A list of the most recent deficiencies for Mission Hills Post Acute Care. 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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-24 | 2022-04-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-10 | 2022-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-10 | 2022-03-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-10 | 2022-03-14 | 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 | 2022-01-27 | 2022-02-24 | 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 | 2022-01-27 | 2022-02-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-27 | 2022-02-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-01-27 | 2022-02-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-27 | 2022-02-24 | 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 | 2022-01-27 | 2022-02-24 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-27 | 2022-02-24 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-01-27 | 2022-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-02-24 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-01-31 | 2022-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-31 | 2022-02-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-31 | 2022-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-31 | 2022-02-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-31 | 2022-02-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-23 | 2021-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-25 | 2021-09-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-27 | 2021-08-27 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-09 | 2021-08-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-22 | 2021-06-14 | Y |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-11-04 | 2019-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2019-11-19 | 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 | 2019-10-10 | 2019-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-10 | 2019-11-10 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-10-10 | 2019-11-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-10-10 | 2019-11-10 | 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 | 2019-10-10 | 2019-11-10 | 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 | 2019-10-10 | 2019-11-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-10 | 2019-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2019-11-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-10 | 2019-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2019-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-10 | 2019-01-04 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-12-10 | 2019-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-10 | 2019-01-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-10 | 2019-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-10 | 2019-01-04 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-12-10 | 2019-01-04 | 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 | 2018-10-04 | 2018-11-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-04 | 2018-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-04 | 2018-11-01 | N |
| Provide appropriate foot care. | Health | 2018-10-04 | 2018-11-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-04 | 2018-11-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-04 | 2018-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-11-01 | N |
