A list of the most recent deficiencies for South Peninsula Hospital Ltc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-11-15 | 2024-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-12 | 2023-07-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-12 | 2023-07-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-11 | 2023-06-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-11 | 2023-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-11 | 2023-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-15 | 2022-02-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-15 | 2022-01-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-17 | 2022-01-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-17 | 2022-01-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-17 | 2022-01-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-17 | 2022-01-01 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-17 | 2022-01-01 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-07 | 2021-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-07 | 2021-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-07 | 2021-05-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-07 | 2021-04-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-03-11 | 2020-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-11 | 2020-05-18 | N |
