South Peninsula Hospital LTC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 28 beds and averages 26.0 residents a day — about 93% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 8.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 5.72 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · E2025-09-12 · tag F0567 — failed to protect residents' money held by the home — pattern
  Honor the resident's right to manage his or her financial affairs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure that interest earned on residents' trust accounts was correctly credited to the residents' accounts. This failure affected 23 of 26 residents reviewed (Residents #1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, and 26). The facility did not apply the interest earned to either the residents' actual account balances or to their account statements. As a result, residents and/or their representatives were not given timely or accurate information about the interest accrued in their personal funds.Findings:.Past non-compliance: The last standard recertification survey was conducted on 8/23/24. During the Recertification survey conducted on 9/12/25 past noncompliance was identified at F567. The state agency verified that the facility took appropriate corrective actions for noncompliance found at F567 with a correction date of 8/6/25. During the 9/8-12/25 recertification survey, it was found that the facility failed to include the trust account interest in the residents' trust account…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Past Non-Compliance
• Potential for harm · D2025-09-12 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure residents and/or resident representatives' participation in the development of the residents' care plan and document in the medical record an explanation of the residents and resident representatives' inability to participate for 2 residents (#3 and #20) out of 12 sampled residents. This failed practice denied the residents and/or resident's representatives the opportunity to make decisions regarding residents' care and treatment .Findings:.Resident #3Record review on 9/8-12/25, revealed Resident #3 was admitted to the facility with diagnoses that included nonrheumatic aortic valve stenosis (a type of heart valve disease wherein the valve is narrowed and doesn't open fully), unspecified dementia (loss of cognitive functioning) and major depression.Review of the Minimum Data Set (MDS - a federally required assessment) quarterly assessment, dated 8/26/25, revealed Resident #3 had a BIMS (Brief Interview of Mental Status) score of 15 (meaning the resident was cognitively intact).During an interview on 9/9/25 at 11:20…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interview, and record review the facility failed to ensure storage and preparation of food in accordance with professional standards for food service safety for 24 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25) out of 25 residents who received meals from the kitchen. This failed practice placed all residents at risk to receive contaminated food and placed these 24 residents at risk of foodborne illnesses. Findings: Food Storage: During an initial tour of the kitchen, on 8/19/24 at 11:03 AM, revealed in the stand-alone refrigerator near the preparation station in the main kitchen, unlabeled food items were stored such as: one unlabeled bag of frozen breaded items resembling chicken, one unlabeled bag of frozen breaded items resembling Chicken Cordon Blue, one unlabeled brown bag resembling frozen potato fries, one unlabeled rectangular container of what appeared to be pre-made chicken salad wrapped in saran wrap.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-05-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature. This failed practice had the potential to place all residents, based on a census of 25, at risk for poor nutrition due to foods served outside of palatable temperatures. Findings: During an observation beginning in the main kitchen on 5/8/23 at 12:20 PM, [NAME] #1 placed all the food from the steam table onto a cart and delivered the food to the Long-Term Care (LTC) kitchen. Upon reaching the LTC kitchen he/she washed his/her hands, put on gloves, prepared a pail of bleach water, wiped the steam table and placed the pans from the cart onto the steam table. He/she removed gloves, sanitized his/her hands and put on new gloves. Then, the cook began plating food according to each resident's diet card. The [NAME] did not check the temperature of the food which included mechanically altered food such as pork, potato, gravy, and soup. During an interview on 5/8/23 at 1:10 PM, Resident #17…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-05-12 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observation and interview, the facility failed to ensure their medication error rate was below 5%. Specifically, errors for 3 out of 27 medication opportunities during medication administration review resulted in a 11% error rate. This failed practice placed 2 residents (#'s 77 and 18) at risk for adverse effects. Findings: Resident #77: Record review from 5/8-12/23 revealed Resident #77 was admitted to the facility with diagnoses that included dementia and hypothyroidism. Review of Resident #77's current Physician's Orders revealed an order for Levothyroxine Sodium Oral Tablet [Synthroid-a thyroid medication] 75 mcg [micrograms] .one time a day related to HYPOTHYROIDISM, UNSPECIFIED. During an observation on 5/10/23 at 8:50 AM, Licensed Nurse (LN) #3 began preparing Resident #77's morning medications, which included the Levothyroxine Sodium Oral Tablet. The Resident was observed to be seated in the dining room eating his/her breakfast when LN #3 administered the medications to the resident. During an interview on 5/11/23 at 10:42 AM, when asked the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• No harm found · C2024-08-23 · tag F0568 — widespread
  Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure full and complete accounting of personal funds were reported quarterly to all 25 residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26) out of 25 residents residing at the facility, or their representatives with personal funds being managed by the facility. This failed practice denied the residents and/or representatives the right to be informed of a detailed accounting of their personal funds. Findings: During a joint interview on 8/21/24 at 4:09 PM with Account Specialist (AS) #1, Business Office Supervisor (BOS), Activities Coordinator (AC), Director of Nursing (DON), and Social Worker (SW), AS #1 stated the facility managed the residents' personal funds. The BOS stated each resident had an individual personal fund account recorded in Point Click Care (PCC). She stated all residents' personal funds were deposited in one trust account at the bank. The trust account was an interest-bearing account. The interest would be divided based on the individual accounts of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in AK