Peabody Manor

Inspection findings

1. Mar 19, 2026 Health · 13 findings
   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 20, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 20, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Mar 20, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 20, 2026 · CMS fire safety

2. Jul 7, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jul 30, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 30, 2025 · CMS health inspection

3. Dec 18, 2024 Fire Safety · 17 findings
   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jan 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Jan 15, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Jan 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0161 Construction Deficiencies

     Use approved construction type or materials.

     Corrected Jan 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Jan 13, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 22, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Jan 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Jan 13, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jan 13, 2025 · CMS fire safety

4. Jun 5, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 1, 2024 · CMS health inspection

5. Sep 13, 2023 Fire Safety · 19 findings
   • Not serious Scope/severity F

     E0001 Emergency Preparedness Deficiencies

     Establish an Emergency Preparedness Program (EP).

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0023 Emergency Preparedness Deficiencies

     Establish policies and procedures for medical documentation.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0024 Emergency Preparedness Deficiencies

     Establish policies and procedures for volunteers.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0033 Emergency Preparedness Deficiencies

     Establish methods for sharing information.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Oct 2, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Sep 29, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Oct 2, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 6, 2023 · CMS health inspection

   • Not serious Scope/severity C

     K0531 Services Deficiencies

     Have elevators that firefighters can control in the event of a fire.

     Corrected Sep 29, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Oct 31, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Oct 5, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ANDRABI, IMRAN — operational/managerial control, NOT APPLICABLE, since 06/28/2017
• CARTER, LAURIE — operational/managerial control, NOT APPLICABLE, since 02/01/2022
• DALLAS, CHUCK — operational/managerial control, NOT APPLICABLE, since 02/11/2021
• DETTERMAN, BUFFY — operational/managerial control, NOT APPLICABLE, since 06/01/2025
• FLETT, WILLIAM — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• GLASHEEN, JENNIFER — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• GOGGANS, MARY — operational/managerial control, NOT APPLICABLE, since 02/01/2022
• GOGGANS, MARY — trustee of the snf, NOT APPLICABLE, since 02/11/2022
• KOEPER, DAVID — operational/managerial control, NOT APPLICABLE, since 01/01/2017
• KOESHALL, JACOB — adp of the snf, NOT APPLICABLE, since 01/01/2025
• KOESHALL, JACOB — operational/managerial control, NOT APPLICABLE, since 01/01/2025
• LOUX, ALAN — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• MORSE, MICHAEL — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• PAHL, SUSAN — operational/managerial control, NOT APPLICABLE, since 01/15/2025
• PIGEON, KATHLEEN — operational/managerial control, NOT APPLICABLE, since 01/15/2025
• PRICE, STEVEN — operational/managerial control, NOT APPLICABLE, since 02/01/2023
• SCHREIBER, RONALD — operational/managerial control, NOT APPLICABLE, since 03/01/2024
• SCHREIBER, RONALD — adp of the snf, NOT APPLICABLE, since 03/01/2024
• FROEDTERT THEDACARE HEALTH, INC. — operational/managerial control, NOT APPLICABLE, since 01/01/2024