Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Beverly Hills
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Beverly Hills. 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 smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-24 | 2023-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-12-11 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-10-26 | 2023-12-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-26 | 2023-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-12-11 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-26 | 2023-12-11 | 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 | 2023-10-26 | 2023-12-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-26 | 2023-12-11 | 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 | 2023-10-26 | 2023-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-12-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-26 | 2023-12-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-26 | 2023-12-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-26 | 2023-12-11 | 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 | 2023-10-26 | 2023-12-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-26 | 2023-12-11 | 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 | 2023-10-26 | 2023-12-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-12-11 | Y |
| 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 | 2023-10-26 | 2023-12-11 | Y |
| 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 | 2023-10-26 | 2023-12-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-26 | 2023-12-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-26 | 2023-12-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-12-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-26 | 2023-12-11 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-24 | 2023-12-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-08-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-03 | 2023-08-24 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-03 | 2023-08-24 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-03 | 2023-08-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-03 | 2023-08-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-21 | 2023-08-24 | 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 | 2023-06-09 | 2023-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-07-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-09 | 2023-07-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-09 | 2023-07-06 | 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 | 2023-06-09 | 2023-07-06 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-09 | 2023-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-09 | 2023-07-06 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-09 | 2023-07-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-06 | 2022-11-18 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-06 | 2022-11-18 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-09-06 | 2022-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-06 | 2022-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-11-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-06 | 2022-11-18 | 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 | 2022-09-06 | 2022-11-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-06 | 2022-11-18 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-06 | 2022-11-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-06 | 2022-11-18 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-31 | 2022-11-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-06 | 2022-10-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-06 | 2022-10-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-06 | 2022-10-04 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-09-06 | 2022-10-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-06 | 2022-10-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-06 | 2022-10-04 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-06 | 2022-10-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-06 | 2022-10-04 | 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 | 2022-09-06 | 2022-10-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-06 | 2022-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-06 | 2022-10-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-06 | 2022-10-04 | 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 | 2022-09-06 | 2022-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-06 | 2022-10-04 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-09-06 | 2022-10-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-06 | 2022-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-06 | 2022-10-04 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-06 | 2022-10-04 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-09-06 | 2022-10-04 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-06 | 2022-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-06 | 2022-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-06 | 2022-10-04 | 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 | 2022-09-06 | 2022-10-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-06 | 2022-10-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-06 | 2022-10-04 | Y |
| 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 | 2022-09-06 | 2022-10-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-06 | 2022-10-04 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-06 | 2022-10-04 | Y |
| Post nurse staffing information every day. | Health | 2022-09-06 | 2022-10-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-06 | 2022-10-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-31 | 2022-10-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-05 | 2022-07-13 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-05 | 2022-07-13 | 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 | 2022-05-05 | 2022-06-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-05 | 2022-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-05 | 2022-06-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-05 | 2022-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-06-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-05 | 2022-06-01 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-05-05 | 2022-06-01 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-05-05 | 2022-06-01 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-05-05 | 2022-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-06-01 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-05 | 2022-06-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-01 | 2021-09-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-01 | 2021-09-15 | Y |
| 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 | 2021-06-17 | 2021-09-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-03 | 2021-08-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-16 | 2021-07-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-16 | 2021-07-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-16 | 2021-07-27 | 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 | 2021-06-17 | 2021-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-17 | 2021-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-07-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-17 | 2021-07-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-06-17 | 2021-07-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-17 | 2021-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-17 | 2021-07-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-17 | 2021-07-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-17 | 2021-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-17 | 2021-07-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-17 | 2021-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-26 | 2021-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-06-17 | Y |
