The aide at Miracle Mile Healthcare Center said the elevator "would sometimes stop functioning" during his 7 a.m. to 3 p.m. shift. When it breaks down, he notifies the receptionist to watch for residents trying to leave the building while he goes to the garage to reset the breaker.
"The Maintenance Supervisor, Administrator, and all of the Nursing Supervisors are aware of the elevator not functioning properly," the monitor aide told inspectors during their January visit.
A certified nursing assistant said she had been stuck in the elevator for about two minutes. "Staff get stuck frequently," she told inspectors.
The maintenance assistant said the elevator problems had persisted for at least a year. He said he had been trapped "many times for about 1-3 minutes" and that "multiple employees had gotten stuck in the elevator daily." The last time he was stuck was two days before the inspection.
When someone gets trapped, another staff member resets the elevator so the doors open properly, the maintenance assistant explained.
Golden State Elevator Service performed an urgent inspection on August 29, 2024, according to facility records. The elevator company's report stated the door equipment was "original equipment" that had "become very troublesome" and was "out of date." The company "highly recommends the updating meet all current elevator codes."
Despite the urgent repair recommendation, the Director of Nursing confirmed the elevator remained unfixed as of the January inspection. He told inspectors he was "in the process of discussing the issue with the elevators with the corporate office to see how soon the elevator can be repaired."
The nursing director acknowledged that if staff or residents get stuck, "they can get injured or be fearful of using the elevators."
The elevator problems represent just one of multiple safety and care failures inspectors documented at the 111-bed facility on South Fairfax Avenue.
Resident 96, who has cerebral palsy and requires extensive assistance with daily activities, told inspectors she hadn't showered in three weeks because staff claimed the Hoyer lift was broken. She said when she calls for help changing her diaper, she waits over an hour and "sometimes she does not get changed at all."
The resident described one incident where she asked a nursing assistant to change her diaper. "The CNA walked out of her room and never came back the entire shift," according to the inspection report. "Resident 96 stated she felt so embarrassed that she had to sit in urine the entire shift."
But when inspectors checked with a licensed nurse, they found two working Hoyer lifts in the hallway. The nurse said if the lifts weren't working, maintenance would fix them within one or two days.
Records showed no documentation of daily living activities for Resident 96 during the entire month of November, despite facility policy requiring such documentation for all residents.
A resident with a colostomy said nurses weren't changing his bag as needed, causing his skin to become red and irritated. "Sometimes he go the whole day without his colostomy bag being changed and this makes him very angry that he had to go all day and night with his colostomy bag full of feces," the inspection report stated.
The resident said his skin was reddened "because of his colostomy bag not being changed in a timely manner." A registry nurse confirmed the skin around the colostomy site appeared red and macerated, warning that delayed changes could cause infection and breakdown.
Another resident spent an entire day without bed linens after a nursing assistant removed them for washing but couldn't replace them because clean linens hadn't been delivered to the floor. The resident was found lying on a bare mattress with only a fitted sheet at 7 p.m., having been without proper bedding since morning.
In the kitchen, inspectors found multiple food safety violations. A dietary supervisor's cell phone and speaker were sitting on the food preparation sink. A dietary aide loaded dirty dishes into the washing machine, then removed clean dishes without washing her hands between tasks.
Open bags of hash browns in the freezer lacked date labels, making it impossible to determine how long they had been opened. The dietary supervisor acknowledged all these practices "could lead to foodborne illness."
Medication safety also suffered. Expired controlled substances weren't stored in locked containers as required by facility policy. The Director of Nursing found narcotics in an unlocked, easily accessible compartment, admitting "the medications should be in a locked container prevent diversion."
The facility lacked required logs tracking when pharmacists came to destroy controlled medications or when disposal companies picked them up, despite policy requiring such records be maintained for three years.
A dialysis patient's post-treatment assessments were missing from six different dates, including monitoring of vital signs and the arteriovenous shunt used for dialysis access. The nursing supervisor confirmed no progress notes documented these critical post-dialysis evaluations.
Infection control lapses included storing clean linens and a wheelchair in a resident's bathroom, and a nurse walking into the hallway while wearing contaminated gloves and carrying topical medication after treating a resident on enhanced precautions.
One resident said she had been asking the social services designee for months to retrieve personal belongings from her previous nursing home, but received no updates on their status. She told inspectors she was "on the verge of giving up on every getting her belongings back."
The industrial washing machine used for facility linens was also broken, creating potential delays in providing clean bedding and clothing for all 111 residents.
Facility policy requires maintaining buildings, grounds and equipment "in a safe and operable manner at all times." But the pattern of broken equipment and delayed repairs suggests a facility struggling to meet basic operational standards while residents wait for care that doesn't come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miracle Mile Healthcare Center, LLC from 2025-01-05 including all violations, facility responses, and corrective action plans.
Additional Resources
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