Deficiency Records for South Peninsula Hospital Ltc
Updated as of November 01, 2021
This is not the most recent data for South Peninsula Hospital Ltc. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-10-27 | 2020-12-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-10-27 | 2020-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-12 | 2020-09-26 | 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 |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-01-24 | 2020-02-25 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-10-26 | 2019-01-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-26 | 2018-12-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-26 | 2018-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-26 | 2018-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-26 | 2018-12-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-26 | 2018-12-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-26 | 2018-12-08 | N |
| 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. | Health | 2018-10-26 | 2018-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-26 | 2018-11-23 | N |
| 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 | 2018-10-26 | 2018-11-21 | 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 | 2018-10-26 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-26 | 2018-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-26 | 2018-11-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-24 | 2018-11-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-24 | 2018-11-17 | N |
| Keep all essential equipment working safely. | Health | 2018-10-26 | 2018-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-24 | 2017-10-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-24 | 2017-10-13 | N |
| Meet other general requirements. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-28 | 2017-10-12 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-08-24 | 2017-10-08 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-08-24 | 2017-10-08 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-24 | 2017-10-08 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-24 | 2017-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-08-24 | 2017-10-08 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-08-24 | 2017-10-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-24 | 2017-10-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-24 | 2017-10-08 | N |
