Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Beverly Hills
Updated as of January 01, 2023
This is not the most recent data for Mission Point Nsg and Phy Rehab Ctr of Beverly Hills. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-31 | 2022-11-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-06 | 2022-10-05 | 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 | 2022-10-05 | 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 | 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 |
| 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 | 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-06 | 2022-10-04 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-06 | 2022-10-04 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | 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 |
| 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 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-06 | 2022-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-10-04 | 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 | 2022-09-06 | 2022-10-04 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-06 | 2022-10-04 | N |
| 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 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-06 | 2022-10-04 | N |
| Post nurse staffing information every day. | 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 |
| 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 | 2022-10-04 | 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 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-06 | 2022-10-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-06 | 2022-10-04 | N |
| 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 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-09-28 | 2020-09-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-29 | 2020-08-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-07-28 | 2020-08-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-28 | 2020-08-14 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-07-28 | 2020-08-14 | Y |
| 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 | 2020-07-28 | 2020-08-14 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-07-28 | 2020-08-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-24 | 2020-03-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-13 | 2020-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-13 | 2020-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-13 | 2020-02-17 | 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 | 2019-05-15 | 2019-06-21 | 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 | 2019-05-15 | 2019-06-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-15 | 2019-06-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-15 | 2019-06-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-15 | 2019-06-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-15 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-15 | 2019-06-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-05-15 | 2019-06-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-15 | 2019-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-15 | 2019-06-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-05-15 | 2019-06-21 | 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 | 2019-05-15 | 2019-06-21 | 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 | 2019-05-15 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-15 | 2019-06-21 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-05-15 | 2019-06-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-15 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-15 | 2019-06-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-15 | 2019-06-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-15 | 2019-06-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-15 | 2019-06-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-14 | 2019-06-21 | 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 | 2019-05-14 | 2019-06-21 | 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 | 2019-05-14 | 2019-06-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-14 | 2019-06-21 | 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 | 2019-05-14 | 2019-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
