Health inspection·December 11, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few all medical, social, and functional needs are met for optimal recovery and well-being] was notified. MD [Medical Doctor] was notified. A review of Resident 1's SBAR dated 10/11/2025 at 8:45 pm, indicated, Resident was noted by morning shift with change of behavior attempting to get-out of fire door causing alarm to be activated. In evening shift, she [Resident 1] was noted with physical aggressiveness / combativeness during care. She [Resident 1] was very delusional [having a strong, false belief that isn't based in reality and persists even when presented with clear evidence against it, often stemming from mental health conditions] verbalizing she is Jehova, claiming she is GOD & calling staff devils. Her Physical Aggressiveness poses danger to self & to others. The NP was notified and ordered Haldol 5 mg (milligrams- unit of measurement and Benadryl 50 mg. A review of Resident 1's physician order dated 10/12/2025, indicated Resident 1 to, transfer to acute hospital [GACH 2] on 5150 [California law code that allows a qualified officer or clinician to involuntarily detain someone on a 72-hour psychiatric hold] for evaluation and management of delusion of grandeur (false, unshakable beliefs that one possesses exceptional abilities, wealth, fame, power, or a special identity [like being a deity or historical figure] that she is Jehovah [God saying she is god leading to physical aggressiveness posing danger to self and others). A review of Resident 1's physician orders for readmission dated 10/20/25, indicated that Resident 1 was readmitted to the facility on [DATE]. A review of Resident 1 document titled, Wandering Risk and Elopement Screening Assessment, dated 10/20/2025, with columns to indicate wandering and elopement behaviors, was left all blank and no initial of the nurse completing the assessment. The only entry is the date 10/20/2025. A review of Resident 1's Order Summary Report Active Orders, indicated that on 10/20/2025, Resident 1 had a physician's order to, monitor behavior of delusional disorder M/B (manifested by) claiming she [Resident 1] was a millionaire that have money cause she was selling cookies. Monitor for behavior: psychosis schizophrenia [a serious brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality through symptoms like hallucinations (hearing voices, seeing things) and delusions (false beliefs)] vs schizoaffective [psychosis like hallucinations/delusions with a mood disorder] m/b [manifested by] delusion of grandeur. A review of Resident 1's history and physical (H&P) dated 10/30/2025 indicated that Resident 1 was able to make needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2025, indicated the resident had memory problems and had moderate cognitive impairment (poor decision-making requiring cues and supervision). The same MDS indicated Resident 1 had not exhibited wandering behaviors and required between supervision or touching assistance to set up or clean-up-assistance for Activities of Daily Living (ADLs) such as toileting hygiene, Shower/bathe, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 1's SBAR progress note dated 11/4/2025 at 7:10 pm, indicated, after dinner, Resident 1 was observed displaying exit seeking behavior and aggression towards staff when re-directed. The same SBAR indicated at approximately 6:30 pm, Resident 1 climbed on her bed and began kicking the window next to her bed. The SBAR indicated, NP (Nurse Practitioner - is a registered nurse who has advanced clinical education and training. NP share many of the same duties as doctors) gave order of Haldol [used to treat nervous, emotional, and mental conditions e.g., schizophrenia] 5mg IM [intramuscular - Inject into a muscle] x 1 [one dose] and Benadryl [medications used to treat allergies] 25mg IM x 1 dose. and 1:1 (one to one - refers to dedicated, personalized care where one healthcare professional provides constant, focused support to a single patient provided immediately) however, despite medication and 1:1. The same SBAR indicated that Resident 1 continued to kick the windows using her knees, resulting in the window breaking; Called 911 for emergency assistance. Following this, she stops and got down from bed; and continue with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 2 of 6 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 12/11/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few non-sensical verbal outburst. The same SBAR indicated that Resident 1 then started complaining on bilateral (both) knee pain pointing towards the knees with limited rom [Range of motion - is the full extent or limit a joint can move in various directions] at this time, sat by the bed. A review of Resident 1's 911 Runsheet (often referred to as an incident report which details of an incident) dated 11/4/2025 at 9:16 pm indicated the paramedics [a highly trained emergency medical professional who provides advanced, life-saving care to critically ill or injured people at the scene of an emergency] arrived on scene (facility) at 9:27 pm. The same 911 Runsheet indicated the chief complaint of blunt leg injury (damage to the lower limb caused by a forceful impact, collision, or fall where the skin is not broken or pierced) and provider primary impression of traumatic injury (a sudden, severe physical harm to the body from an external force, like a car crash, fall, or blow, requiring immediate medical attention due to its severity, which can range from broken bones and severe bleeding to life-threatening internal damage needing urgent care to save life or limb). A review of Resident 1's GACH document titled, ISP Hospitalist Discharge Summary dated 11/4/2025, indicated, Resident (Resident 1) was admitted to GACH on 11/4/2025 and discharged on 11/29/2025. The ISP discharge summary document indicated Resident 1 had a consultation with an orthopedic surgeon (orthopedist - is a medical doctor specializing in diagnosing, treating, preventing, and rehabilitating injuries and diseases of the musculoskeletal system such as bones, joints, ligaments, tendons, muscles, and nerves-using both surgical and non-surgical methods). The ISP discharge summary documentation indicated Resident 1 was status post (after/following) right lower extremity (RLE) external fixator (ex-fix - a medical device used to stabilize broken bones from the outside of the body). The ISP discharge summary document indicated Resident 1's admission diagnosis was right tibial plateau fracture and comminuted fracture of the fibular head and neck. A review of Resident 1 GACH ISP discharge under summary of the internal medicine notes indicated Resident 1 had, cerebrovascular accident [CVA - stroke, happens when blood flow to part of the brain is cut off (by a clot or bleed)] x2 [twice], and dementia. The GACH ISP discharge under summary of the internal medicine notes indicated Resident 1 was admitted on [DATE] after sustaining right knee pain following a self-inflicted traumatic event in which she [Resident 1] kicked through a window, resulting in a right bicondylar [a joint where two distinct, rounded surfaces (condyles) on one bone fit into corresponding depressions on another bone, allowing movement in two planes, like flexion/extension and side-to-side motion] tibial plateau fracture and a comminuted fracture of the right fibular head and neck. Resident 1 was diagnosed with a Schatzker type [a system used to categorize tibial plateau fractures based on the pattern of the break and severity. It consists of six types, with higher numbers generally indicating higher-energy trauma, more damage, and a worse prognosis] VI [six] bicondylar right tibial plateau fracture with associated lipohemarthrosis [the presence of both fat and blood within a joint, usually caused by an intra-articular fracture {a break in the bone that extends into the joint} and a comminuted fracture of the right fibular head and neck was confirmed by right knee x-ray and CT imaging. Orthopedic surgery was consulted, and she [Resident 1] underwent right lower extremity external fixator placement on 11/5/2025, followed by removal of the external fixator and open reduction internal fixation [ORIF - a surgery to fix severe broken bones where a surgeon makes an incision] of the right tibial plateau on 11/7/2025. Both procedures were performed by orthopedist, with intraoperative findings of an unstable, displaced bicondylar tibial plateau fracture. During an observation and interview with Resident 1 on 12/9/2025 at 11 am, Resident 1 was in her room sitting in a wheelchair. Resident 1 was observed with dressing to the inner and outer potions of the right knee. Resident 1 stated that she recalled climbing on some sort of table and tried to escape at the facility. Resident 1 stated she saw the window as a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 3 of 6 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 12/11/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few way out because she just wanted to go home and that no one was listening to her. During an interview on 12/9/2025 at 12:26 PM, Certified Nursing Assistant) 1 stated that Resident 1 was ambulatory, alert, but mostly confused. During an interview on 12/9/2025 at 12:26 PM, Certified Nursing Assistant (CNA) 1 stated that Resident 1 was ambulatory, alert, but mostly confused. CNA 1 stated that the resident would run away when confused, would push the door and try to run to the elevator in the facility. CNA 1 stated that most of the times Resident 1, was with it (moments of mental clarity), related well and communicated well. CNA 1 stated that she was not aware Resident 1 had 1:1 sitter (a designated staff member-such as a CNA, technician, or nurse-assigned dedicated staff member to monitor/stay with a single high-risk patient providing constant supervision to prevent falls, self-harm (suicide), wandering, or harm to others, acting as a safety measure often when patients are confused, suicidal, or agitated). CNA 1 stated that Resident 1 would say things like I see your millions (money) coming through. During an interview on 12/9/2025 at 2:04 PM, LVN 1 stated that Resident 1 has periods of confusion, is an elopement (a vulnerable patient leaves a healthcare facility or safe area without permission, often resulting in serious harm, injury, or even death) risk, and tried to find exits/entrances. LVN 1 stated that Resident 1 had verbalized that she wanted to go home on multiple times. LVN 1 stated that on 11/4/2025 after dinner at around 5 pm to 6 pm, LVN 1 contacted a NP when Resident 1 was exhibiting exit seeking behavior and got agitated when staff tried to redirect the resident. LVN 1 stated that this was the first time he had observed Resident 1 get agitated and was not aware of any other episodes/incidents of Resident 1 getting agitated before 11/4/2025. LVN 1 stated the NP ordered 1:1 and some intramuscular medications (Haldol and Benadryl). LVN 1 stated that he sat (as a 1:1 sitter) with the resident and would switch out with someone when other residents needed something. LVN 1 stated that he administered the IM medication to Resident 1 and the resident remained in bed. LVN 1 stated that he was sitting at the resident's bedside when Resident suddenly got up in bed and started kicking the window with both legs at approximately 6:30 pm but was unable to state how long. LVN 1 stated that he yelled for help in the hallway and that LVN 2, who was working as desk nurse (an administrative nurse who works primarily at a central nursing station rather than providing direct, hands-on care at the bedside) that day (11/4/2025), came into the room. LVN 1 stated that the window was shattered, and a few pieces of glass fell on Resident 1's bed. LVN 1 stated that he did not stop the resident because he did not want to risk getting injured because he is relatively smaller. LVN 1 stated that the resident stopped kicking the window and then complained of right knee pain. LVN 1 stated Resident 1 was assisted off the bed onto the wheelchair (WC) by a few other nurses (LVN 1, LVN 2 and other nurses that he could not recall). LVN 1 stated Resident 1 was evaluated by himself as well as LVN 2 (who was working as a desk nurse) with no visual injuries however, Resident 1 had decreased range of motion (to the right knee). LVN 1 stated that he provided 1:1 service continuously from the time 1:1 was ordered at 6:30 pm until Resident 1 was transferred to GACH via 911 around 9 pm. LVN 1 stated he was also assigned 28 residents to provide care too. LVN 1 also stated that all CNAs were busy, so he took it upon himself to be the 1:1 sitter for Resident 1. LVN 1 stated that he did not inform the DON or the administrator that Resident 1 neededan extra staff to supervise and 1:1 monitoring for safety even though he (LVN 1) still had the full assignment and duties as a charge nurse. During an interview on 12/9/2025 at 3:12 PM, LVN 2 who was working as the desk nurse on 11/4/2025 and also covers as a charge nurse (LVN). LVN 2, stated that she worked on 11/4/2025 on the 3 pm to 11 pm shift and is familiar with Resident 1. LVN 2 stated that Resident 1 has days when she displayed behaviors such as exit seeking as well as talking about stories that did not make sense such as stating that she was God and could fly. LVN 2 stated the resident was at risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 4 of 6 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 12/11/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few elopement and could be redirected. LVN 2 stated she remembered that on 11/4/2025 sometime after dinner, LVN 1 was calling for help because Resident 1 was in the room and on top of the resident's bed and was kicking and broke the window because the resident was trying to leave. LVN 2 stated that LVN2 did not observe Resident 1 with bleeding or cuts even from kicking and breaking the window. LVN 2 stated Resident 1's bed had broken shards of glass and that LVN 1 and LVN 2 assisted Resident 1 from the bed onto a wheelchair. LVN 2 stated that Resident 1 complained of right knee pain. LVN 1 stated she completed a body check on Resident 1 and observed that Resident 1 had decreased ROM to the right knee with no swelling. LVN 2 stated she called 911 twice the first time was when Resident 1 started to kick the window while standing in bed. LVN 2 stated after 5 minutes she called 911 a second time because Resident 1 complained of right knee pain. LVN 2 stated that the potential of the resident kicking the window included injuries such as falls, cuts, and fractures. During a follow up interview with LVN 2 on 12/9/2025 at 3:35 pm, LVN 2 denied LVN 1's claim that on 11/4/2025, she (LVN 2) relieved LVN 1 as 1:1 sitter for Resident 1. During a telephone interview on 12/9/2025 at 4 pm, CNA 2 stated that on 11/4/2025 on the 3 pm to 11 pm shift, she was assigned Resident 1. CNA 2 stated that while she was making her rounds at the beginning of her shift, Resident 1 sitting in her bed. CNA 2 stated she asked Resident 1 how the resident was doing however the resident immediately got up and ran to another resident's room. CNA 2 stated Resident 1 was trying to jump while seeking the exit/entrances doors. CNA 2 stated she redirected and assisted Resident 1back to bed and reported about Resident 1's behavior to LVN 1 because the resident appeared anxious. CNA 2 stated that on 11/4/2025 at 3:35 pm she went to check on Resident 1 and found that Resident 1 had pulled out a bed railing from a bed of which took from Resident 1 and gave it to LVN 1 because CNA 2 feared that Resident 1 could hurt herself with the bed side rail. CNA 2 stated that she felt that LVN 1 was ignoring her concerns for Resident 1's safety because LVN 1 failed to assess Resident 1 despite reporting to LVN 2 three times about Resident 1's behaviors and that LVN 1, LVN 2 and Registered Nurse Supervisor (RNS) continued to sit at the nurse's station. CNA 2 stated that while she was providing personal care to a different resident later on 11/4/2025 that approximately 8:30 pm to almost 9 pm, she heard a very loud banging sound coming from Resident 1's room. CNA 2 stated that she rushed to Resident 1's room and observed Resident 1 attempting to hit the window with a metal pole (IV pole- a pole used to hang intravenous medications and formulars for feeding) which CNA 2. CNA 2 stated that she observed Resident 1 fall from the nightstand to the floor/ground and landed on the (Resident 1) right side and that she (CNA 2) yelled loudly for help. CNA 2 stated that Resident 1 reported that she was trying to leave through the window. CNA 2 stated that LVN 1 approached CNA 2 and told CNA 2 to say that Resident 1 did not fall but that the resident kicked the window. CNA 2 further stated that LVN 1 instructed CNA 2 to state (if asked) that LVN 2 was present in the room with Resident 1 when the incident occurred. CNA 2 stated that she firmly refused and told LVN 2 that she did not want to lie. CNA 2 stated that on 11/5/2025, the facility Director of Nursing (DON) called her to the DON's office and pressured CNA 2 to sign a falsely already prepared statement that indicated LVN 1 was in Resident 1's room and that the resident was kicking the window instead of the resident falling down. CNA 2 stated that under duress she signed the already prepared statement in order to keep her job. CNA 2 stated that on 11/6/2025, the DON called her and told that the Department of Public Health (DPH) was in the facility and that whenever DPH called her to let DPH know that she did not know anything about the incident with Resident 1. CNA 2 stated that she continued to insist that she would tell the truth. However, CNA 2 stated that on 11/14/2025, the DON contacted her to go to the facility. However, the DON fired/terminated her when she arrived at the facility. On 12/9/2025 at 5:30 pm, the author requested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555139 If continuation sheet Page 5 of 6 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 12/11/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the DON for Resident 1's elopement risk/wanderer assessment was requested for the initial admission dated 9/26/2025 however, the facility did not provide any documents that the assessment was completed. During an interview on 12/10/2025 at 2:20 pm, RNS stated that she worked on 11/4/2025 on the 3 pm to 11 pm shift and noted that Resident 1 was confused and wanted to exit from every exit door. RNS stated that she attempted to deescalate (did not specify methods used) the resident but unfortunately, Resident 1 got hurt. RNS stated that when a resident is attempting to elope, the physician must be notified immediately to prevent further escalation which may result in injuries. RNS confirmed and stated that LVN 1 and herself (RNS) were both at the nurse's station and that RNS was completing admission documentation when CNA 2 informed her and LVN 1 that Resident 1 fell. RNS stated that CNA 2 had informed both LVN 1 and herself about Resident 1's behaviors that included seeking exits, being aggressive towards staff, and was not directable. During an interview and concurrent record review of Resident 1's Physician Order on 12/11/2025 at 5 PM, the DON stated that for consult orders such as psychiatry evaluation for Resident 1 dated 9/26/2025, the facility must complete and follow up within seven days to ensure resident was seen as ordered. The DON stated that the psychiatry consultation was ordered because Resident 1 had psychosis due to delusion of grandeur stating she (Resident 1) can fly. The DON stated the psychiatry consultation order was not done which placed Resident 1 at risk to result in behaviors that may lead to accidents/injuries. During the same interview and concurrent record review of Resident 1's of Wandering Risk and Elopement Screening Assessment, the DON confirmed and stated that Resident 1's Wandering Risk and Elopement Screening Assessment had a handwritten date of 10/20/25 and the rest of document had unchecked/blank boxes. The DON stated that the elopement risk assessment was not done. The DON stated that elopement assessment helps to identify residents at risk for elopement. The DON stated that the potential for not accurately identifying residents at risk for elopement could result in residents easily eloping or attempting to elope from the facility. The DON stated staff must intervene immediately to prevent injury/ies such as fractures when a resident is engaged in an activity that will cause injury/ies. The DON stated unreported resident behavioral issues can result in injury/ies to the resident. A review of the facility P&P titled Behavioral Assessment, Intervention and Monitoring reviewed on 1/26/2025, indicated, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical (unusual or different) behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress . A review of the facility P&P titled, Safety and Supervision of Residents dated 1/25/2025, indicated that, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review of facility P&P titled Wandering and Elopement Intervention Protocol Based on Risk Score dated 1/25/2025, indicated . Provide 1:1 monitoring until discharge to an appropriate facility that can handle resident's exit seeking wandering behavior. Event ID: Facility ID: 555139 If continuation sheet Page 6 of 6