Health inspection·September 15, 2025

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep the call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) within reach for one of three random selected residents (Resident 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents.During a review of Resident 3's Record of Admission (undated), indicated, Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic lung condition that causes the airways to become inflamed and narrow, making it difficult to breathe), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and hyperlipidemia (a medical condition characterized by abnormally high levels of fats (lipids) in the bloodstream). During a review of Resident 3's History and Physical (H&P), dated 11/26/2024 indicated, Resident 3 was had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 7/22/2025, indicated that Resident 3 was cognitively intact (a person's thinking, memory, and other conscious mental processes are normal and functioning well, allowing them to manage daily tasks and environmental demands without significant impairment). The same MDS further indicated Resident 3 was mostly required partial/moderate assistance for her Activities of Daily Living (ADLs-toileting, shower/bathe self, lower body dressing, and putting on/taking off footwear). During a review of Resident 3's Care Plan (CP) created 8/20/2024 with a focus The resident has an ADL self-care performance deficit r/t (related to), multiple diagnoses, the CP indicated interventions which included:- Encourage the resident (Resident 3) to use bell to call for assistThe resident (Resident 3) requires assistance by (1) staff with personal hygiene and oral care.During a concurrent observation and interview of Resident 3 on 9/15/2025 at 12:04 pm, Resident 3 was heard screaming for a CNA to come and assist her. Resident 3 stated that she had been calling for about 4 hours with no help in sight. Resident 3 stated that she was unable to reach the call light, which was a very common occurrence and was left without receiving much-needed help. The call light was observed on the floor to the left side of her bed and out of reach. Resident 3 stated that she was calling because she needed some help with removing the extra clothing that had bunched up under and was uncomfortable. Resident 3 stated that her skin was clear. During a concurrent observation and interview of Resident 3 on 9/15/2025 at 12:05 pm with the Registered Nurse Supervisor (RNS), RNS confirmed that the call light was out of reach of Resident 3. RNS stated that call lights must be within reach of residents so that the resident's needs such as requests for receiving medications or emergency situations such as shortness of breath and falls. During an interview with the Director of Nursing (DON) on 9/15/2025 at 1:04 pm, the DON stated that call light must be within reach to ensure that they had access to call the facility staff. The DON stated that not having the call light within Residents Affected - Few Page 1 of 2 555139 555139 09/15/2025 Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach could potentially place the residents at risk for injuries from accidents such as falls. During a review of the facility's policy and procedures (P&P), titled, Answering the Call Light, reviewed 1/25/2025, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. The same P&P indicated the following guidelines:- Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.- Ask the resident to return the demonstration,- Explain to the resident that a call system is also located in his/her bathroom. Be sure that the call light is plugged in and functioning at all times.- Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.- Report all defective call lights to the nurse supervisor promptly. 555139 Page 2 of 2