Health inspection·June 5, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote dignity and respect for one of three sampled residents (Resident 3) by failing to: 1. Provide clean clothings and linen. 2. Provide an incontinence (Inability to control the flow of urine from the bladder [urinary incontinence] or the escape of stool from the rectum [fecal incontinence] diaper. This deficient practice placed Resident 3 to feel uncared for and embarrassed. Findings: During a review of Resident 3 ' s admission record indicated the facility was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included End Stage Renal Disease (ESRD- the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (HD- a procedure that cleans your blood when your kidneys can't do it properly), and chronic obstructive pulmonary disease (COPD- a progressive lung disease that causes long-term inflammation and damage to the airways and lungs). During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool) dated 5/8/2025, indicated Resident 3 had mild cognitive impairment (a condition where individuals experience memory or other cognitive issues, such as language or judgment, that are noticeable but don't significantly interfere with daily activities). The same MDS indicated Resident 3 required between partial/moderate and substantial/maximal assistance for most of his Activities of Daily Living such as: (ADLs routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a concurrent observation and interview with Resident 3 on 6/5/2025 at 8:43 am, Resident 3 was observed in the hallway of the unit propelling himself in his wheelchair. Resident 3 was noted to be wearing a white t-shirt and green pants; the pants were unzipped and about midway around the hips. Resident 3 ' s white t-shirt was observed to have several yellowish and brownish stains. Resident 3 stated that he usually feels embarrassed and uncared for because the facility staff did not assist him to look presentable especially when he goes out to his HD appointments. He (Resident 3) stated that his incontinence diaper usually gets very soiled and gets forced to remove it and stay without for long periods of time. In Resident 3 ' s room, Resident ' s clothing were on both sides of his (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 2 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 06/05/2025 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)