Health inspection·November 17, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few joint). involving the metaphysis and extending to the articular surface of the lateral tibial plateau and likely the tibial spine. 2. Acute, mildly displaced fracture of the proximal fibular metaphysis (the upper part of the calf bone). A review of Resident 1's GACH 1 progress notes dated 11/20/2025, indicated Resident 1 had Acute Schatzker type VI (split wedge) bicondylar right tibial plateau fracture with moderate associated lipohemarthrosis status post (s/p) right lower extremity (RLE- right lower leg) external fixation (ex-fix) on 11/5/2025. On 11/7/2025, Resident 1 underwent open reduction internal fixation (ORIF- a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods) to the RLE. A review of Resident 3's admission record indicated Resident 3, was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis that included essential hypertension (High blood pressure that has no identifiable medical cause), Anemia (a condition where your blood has too few healthy red blood cells, which means your body doesn't get enough oxygen). A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition (the mental ability to understand and make decisions of daily living) was moderately intact. The MDS indicated Resident 3 had impairment to upper extremities (arms) and lower extremities (legs). Resident 3 was unable to ambulate. Resident 3 required assistance with eating, oral hygiene, upper body dressing, and was dependent with toileting, shower/bathe self, lower body dressing, and personal hygiene. A review of Resident 3's care plan initiation date 10/30/2025, indicated: Focus: Resident 3 is alert and oriented times 3 (three-name, place, time and date). During an observation, interview, and concurrent record review, on 11/12/2025 at 11:06 a.m., Resident 3 noted sitting up in bed. Resident 3 stated that Resident 1 acts erratic from time to time. Resident 3 stated that on 11/4/2025, Resident 1 climbed on top of the nightstand and broke the window with something in her (Resident 1) hand. Resident 3 stated Resident 1 wonders in and out of the room and disturbs Resident 3's sleep and that the nurses don't do anything about Resident 3's behavior of wandering around. Resident 3 stated was very scary to be in the same room with Resident 1 and was happy that Resident 1 was moved to another room. Resident 3 stated she was now able to sleep in peace and was not afraid to go to sleep. During an interview and concurrent record review on 11/12/25 at 2:23 p.m., License Vocational Nurse (LVN) 2 stated she was the Desk nurse on night (11/4/2025) of the incident with Resident 1. on the 3 pm-11 pm shift. LVN 2 stated she notified the Psychiatry Nurse Practitioner (NP) about Resident 1's aggressive behavior. LVN 2 stated she received a new order for Resident 1 to received intramuscular (IM - into muscle) Haldol medication for mental illness) and Benadryl (medication to sedate/make sleepy) one time dose was order. LVN 2 stated the NP did not give her an order to transfer the Resident 1 to a hospital. LVN 2 stated Resident 1's behavior continued to increase by hitting and kicking the window in Resident 1's room. LVN 2 stated she heard a nurse calling for help and when she got to Resident 1's room, Resident 1 was already on the floor complaining of pain in her right leg. LVN 2 stated she then feared for safety of the staff and the other residents/roommates and called 911 (emergency medical response number). LVN 2 stated she assisted LVN 4 Charge Nurse to perform a head-to-toe assessment on Resident 1. LVN 2 stated she noted the window in Resident 1's was broken so she placed the Resident 1 in the wheelchair for safety. LVN 2 stated the paramedics came and transferred Resident 1 to GACH 1. LVN 2 stated that the police came to the facility after the resident was transferred to GACH 1. During an interview and concurrent record review on 11/12/25 at 3:33 p.m., LVN 4 she works the 3pm-11pm shift and that on 11/4/2025LVN 4stated Resident 1 has had behavior issues but was sent to the hospital on a 5150 (72 hours involuntarily psychiatric hold) hold on 10/12/25. LVN 4 stated earlier on in his shift, Resident 1 has been trying to elope from the facility on multiple occasions and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 2 of 5 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 11/17/2025 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)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was being aggressive with the staff. LVN 4 stated the NP was notified who gave an order to administer IM medication Haldol and Benadryl times 1 dose. LVN 4 first stated he heard the CNA yelling for help and when he got to the room Resident 1 was already on the floor with a swollen right leg. LVN 4 stated he yelled for help from the other license nurses because Resident 1 was on the floor complaining about pain in the right leg, and that the right leg was swollen. During an interview on 11/12/25 at 3:46 p.m., Director of Nursing (DON) stated LVN 2 notified her via telephone on the night (11/4/2025) of the incident that Resident 1 had a psychotic episode and broke the window and injured the right leg. DON stated Resident 1 was sent out on 10/11/25 and placed on a 5150 hold for being delusional. DON stated that during the telephone call with LVN 4 she did not ask why Resident 1 was not transferred to the hospital for trying to elope on multiple occasions. DON stated, Yes. Resident 1's episode of breaking the window and injuring her leg could have been avoided if the resident was sent to the hospital for evaluation of trying to elope on multiple occasions. During an interview on 11/17/25 at 9:03 p.m., CNA 2 stated that on 11/4/25 she worked the 3pm-11pm shift. CNA 2 stated at the beginning of her shift, that she reported to LVN 4 that Resident 1 was attempting to elope from the facility and was presenting with aggressive behavior. CNA 2 stated she reported to LVN 4 but LVN 4 just sat at the nurses' station and did nothing. CNA 2 stated she was across the hall taking care of another Resident and she heard loud banging coming from Resident 1's room. CNA 2 stated she went inside Resident 1's room and witnessed Resident 1 fall on the floor from off of the nightstand. CNA 2 stated she noticed Resident 1 had a metal object in her hand. CNA 2 stated Resident 1's right leg started to swell right away. A review of the facility Policy and Procedures titled< Accident and Incidents-Investigating and Reporting with a reviewed date 1/25/25, indicated, Policy Interpretation and Implementation: 1. the Nurse Supervisor/Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigations of the accident or incident. 2. b. the nature of the injury/illness. c. the circumstances surrounding the accident or incident. Event ID: Facility ID: 555139 If continuation sheet Page 3 of 5 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 11/17/2025 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2), by failing to ensure:1. Resident 2 was not admitted and remained in a cold room with a broken window on 11/4/2025 2. Repaired broken window in a timely manner.3. Checked and logged the resident's room temperature to ensure the room temperature was comfortable and not cold.4. Provide Resident 2 with extra blankets to keep the resident warm.5. Move resident 2 to another room with no broken window. These failures:1. Resulted in Resident 2 stating he was very angry and suffered/endured the from extreme cold temperature for two days and nights placing Resident 1 at increased risk to suffer hypothermia (a condition that occurs when core body temperature drops below 95 degrees Fahrenheit). Resident 2 was at risk suffer injury(ies) from the broken glass.2. Had the potential for insects/rodents to enter Resident 2's room through the broken window.Findings: A review of Resident 2's admission record indicated Resident 2, was originally admitted to the facility on [DATE] with diagnoses that include heart failure (ongoing condition where the heart muscle becomes too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), bipolar disorder (a mental health condition characterized by extreme mood swings that include episodes of high energy and euphoria (mania or hypomania)and episodes of low mood sadness (depression) and acute respiratory failure with hypoxia (is when your lung's can't get enough oxygen into your blood to deliver to the rest of your body, which can happen suddenly). A review of Resident 2's History and Physical dated 9/19/25, indicated Resident 2 had the capacity to make medical decisions. A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, indicated Resident 2's cognition (the mental ability to understand and make decisions of daily living) was moderately impaired. Resident 2 had no impairment to upper extremities (arms) and no impairment to lower extremities (legs) and ambulated independently. Resident 2 required supervision or touching assistance with eating, oral hygiene, upper body dressing, and personal hygiene, and partial/moderate assistance with toileting, shower/bathe self, with lower body dressing. During an observation and concurrent interview on 11/12/2025 at 10:33 a.m., Resident 2 was noted in his room (Room B) sitting on his bed with long pants, shirt, and a black sweatshirt and hood on his head with both arms folded and leaning forward. A window in Resident 2's room was noted without a glass covering (broken). Resident 2's room temperature felt very cold. Resident 2 stated he was very cold and has been in the same room with the window broken for two days. Resident 2 stated, It was a hole in the glass of the window that is big enough to put my hand through. The air coming through the window causing me to be very cold, especially at night. Resident 2 stated none of the staff gave him extra blankets to keep him warm at night. Resident 2 stated it made him angry that he had to sleep in a cold room all night and his room was changed. Resident 2 stated he was in Room B, and he wanted to go back to his old room (Room A). During observation, interview, and concurrent record review on 11/12/25 at 1:10 p.m., with Maintenance Director (MD). There was a broken window in Room A (Resident 2's room) and floor heater was also on. MD stated the window in Room A had been broken since 11/5/25. MD stated he needed to order a replacement window from a retail store but had not placed the order yet. MD stated the window should have been replaced right away (as soon as the window was broken) to prevent cold air from entering the room and the facility, and to prevent the residents to get injured from the broken glass. MD then checked and recorded the temperature for Room . with portable thermometer and recorded Room . MD stated he checks the temperatures in the resident's rooms daily and records them in the temperature log that is stored in his office in a binder for the year 2025. MD stated the temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 4 of 5 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 11/17/2025 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete logs were also sent to his Consultant daily. A review of the facility temperature logs folder/binder in the MD's office indicated there was only one incomplete log for 10/2025. MD confirmed and stated that he did not have any other temperature logs. MD stated he could not show the surveyor temperature logs in the computer because he did not know how to access the logs. A review of a retail store purchase receipt dated 11/12/2025, indicated the facility purchased a replacement window on 11/12/2025 at 11:29 a.m. During an interview and concurrent record review on 11/12/2025 at 3:46 p.m., Director of Nursing (DON) stated she was not aware that Resident 2 was moved to Room B on 11/11/2025. DON stated she did not know who moved Resident 2 to Room A with a broken window. DON stated placing a resident in a room with a broken window could be a danger to the resident. DON stated Resident 2 could get an infection, experience hypothermia, become uncomfortable due to being cold room, and could get injured due to broken window. DON stated the MD is supposed to check the temperatures in all the resident's rooms daily and record the temperatures in the room temperature binder. DON stated it was communicated (did not specify who did) during facility stand-up meetings, and all of the staff were made aware that Room A was not in use due to the broken window. DON stated the MD is supposed to cover and repair the broken window immediately for safety of the resident and to keep the cold air out. A review of the facility policy and procedures titled Maintenance Service with a reviewed date of 1/25/25, indicated, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. 8. The Maintenance Director is responsible for maintaining the following records/reports: a. inspection of the building. b. Work order request. 9. Records shall be maintained in the Maintenance Directors office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Event ID: Facility ID: 555139 If continuation sheet Page 5 of 5