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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 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 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

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