Health inspection·March 14, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to Residential Care Facility for the Elderly (RCFE) for one of three sampled residents (Resident 1) by failing to: 1. to have resident's physician document the reason for discharge in the medical record. 2. have documentation of communication with the receiving facility about Resident 1's discharge and follow up call to the facility on how the resident was adjusting to the new facility. These failures had the potential to result in ineffective discharge planning, with disruption in continuity of care, and complications in the resident's recovery. Cross reference with F712. Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further indicated Resident 1 was self- responsible. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/24 indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and had medically complex conditions. The MDS further indicated Resident 1 required set up or clean-up assistance to supervision or touching assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), toilet transfers and walking, and was independent with bed mobility. During a review of Resident 1's physician order dated 9/11/24 indicated may discharge to Residential Care Facility for the Elderly (RCFE) with Home Health Agency (HHA) with Physical Therapy, Occupational Therapy and Registered Nurse. No Durable Medical Equipment (DME -refers to medical devices like wheelchairs, walkers, oxygen equipment, and hospital beds that are designed to be used repeatedly at home) for discharge. Follow up with Primary Care Provider (PCP), Psychiatry after discharge (RCFE to arrange). May have all remaining medications. Social Services Director (SSD) to arrange necessary arrangements. (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 6 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 03/14/2025 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)