Peabody Retirement Community

F-F686.

3.1-52(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48146 potential for actual harm A. Based on observation, interview and record review, the facility failed to utilize infection prevention and Residents Affected - Some control practices for residents in droplet precautions for 6 of 9 residents reviewed for infection control. (Residents 369, 15, 109, 147, 29, and 153). This deficiency had the potential to affect 38 of 38 residents with orders for droplet precautions.

B. Based on observation and interview, the facility failed to ensure infection prevention and control practices were followed during dining services for 3 of 8 residents observed in the Evergreen Park Unit dining room. (Residents 75, 76, and 94)

Findings include:

A1. On 4/3/25 at 10:23 a.m., Resident 109's room had a Droplet Precautions sign posted by the door. CNA 20 exited Resident 109's room, leaving the door open. No hand hygiene was performed upon exiting the room. CNA 20 walked to another area of the unit and retrieved a mechanical lift. CNA 20 re-entered Resident 109's room and closed the door. Upon exiting the room, CNA 20 carried a bag of trash to the appropriate trash receptacle. Resident 109 was seated in a wheelchair beside the bed. CNA 20 washed their hands with soap and water. The CNA returned to the resident's room, retrieved the mechanical lift, and walked to another area of the unit. CNA 20 was not wearing eye covering during any part of the observation.

Resident 109's clinical record was reviewed on 4/9/25 at 1:36 p.m. Diagnoses included unspecified dementia, coronary artery disease, and type 2 diabetes mellitus.

A current physician's order, dated 3/25/29, indicated droplet precautions, every shift, related to viral syndrome such as coughing and wheezing.

A 2/28/25, Quarterly Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Resident 109 was dependent on staff for bed mobility and transfers.

A2. During an observation, on 4/3/25 at 2:37 p.m., Resident 15's room had a Droplet Precautions sign posted by the door, noticeable before entry. QMA 11 answered the call light for Resident 15, leaving the door open. QMA 11 entered the resident's room, stood at the resident's bedside and spoke with them for several minutes. QMA 11 exited Resident 15's room. No hand hygiene was performed. QMA 11 was not wearing eye covering during the observation.

Resident 15's clinical record was reviewed on 4/9/25 at 1:37 p.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, and morbid obesity.

A current physician's order, dated 3/25/29, indicated droplet precautions, every shift, related to Influenza A diagnosis.

A 1/22/25, Quarterly MDS assessment indicated the resident was cognitively intact. Resident 15 required substantial assistance from staff for bed mobility and transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An isolation precaution care plan, initiated 3/31/25, indicated Resident 15 required droplet isolation for seven (7) days related to a diagnosis of Influenza A. Interventions included all good and services brought to Level of Harm - Minimal harm or resident's room, droplet precautions as ordered, and resident to remain in private room to prevent spread. potential for actual harm A3. During an observation, on 4/7/25 at 1:04 p.m., Resident 369's room had a Droplet Precautions sign Residents Affected - Some posted by the door. CNA 21 answered the call light for Resident 369. CNA 21 entered the resident's room and closed the door. CNA 21 was not wearing eye covering during the observation. No hand hygiene was performed upon exiting the room. Resident 369's room had a Droplet Precautions sign posted by the door.

During an interview, at the time of the observation, CNA 21 indicated since the Personal Protective Equipment (PPE) was not visible at the resident's doorway, she went into the room anyway. If the PPE isn't easily noticeable, she would talk to the nurse manager to get help finding it. CNA 21 indicated she should have done this before she entered the resident's room.

During an observation, on 4/7/25 at 1:22 p.m., Resident 369's room had a Droplet Precautions sign posted by the door. Dietary Aide 22 entered Resident 369's room. Dietary Aide 22 stood at the resident's bedside and spoke with them for several minutes. No hand hygiene was completed upon exiting the room. Dietary aide 22 was not wearing eye covering during the observation.

During an interview, at the time of the observation, Dietary Aide 22 indicated the Droplet Isolation sign at the doorway meant staff needed to wear gowns and gloves to prevent the spread of infections when they were working closely with the resident. Since she had talked with the resident, she had not needed to wear any PPE while in the resident's room.

Resident 369's clinical record was reviewed on 4/7/25 at 12:55 p.m. Diagnoses included type 2 diabetes mellitus, morbid obesity, and unspecified cirrhosis of the liver.

A current physician's order, dated 3/31/25, indicated droplet isolation related to cough, shortness of breath, and respiratory flu symptoms until 4/8/25.

A care plan, initiated on 3/30/25, indicated Resident 369 required droplet isolation related to signs and symptoms of Influenza A for 7 days. Interventions included to encourage good oral intake, give medications as ordered for fever and pain, and monitor, document, and report signs of dehydration.

A 3/13/25, Admission MDS indicated the resident was moderately cognitively impaired. Resident 369 required substantial assistance from staff for bed mobility. He was dependent on staff for transfers.

45122

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A4. During an observation, on 4/4/25 at 9:42 a.m., signage on Resident 147's room indicated the following: DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when Level of Harm - Minimal harm or leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry . The signage potential for actual harm had a picture of a person wearing a face shield and a person wearing goggles with an or between the pictures. CNA 6 donned a gown, gloves, and placed an N95 mask over her surgical mask. She entered the Residents Affected - Some room and spoke with the resident. She removed her personal protective equipment (PPE) prior to exiting the room. She sanitized her hands and applied a clean surgical mask.

During an interview, on 4/4/25 at 9:45 a.m., CNA 6 indicated she was supposed to fully apply PPE to enter

the resident's room. The facility training had indicated she did not need a face shield for Resident 147 nor Resident 29.

Resident 147's clinical record was reviewed on 4/4/25 at 10:39 a.m. Diagnoses included chronic obstructive pulmonary disease and bronchitis.

A current physician's order, dated 3/31/25, indicated the resident was to remain in droplet precautions isolation due to a diagnosis of bronchitis until the symptoms resolved or resident was fever free for 48 hours without intervention.

A quarterly Minimum Data Set (MDS) assessment, dated 1/8/25, indicated the resident was severely cognitively impaired. He required substantial/maximal assistance with oral hygiene, toileting, showering/bathing, upper/lower body dressing, personal hygiene, moving from sitting to lying, moving from lying to sitting, and transfers. He was dependent on the staff for putting on/taking off footwear.

A5. During an observation, on 4/4/25 at 9:48 a.m., a droplet precautions sign was on Resident 29's door. QMA 7 sanitized her hands, donned a gown, gloves, and placed an N95 mask over her surgical mask. She removed her eyeglasses and entered the resident's room. She delivered medications to the resident. She removed her PPE and exited the room, leaving her surgical mask on. She put on her glasses.

During an interview on 4/4/25 at 9:51 a.m., QMA 7 indicated she was not required to wear the N95 mask, but

she did so because she wanted to have extra protection against the respiratory infections. The facility did not require face shields/ eye protection for the droplet rooms, which included Resident 29 and Resident 147.

During an interview on 4/4/25 at 9:57 a.m., QMA 7 indicated she should have worn a face shield into the residents' rooms with droplet precautions.

Resident 29's clinical record was reviewed on 4/7/25 at 10:59 a.m. Diagnoses included unspecified asthma, chronic obstructive pulmonary disease, dependence on supplemental oxygen, pneumonia, acute respiratory failure with hypoxia, and shortness of breath.

Physician's orders included prednisone 40 milligrams (mg) daily for increased cough for five days (3/31/25), amoxicillin 500 mg (antibiotic) two times a day for pneumonia (4/1/25), and azithromycin (antibiotic) 500 mg for one day (started 3/31/25 and discontinued 3/31/25), azithromycin 250 mg daily for four days (4/1/25), oxygen at two to three liters per minute via nasal cannula (3/31/25), and the resident was to remain on droplet precautions until symptom resolution or was fever free without intervention (started 3/31/25, discontinued 4/4/25).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An admission MDS, dated [DATE REDACTED], indicated the resident was cognitively intact. She required partial/moderate assistance with toileting hygiene, showering/bathing, upper body dressing, and ambulating Level of Harm - Minimal harm or 10 feet. She required substantial/maximal assistance with lower body dressing, putting on/taking off potential for actual harm footwear, rolling in bed, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, bed to chair/chair to bed transfers, and toilet transfers. Residents Affected - Some

During an interview on 4/8/25 at 5:07 p.m., the Infection Preventionist indicated eye protection was required to enter rooms with droplet precautions. The staff were expected to read and follow the isolation signage on

the doors.

42685

A6. During an observation on 4/2/25 at 4:52 p.m., CNA 15 approached Resident 153's room, where a droplet isolation sign was in place at the door. The droplet isolation sign indicated everyone was required to perform hand hygiene before entering and when leaving the room. A face shield or goggles was required. The face protection was required to be removed prior to exiting the room. She donned a gown and gloves, and entered the resident's room. CNA 15 already had a surgical mask in place when she approached the resident's room. The mask was not changed when she entered the room and delivered a cup of water to the resident. She wore regular eyeglasses. Eye protection was not worn during the observation. CNA 15 doffed her gown and gloves and exited the room at 4:54 p.m., without removing her surgical mask. She continued to deliver water to random residents' rooms on the Cedar Ridge Unit.

Resident 153's clinical record was reviewed on 4/4/25 at 10:52 a.m. Diagnoses included influenza due to identified novel Influenza A virus with other respiratory manifestations.

A physician's order, from 3/27/25 to 4/3/25, indicated the resident was required to remain on droplet precautions isolation due to a diagnosis of Influenza A.

An isolation precaution care plan, initiated 3/27/25 and discontinued on 4/4/25, indicated the resident required droplet isolation for seven days related to a diagnosis of Influenza A. Interventions included droplet precautions as ordered (3/28/25).

During an interview on 4/4/25 at 1:17 p.m., CNA 25 indicated staff were required to don a gown, gloves, surgical mask, and a face shield prior to the entrance of residents' rooms on droplet precautions.

During an interview on 4/7/25 at 1:41 p.m., CNA 15 indicated staff were required to don a gown, gloves, face mask, and a face shield prior to the entrance of residents' rooms on droplet precautions. She had not donned

a face shield during the observation on 4/2/25 when she delivered ice water to Resident 153. Face shields were readily available and the droplet signs indicated goggles or a face shield was required.

During an interview on 4/7/25 at 2:36 p.m., the Infection Preventionist (IP) indicated the staff were required to wear a surgical face mask and a face shield or goggles for residents requiring droplet precautions. If the staff were at risk for high contact with the resident, their surroundings, or bodily fluids, they were expected to wear

a gown and gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 4/8/25 at 11:23 a.m., the IP (Infection Preventionist) indicated the facility followed the Center for Disease Control (CDC) guidelines for droplet precautions. Level of Harm - Minimal harm or potential for actual harm A current facility policy, dated 2001 and titled Isolation - Categories of Transmission-Based Precautions, provided by the DON on 4/7/25 at 9:25 a.m., indicated the following: .Policy Statement . Transmission-based Residents Affected - Some precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . Policy Interpretation and Implementation . 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and

on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precautions(s), instructions for use of PPE . Droplet Precautions . 4. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions

51985

B1. During a continuous observation on 4/2/25 from 11:35 a.m. to 12:20 p.m., CNA 10 was assisting Resident 75 with his meal. The CNA rested her elbows on the dining room table and used her left index finger to rub her nose. She picked up the resident's fork and assisted him with his meal. She palmed over the top of Resident 75's drinking cup with her right hand and assisted the resident with a drink. She turned to her left and used the same hand to palm the top of Resident 94's bowl. She obtained a spoonful of food, brought

it up to her lips, and blew on the food. She indicated that the food was hot and placed the spoonful of food into Resident 94's mouth. The CNA palmed the top of Resident 94's cup and gave the resident a drink. She wiped Resident 94's mouth with a napkin. She turned back to Resident 75 and offered the resident a bite of food. She indicated to Resident 75 the food was not hot because she had blown on it. Resident 75 took a bite of the food. She picked up Resident 94's unused fork, reached across the table, and used the fork to move the remaining food around on Resident 76's plate. She sat the fork down back in front of Resident 94.

She stood up and left the table. She approached the kitchenette in the dining room and requested dietary staff to get Resident 76 more onion rings. She retrieved a clean cup, walked over to the refrigerator, and used her hands to open the refrigerator door. She balanced the cup on the refrigerator door and put her finger inside the rim of the cup. She poured milk into the cup. She picked up the previously used fork in front of Resident 94 and used it to offer Resident 75 his dessert. She assisted Resident 75 with his meal. She palmed the top of Resident 75's cup and assisted the resident with a drink. CNA 10 did not perform hand hygiene throughout the observation.

During an interview on 4/8/25 at 12:20 p.m., CNA 24 indicated plates, bowls, and cups were handled from

the bottom and the tops of bowls and cups were not touched. Hand hygiene was to be done frequently when

in the dining room. Hand hygiene was to be performed after personal clothing, face, and hair was touched. Food was never touched bare handed. Utensils were not shared among residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 155655 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155655 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peabody Retirement Community 400 W Seventh St North Manchester, IN 46962

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 4/9/25 at 11:09 a.m., the Infection Preventionist indicated staff had been encouraged to carry their own hand sanitizer when they assisted in the dining room. Hand hygiene was to be performed Level of Harm - Minimal harm or often during individual dining assistance and between multiple residents. Hand hygiene was to be performed potential for actual harm when personal clothing, face, or hair were touched. Utensils, cups, or plates were not to be shared among residents. Food was to be cooled naturally, and a replacement plate item obtained if it was too hot and not Residents Affected - Some cooled down timely. Food was not to be touched with bare hands and was not to have been blown on to cool

it off. Tableware was to be handled from the underside and the top rim or lip area of cups, and bowls were not to be touched.

A current facility policy, revised on March 2022 and provided by the DON on 4/9/25 at 10:00 a.m., titled Assistance with Meals, indicated the following: .All Residents: 3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling

3.1-18(a)

3.1-18(b)(2)

3.1-18(l)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 155655