising wound management. Staff confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident reported worsening pain and limited range of motion in the right hand, affecting daily activities. Despite the resident's complaints, the nursing summary and care plans did not reflect any impairment, and staff were either unaware or had not observed significant changes. The Occupational Therapist confirmed the resident's condition, but no referral to therapy was made.
The facility failed to maintain acceptable nutrition parameters for two residents, leading to significant weight loss. One resident with Alzheimer's disease experienced an 8.98% weight loss without intervention, while another resident with multiple diagnoses had a 12.08% weight loss that was not timely reweighed or addressed. The facility did not follow its policy for monitoring and addressing significant weight changes.
The facility failed to re-evaluate PRN psychotropic medications after 14 days for two residents with severe cognitive impairments. Both residents had PRN orders for Ativan that lacked end dates, contrary to facility policy. Staff interviews confirmed the oversight.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles across three units. On multiple occasions, treatment carts were left unlocked and unattended, allowing unauthorized access to medicated creams and ointments. Additionally, a medication room was left unsupervised with a surveyor inside, which was against the facility's policy. Interviews with nursing staff and the Director of Nurses confirmed that these practices were not in line with the facility's policies, which require treatment carts to be locked when unattended and medication rooms to be supervised. The facility also failed to properly label and store medications in medication carts on two units. Unopened insulin vials and pens were found in a medication cart instead of being stored in a refrigerator. A bottle of liquid protein was opened without an open date, and there were spills in the medication cart that had not been cleaned. Cleaning wipes were stored with oral medications, and an inhaler was found without a resident label. Interviews with nursing staff and the Infection Preventionist highlighted these discrepancies, noting that medications with shortened expiration dates should be labeled when opened, and cleaning supplies should not be stored with medications. In the case of Resident #90, medications were not secured properly in the resident's room. Approximately eight pills were found on the floor under the resident's bed, which had been knocked off a meal tray by an unidentified staff member. The resident, who was assessed to self-administer medications, reported that the pills had been on the floor for a couple of days and that no staff had returned to remove them. The Director of Nurses confirmed that medications should be secured and not left on the floor, indicating a lapse in adherence to medication security protocols.
Failure to Update Care Plan for Resident with ADL Needs
Penalty
Summary
The facility failed to update the care plan for a resident with a history of stroke and dysphagia, who was admitted in February 2025. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for partial/moderate assistance with meals, including the use of built-up utensils and a lip plate. However, observations over several days revealed that the resident was not provided with built-up utensils during meals, and there was no staff present to assist, despite the resident's physician's orders and care plan indicating the need for such adaptive equipment and assistance. Interviews with staff, including the Speech Language Pathologist (SLP) and the Unit Manager, revealed a lack of awareness and communication regarding the resident's current needs and care plan updates. The SLP noted that the resident should be seated upright during meals and have food cut up, but did not require supervision. The Unit Manager acknowledged that the care plan, physician orders, and documentation did not reflect the resident's current level of care, which should have been updated to indicate that the resident only required meal setup and no longer needed built-up utensils. This discrepancy between the resident's documented needs and the care provided led to the deficiency.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to adhere to professional standards of practice by not implementing a physician's order for a resident with heart failure and chronic respiratory failure. The order required notifying the provider if the resident's daily weight increased by more than two pounds. Despite a significant weight gain of 11.4 pounds over four days, the facility did not notify the physician as required. The resident's daily weights showed a gain of 5.4 pounds on the first day, followed by additional gains over the next three days, yet there was no documentation of physician notification during this period. Interviews with facility staff revealed a lack of awareness and adherence to the physician's order. The Unit Manager was unaware that the physician had not been notified of the resident's weight gain, and the Director of Nursing acknowledged that the physician's orders should have been followed and documented in the nursing notes. This oversight indicates a failure in communication and documentation processes within the facility, leading to the deficiency.
Failure in Communication and Implementation of Dialysis Care Recommendations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring renal dialysis. Specifically, the facility did not ensure complete and accurate communication with the dialysis facility and failed to implement a dietitian's recommendation for phosphate binders. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had elevated phosphorus levels, but there was no physician's order or record of administration for the recommended calcium acetate in the resident's Medication Administration Record. Interviews revealed that it was the responsibility of the medication nurse or unit manager to check the dialysis communication book upon the resident's return from dialysis. However, this was not done, resulting in the absence of an order for calcium acetate. The Director of Nursing confirmed that the nurse or unit manager should update the physician on any orders or recommendations from the dialysis center. The dialysis nurse indicated that communication reports from the dietitian were provided monthly, but the facility failed to act on the recommendations in a timely manner.
Insufficient Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the personal and cognitive care needs of residents. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2024 indicated excessively low weekend staffing. The facility's daily schedules from October to December 2023 and January to April 2024 showed that the majority of weekday and weekend shifts were below the expected staffing levels. Specifically, 59 of 66 weekday shifts and 19 of 27 weekend shifts from October to December 2023, and 65 of 73 weekday shifts and 12 of 28 weekend shifts from January to April 2024, did not meet the facility's expected PPD levels. Interviews with CNAs and a nurse revealed that due to insufficient staffing, they were unable to shower residents, change residents on time, or answer call lights promptly. Additionally, a nurse mentioned that she did not know the residents on her assignment because she had to float around different units due to staffing shortages. The Administrator acknowledged the staffing challenges but believed that significant improvements had been made in recent months through recruitment efforts. Despite these efforts, the daily staffing PPD levels were not consistently met. The Administrator also noted that it is common for staff to complain about insufficient staffing and that the facility staffs according to the census. However, the reported data and staff interviews indicate that the facility did not maintain adequate staffing levels to ensure the safety and well-being of the residents.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience on the second and third floor units. Observations made by the surveyor included staff referring to residents as 'feeders' or 'feeds' while organizing meal carts in the hallway, with other residents sitting nearby. Additionally, a staff member was observed standing over a resident in a wheelchair while feeding them oatmeal, rather than sitting at eye level. These actions were in direct violation of the facility's policies on Assistance with Meals and Dignity, which emphasize the importance of meeting individual needs and providing a dignified dining experience. During interviews, the Staff Development Coordinator and the Director of Nursing both confirmed that staff should not be standing while feeding residents or referring to them as 'feeders' or 'feeds.' The Staff Development Coordinator, who was covering as the third-floor unit manager, reiterated that staff should be sitting at eye level when assisting residents with feeding. These observations and interviews highlight the facility's failure to adhere to its own policies, resulting in a lack of dignity and respect for the residents during meal times.
Failure to Provide ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide assistance for Activities of Daily Living (ADLs) for five residents. Specifically, three residents were not provided with their scheduled showers. Resident #414, who had severe cognitive impairment, was observed with greasy hair and reported not receiving a full shower despite being scheduled for two showers a week. Resident #100, who was cognitively intact but dependent on staff for showering, reported not fitting in the shower chair and not receiving scheduled showers. Resident #19, with severe cognitive impairment, was also not given showers as scheduled, and his spouse confirmed the infrequency of showers. The facility also failed to provide supervision during meals for Resident #95, who had moderate cognitive impairment and required supervision due to dysphagia. Observations revealed that Resident #95 was left unsupervised during meals on multiple occasions, leading to difficulties in eating and potential safety risks. Despite the care plan indicating the need for supervision, staff did not consistently monitor the resident during meal times. Additionally, the facility did not provide timely incontinence care for Resident #61, who had severe cognitive impairment and was frequently incontinent. The resident was observed for five continuous hours without being checked for incontinence, resulting in saturated briefs and an odor of urine. Staff interviews confirmed that residents with incontinence should be checked every two to three hours, but this protocol was not followed for Resident #61.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a surveyor observed a staff member in the food preparation area without a hair restraint, a significantly dented can of marinara on the can rack in the dry storage room, and multiple containers of food in the walk-in refrigerator that were either undated, unlabeled, or past their use-by dates. Additionally, the surveyor found two containers of juice opened but unlabeled in a reach-in refrigerator. Similar issues were observed in the unit kitchenettes on the second, third, and first floors, where opened and undated containers of juice, salads, and resident food were found. Some of the food items showed signs of decomposition, such as browning lettuce in salads. During an interview, the Food Service Director (FSD) confirmed that all food should be labeled when opened or prepared, and that the use-by dates are automatically generated by the label-printing system. The FSD stated that all food items should be discarded after the use-by date and that the dietary department is responsible for regularly checking the kitchenette refrigerators. The FSD also confirmed that all staff members in the food preparation area should wear hairnets at all times and that dented cans should be inspected on delivery and placed in his office for disposal, not on the can rack, to avoid the risk of botulism.
Inaccurate Medical Records Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care documentation. For Resident #100, the facility did not complete daily documentation for Activities of Daily Living (ADLs) for 15 out of 27 nursing shifts. Both the Staff Development Coordinator (SDC) and the Director of Nursing (DON) acknowledged that CNAs should document every shift, and the facility needs a plan to ensure complete documentation across all shifts. For Resident #18, the facility did not accurately document the presence and function of an air mattress. Despite a physician's order to check the air mattress every shift, the Treatment Administration Record (TAR) indicated compliance even though the resident was observed without an air mattress. The Unit Manager admitted to discontinuing the air mattress order without consulting the physician, and both the Assistant Director of Nursing (ADON) and the DON confirmed that the order should not have been marked as implemented if the resident was not on an air mattress. Resident #41's wound care was also inadequately documented. The resident was observed without a dressing on a wound that should have been treated daily according to physician's orders. The Treatment Administration Record falsely indicated that the wound care was completed. Both the ADON and the DON stated that the dressing should not have been documented as completed if it was not done. Additionally, for Resident #61, there was a discrepancy in the documentation of a physician's plan of care for liquid protein supplements. The physician's note to continue the supplements was in error, as the order had been discontinued months earlier. The DON confirmed this documentation error.
Failure to Implement Physician's Orders for Wound Care and Suture Removal
Penalty
Summary
The facility failed to provide services that met professional standards of quality for three residents. For Resident #61, the facility did not transcribe and implement the physician's updated orders for a pressure wound treatment. Despite the physician's recommendation to change the dressing, the resident continued to receive the incorrect treatment, leading to the worsening of the wound, including the development of eschar and increased pain. The Assistant Director of Nursing (ADON) acknowledged that the order was not transcribed and the incorrect dressing was applied for several days. For Resident #41, the facility did not implement the physician's order to apply a dressing to an arterial wound. The resident was observed without a dressing on multiple occasions, and the resident reported that the nurse had not applied the dressing due to being too busy. The Treatment Administration Record (TAR) falsely indicated that the dressing had been applied as ordered. Interviews with staff confirmed that the dressing should have been in place and that the resident had not refused care. For Resident #214, the facility failed to remove sutures from the resident's nose as ordered by the physician. The resident reported that the sutures were not removed on the scheduled date, and the Medication Administration Record (MAR) incorrectly showed that the order had been completed. The Unit Manager and Director of Nursing (DON) confirmed that the sutures should have been removed and that there was no documentation of the resident refusing the procedure.
Failure to Provide Audiology Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for two residents, Resident #91 and Resident #41. Resident #91, who has moderate cognitive impairment and requires total dependence on staff for activities of daily living, reported difficulty hearing and expressed a desire to see an ear doctor. Despite a referral being placed with the contracted audiology service in September 2022, there were no records indicating that Resident #91 was ever seen by an audiologist or provided with assistive hearing devices. The Unit Secretary and other staff members were unaware of why the referral was not followed up, and the Director of Nursing acknowledged that the referral should have been addressed given the time elapsed since it was made. Resident #41, who was admitted with diagnoses including dementia and anemia, also experienced issues related to hearing. Despite a request for an audiological consultation being made in August 2023, there were no records indicating that Resident #41 was seen by an audiologist or provided with hearing aids or amplifiers. Observations and interviews revealed that Resident #41 had significant difficulty hearing, which affected their ability to communicate and participate in activities. Staff members had to repeat questions multiple times and adjust their volume to communicate with Resident #41, who expressed a desire for hearing aids. The facility's contracted audiology services had not been consistently available, with the last visit recorded in November 2023. The Unit Secretary and Director of Nursing acknowledged the lack of follow-up on audiology referrals and the need for alternative interventions for residents with hearing impairments. Despite audits being conducted since January 2024, the facility had not ensured that residents received the necessary audiology services or assistive devices, leading to ongoing issues for both Resident #91 and Resident #41.
Failure to Ensure Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in treatment and services. For Resident #18, the facility did not obtain a physician's order to discontinue a dressing for a recently healed pressure ulcer and failed to obtain a physician's order to discontinue an air mattress ordered for skin integrity management. Despite the resident's high risk for skin breakdown, the air mattress was removed without a replacement, and the wound treatment order lacked an end date or instructions for discontinuation. The resident was observed with multiple small open wounds, and staff confirmed the absence of a dressing and air mattress, which were discontinued without physician approval. For Resident #71, the facility did not ensure that the air mattress was set to the correct settings for a resident with multiple pressure ulcers. The air mattress pump was consistently observed at the wrong setting, contrary to the physician's order, which specified a different setting for effective wound management. Staff interviews confirmed that the air mattress should have been set to the correct setting as ordered, but this was not implemented. These deficiencies highlight the facility's failure to adhere to professional standards of practice in managing pressure ulcers, including obtaining necessary physician orders and ensuring proper use of prescribed equipment. The lack of adherence to these protocols resulted in inadequate care for residents at high risk for skin breakdown and pressure ulcers.
Failure to Address Decrease in Range of Motion
Penalty
Summary
The facility failed to identify and provide interventions for a decrease in range of motion for a resident. The resident, admitted with diagnoses including heart failure and stroke, reported difficulty in straightening fingers on the right hand, which had worsened over the past few months. Despite the resident's complaints of pain and reduced ability to perform tasks, the nursing summary and care plans did not reflect any impairment in range of motion or contractures. The most recent Occupational Therapy evaluation also failed to indicate any issues with the resident's right hand. Interviews with the resident and staff revealed that the resident's right-hand fingers had limited range of motion and increased pain, affecting daily activities. The resident's second and fifth fingers could only open to approximately 75% of full range of motion, while the third and fourth fingers could only straighten to about 50%. The resident had to adapt to using utensils differently due to the impairment. Staff members, including nurses and CNAs, were either unaware of the resident's condition or had not observed any significant changes. The Occupational Therapist confirmed that the resident's right-hand fingers were stuck in a bent position and that the resident experienced more pain and less range of motion than previously noted. The Director of Nursing and the Director of Rehabilitation both stated that nursing should have made a referral to therapy if a change in range of motion was observed. However, no such referral was made, and the resident's condition was not adequately addressed in the care plan or through therapy interventions.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition status for two residents, leading to significant weight loss. For Resident #69, who was admitted with Alzheimer's disease and severe cognitive impairment, the facility did not identify or implement an intervention for a significant weight loss of 8.98% over a period of approximately two months. Despite the resident being on hospice services, the Registered Dietitian (RD) was not alerted to the weight loss, and no intervention was put in place. Interviews with the RD, Staff Development Coordinator (SDC), and Director of Nursing (DON) revealed that the facility's process for monitoring and addressing weight changes was not followed, resulting in the oversight of the resident's significant weight loss. For Resident #29, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3, and vascular dementia, the facility failed to reweigh the resident in a timely manner to confirm a significant weight loss of 12.08% within a month. The resident's care plan included interventions for nutrition-related medication management and regular weight monitoring. However, the RD requested a reweigh 20 days after the initial significant weight loss was documented, and no interventions were implemented during this period. Interviews with the RD, SDC, and DON indicated that the facility did not adhere to its policy of promptly reweighing residents to verify significant weight changes and implement necessary interventions. Both cases highlight a failure in the facility's procedures for monitoring and addressing significant weight loss in residents. The facility's policy required timely reweighing and notification of the RD and physician for significant weight changes, but these steps were not followed, resulting in unaddressed weight loss for both residents. The lack of timely intervention and communication among staff contributed to the deficiencies observed in the care of Residents #69 and #29.
Failure to Re-evaluate PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two residents. Resident #49, who was admitted with diagnoses including dementia, dysphagia, and major depressive disorder, had a PRN order for Lorazepam that did not include an end date. The Unit Manager confirmed that PRN orders for Ativan should have a stop date and require re-evaluation by the doctor. Similarly, Resident #69, admitted with Alzheimer's disease, had a PRN order for Ativan that also lacked an end date. The Staff Development Coordinator, acting as Unit Manager, acknowledged that psychotropic medications used on a PRN basis need to be re-evaluated after 14 days and should include a clinical reason for continued use and an end date for further re-evaluation. Interviews with staff revealed a lack of adherence to the facility's policy on psychotropic medication use, which mandates that PRN orders for such medications are limited to 14 days and require documentation for any extension. Both residents were assessed to have severe cognitive impairments, and the failure to re-evaluate their PRN psychotropic medications as required by policy was confirmed by multiple staff members, including the Unit Manager and the Staff Development Coordinator.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Peabody
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Brooksby Village | 1.1 mi | ★★★★★ | 12 | 0 |
| Pilgrim Rehabilitation & Skilled Nursing Center | 1.3 mi | ★★★★★ | 5 | 0 |
| New England Homes For The Deaf, Inc | 1.6 mi | ★★★★★ | 0 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 1.8 mi | ★★★★★ | 6 | 0 |
| Twin Oaks Center | 1.8 mi | ★★★★★ | 0 | 0 |
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