Health inspection·January 27, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff and public by failing to ensure the ceiling was free from water leaks for two of five sampled residents (Resident 2 and Resident 3). This failure had the potential to place Resident 2 and 3 at risk for falls or injury from fracture (break in bone). Findings: I. A review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), hypertensive heart disease without heart failure (the heart is being affected by high blood pressure [hypertension] over a long period of time, causing changes to the heart muscle, but it's not yet weak enough to be considered heart failure where the heart can't pump blood effectively) and hyperlipidemia (abnormally high levels of fats in the blood). A review of the Minimum Data Set (MDS – resident assessment tool) dated 12/18/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 was independent for activities of daily living (ADLsroutine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 2 ' s Care Plan (CP) for at risk for falls, initiated on 10/4/2024 indicated a goal of resident (2) will be free of falls and interventions including, resident (2) needs a safe environment with even floors free from spills and/or clutter. II. A review of the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and - chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of the MDS dated [DATE], indicated Resident 3 ' s skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required moderate to maximal assistance from staff for ADLs. The MDS also indicated, Resident 3 uses manual wheelchair for assistive mobility device. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555139 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)