Peabody Manor

• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0628. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on April 10, 2026.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 10, 2026.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for F0812 3 times since 2023.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on March 20, 2026.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for F0689 2 times since 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on March 20, 2026.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on April 10, 2026.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 10, 2026.

  CMS has cited this home for F0880 3 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0351. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on March 20, 2026.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 10, 2026.

  CMS has cited this home for K0712 2 times since 2023.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for K0353 2 times since 2024.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on March 20, 2026.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for K0923 2 times since 2024.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 30, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on July 30, 2025.

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• Name

  CMS lists a new legal business name for this home.

• Health citation

  CMS removed citation F0623 from the health inspection on December 18, 2024.

• Health citation

  CMS removed citation F0625 from the health inspection on December 18, 2024.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 15, 2025.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 15, 2025.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 15, 2025.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on January 15, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 15, 2025.

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CMS lists this as a standard inspection.

• Citation E0022. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for sheltering.

  CMS lists it as corrected on January 15, 2025.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on January 15, 2025.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on January 13, 2025.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 22, 2025.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on January 13, 2025.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on January 14, 2025.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on January 15, 2025.

• Citation K0753. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have restrictions on the use of highly flammable decorations.

  CMS lists it as corrected on January 15, 2025.

• Citation K0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on January 15, 2025.

• Citation K0914. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on January 13, 2025.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 13, 2025.

• Citation K0781. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on January 15, 2025.

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• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on July 1, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on July 1, 2024.

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• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 5.1 to 4.6 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on October 6, 2023.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on October 2, 2023.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 29, 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on October 30, 2023.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on October 2, 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 6, 2023.

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CMS lists this as a standard inspection.

• Citation E0001. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish an Emergency Preparedness Program (EP).

  CMS lists it as corrected on October 5, 2023.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on October 5, 2023.

• Citation E0007. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address patient/client population and determine types of services needed.

  CMS lists it as corrected on October 5, 2023.

• Citation E0020. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures including evacuation.

  CMS lists it as corrected on October 6, 2023.

• Citation E0023. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on October 5, 2023.

• Citation E0024. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on October 5, 2023.

• Citation E0033. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish methods for sharing information.

  CMS lists it as corrected on October 5, 2023.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on October 5, 2023.

• Citation K0711. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on October 5, 2023.

• Citation K0911. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on October 31, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on October 5, 2023.

• Citation K0531. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on September 29, 2023.

• Citation K0712. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on October 5, 2023.

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