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Deficiency Records for Peninsula Post-Acute
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.
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? |
|---|---|---|---|---|
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-10-18 | 2024-12-10 | Y |
| 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 | 2024-10-18 | 2024-12-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-10-18 | 2024-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-18 | 2024-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-10-18 | 2024-12-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-10-18 | 2024-12-10 | 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 | 2024-10-18 | 2024-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-10-18 | 2024-12-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-18 | 2024-12-10 | 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 | 2024-10-18 | 2024-12-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-10-18 | 2024-12-10 | 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 | 2024-10-18 | 2024-12-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-10-18 | 2024-12-10 | 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 | 2024-10-18 | 2024-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-18 | 2024-12-10 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-10-18 | 2024-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-18 | 2024-12-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Develop a communication plan. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Use approved construction type or materials. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-21 | 2024-11-07 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-04-29 | 2024-05-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-27 | 2024-03-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-27 | 2024-03-22 | Y |
| 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-18 | 2022-04-08 | 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 | 2022-02-18 | 2022-04-08 | N |
| 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 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 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 |
| 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 |
| 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 |
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