Federal inspectors found the ceiling above Resident 3's bed at Miracle Mile Healthcare Center had a visible dent from accumulated water weight, cracks, and water stains. Water pooled on the floor below both residents' beds in the shared room.
The Maintenance Director told inspectors on January 27 that the roof had been repaired "multiple times with no success." The ceiling leaked constantly whenever it rained, he said, and despite repeated attempts, the facility couldn't fix it. The ceiling was "cracked and sagging with water stain visible."
Resident 3, who has metabolic encephalopathy and paranoid schizophrenia, requires moderate to maximal assistance from staff for daily activities and uses a manual wheelchair. His roommate, Resident 2, has an irregular heart rhythm and high blood pressure but can make daily decisions independently.
A Certified Nursing Assistant told inspectors the ceiling leak started two days before the inspection. Neither resident was moved to another room, she said.
Instead, staff moved the residents' beds "to the edge of the room" and placed buckets to catch the dripping water, according to a Registered Nurse interviewed during the inspection.
A Licensed Vocational Nurse said Resident 3 "stays outside his room and are placed in the hallway because of the water leaks in the ceiling."
The Director of Nursing acknowledged the safety risk. "If there are water leaks in resident's room and water on the floor, this puts residents at risk of injury as residents may slip and fall," she told inspectors.
The Registered Nurse made the same assessment: "The water leaks put residents at risk of safety hazard and placed them at risk of falls due to wet area and floors."
Inspectors also discovered broken thermostats throughout the facility. The Maintenance Director said thermostats in multiple resident rooms and the Director of Nursing's office weren't working properly. He couldn't adjust them despite trying to improve comfort for staff and residents, citing possible "electrical or mechanical failure."
The Director of Nursing said his own room "gets cold sometimes." He told inspectors that malfunctioning thermostats could compromise residents' health, particularly concerning since "there are multiple residents in the rooms where the thermostat was located and not working properly."
The facility's own maintenance policy, reviewed in January 2024, requires the maintenance department to maintain buildings "in a safe and operable manner at all times." The policy specifically mandates keeping buildings "in good repair and free from hazards" and maintaining heating and cooling systems "in good working order."
Both residents affected by the ceiling leak have serious medical conditions requiring careful monitoring. Resident 2's atrial fibrillation causes irregular heart rhythms that can lead to blood clots. His hypertensive heart disease means years of high blood pressure have already affected his heart muscle.
Resident 3's metabolic encephalopathy involves chemical imbalances affecting his brain function. Combined with his paranoid schizophrenia and chronic lung disease, his conditions make him particularly vulnerable to environmental hazards.
The inspection occurred after a complaint was filed about conditions at the facility. Inspectors classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents.
The Registered Nurse who reported the ceiling leak to maintenance said she learned about it two days before the inspection. Despite the obvious safety hazard and the facility's acknowledgment that wet floors create fall risks, no one moved the residents to dry rooms.
Water continued dripping onto Resident 3's bed throughout the two-day period, with staff managing the leak through bucket placement rather than resident relocation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miracle Mile Healthcare Center, LLC from 2025-01-27 including all violations, facility responses, and corrective action plans.
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