A list of the most recent deficiencies for Peninsula Post-Acute. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-04-10 | 2023-05-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-21 | 2023-04-14 | Y |
| 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 | 2022-02-18 | 2022-04-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-04-08 | 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 | 2022-02-18 | 2022-04-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-18 | 2022-04-08 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-18 | 2022-04-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-18 | 2022-04-08 | N |
| 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. | Health | 2022-02-18 | 2022-04-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-18 | 2022-04-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-18 | 2022-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-18 | 2022-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-04-08 | N |
| Keep all essential equipment working safely. | Health | 2022-02-18 | 2022-04-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-18 | 2022-04-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-18 | 2022-04-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-18 | 2022-04-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-24 | 2022-03-14 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-25 | 2022-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-14 | 2022-01-31 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-08-04 | 2020-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-08-04 | 2020-08-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-09 | 2020-03-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-09 | 2020-03-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-09 | 2020-03-06 | N |
| 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. | Health | 2020-02-09 | 2020-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-09 | 2020-03-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-09 | 2020-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-19 | 2019-06-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-19 | 2019-06-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-19 | 2019-06-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-19 | 2019-06-19 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-19 | 2019-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-19 | 2019-06-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
