Beverly West Healthcare

F-F689.

Findings:

1a. A review of the Admission Record indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), hypertensive heart disease without heart failure (the heart is being affected by high blood pressure [hypertension] over a long period of time, causing changes to the heart muscle, but it's not yet weak enough to be considered heart failure where the heart can't pump blood effectively) and hyperlipidemia (abnormally high levels of fats in the blood).

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/18/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 was independent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

1b. A review of the Admission Record indicated Resident 3 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and - chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).

A review of the MDS dated [DATE REDACTED], indicated Resident 3 ' s skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required moderate to maximal assistance from staff for ADLs. The MDS also indicated, Resident 3 uses manual wheelchair for assistive mobility device.

During an observation of Resident 2 and Resident 3 ' s room, the ceiling was leaking with dripping water on top of Resident 3 ' s bed. The ceiling had a dent and cracked with a visible water stain. Observed water on

the floor below Resident 2 and Resident 3 ' s bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 555139 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555139 B. Wing 01/27/2025

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 During an interview with Certified Nursing Assistant (CNA 1) on 1/27/2025 at 11:25 a.m., CNA 1 stated, the ceiling started on top of Resident 3 ' s bed two days ago. CNA 1 stated, Resident 2 and Resident 3 is still in Level of Harm - Minimal harm or the same room and was not moved to another room. potential for actual harm

During an interview with Licensed Vocational Nurse (LVN 1) on 1/27/2025 at 11:28 a.m., LVN 1 stated, Residents Affected - Few Resident 3 stays outside his room and are placed in the hallway because of the water leaks in the ceiling. LVN 1 stated, they did not move Resident 2 and Resident 3 ' s room.

During an interview with Maintenance Director (MTD) on 1/27/2025 at 12:13 p.m., MTD stated, the roof on top of Resident 3 ' s bed had been repaired multiple times with n success. The ceiling would constantly leak with water whenever it rains, and facility has tried to fix it with no success. MTD stated, the ceiling has a dent due to weigh of the water that accumulates on the roof, the ceiling was also cracked and sagging with water stain visible.

During an interview with Registered Nurse 1 (RN 1) on 1/27/2025 at 12:44 p.m., RN 1 stated, they relayed

the water leaks on the ceiling for Resident 2 and Resident 3 two days ago from the MTD. RN 1 stated, when

the water started leaking from the ceiling, they moved Resident 2 and Resident 3 ' s room at the edge of the room and they did not move Resident 2 and 3 ' s room and they added buckets to catch the water. RN 1 stated, the water leaks put residents at risk of safety hazard and placed them at risk of falls due to wet area and floors.

During an interview with Director of Nursing (DON) on 1/27/2025 at 1:21 p.m., DON stated, 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.

2. During a concurrent observation and interview with MTD on 1/27/2025 at 12:06 p.m., MTD stated, one of

the thermostats in the facility is not working properly. MTD stated, the thermostat in room [ROOM NUMBER], room [ROOM NUMBER] and DON ' s room does not work. MTD stated, he tried to adjust the thermostat for staff and residents ' comfortability, but he was unable to adjust it. MTD stated, there maybe electrical or mechanical failure.

During an interview with DON on 1/27/2025 at 1:21 p.m., DON stated, he noticed his room gets cold sometimes. DON stated, if the thermostat is not working properly and they are unable to adjust it, it may affect residents ' health, and they may be compromised. DON stated, there are multiple residents in the rooms where the thermostat was located and not working properly.

A review of the facility ' s policy and procedure (P&P) titled, Maintenance Service, reviewed date 1/25/2024,

the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: .maintaining the building in good repair and free from hazards; maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order; establishing priorities in providing repair service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 555139