Miracle Mile Healthcare Center, Llc
MIRACLE MILE HEALTHCARE CENTER, LLC in LOS ANGELES, CA — inspection on January 5, 2025.
Found 16 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 1/5/2025 at 6 pm DON stated with if resident can make medical decisions consent must be signed by the resident agreeing to psychotropic medications. DON further stated the prescribing physician is also supposed to sign the consent, to ensure the order is right, doctor is also supposed to explain the risks and benefits of the medications to the Resident.
A review of facility policy and procedure (P&P) titled, psychoactive medication informed consent, dated 3/2024 indicated, Prior to the administration of any psychoactive medications an informed consent for the specific medication will be obtained by the physician and verified by the nurse Policy further states the prescriber must personally examine the resident and obtain informed written consent signed by the Resident or the Resident's representative long with the signature of the healthcare professional declaring the required material information has been provided.
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Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
required to complete an advance directive within 72 hours of a Residents admission, to know what the
A review of the facility's policy and procedure titled, Advance Directives dated 12/2016, indicated
or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.
Written information will include a description of the facility's policies to implement advance directives and applicable state law. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.
Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive.
Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record.
Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
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Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
possible, the characteristics of the facility that reflect a personalized, homelike setting.
These
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During a concurrent interview and record review on 01/04/25 at 07:02 p.m., with the Medical Record Director (MRD), there is no ADL charting in Resident 96's medical record for the month of November.
The MRD confirmed the findings and stated there was no ADL charting in Resident 96's medical record for the month of November.
During a concurrent record review and interview on 01/04/25 at 07:42 p.m., the DON reviewed Resident 96's record and stated, there is no ADL charting in Resident 96's medical records for the month of November.
The DON stated every resident in the facility should have an ADL documentation in their medical record.
The DON further stated, it is very important for all of the residents to receive ADL care to prevent having a foul odor, skin rashes, or skin breakdown.
During a review of the facility's document titled Activities of Daily Living (ADL's), with a revised date of 3/2018, indicated Residents will be provided with care, treatment and services to maintain or improve their ability to carry out activities of daily living (ADL's).
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
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Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
revised date of 10/2010, the P&P indicated, Purpose: The purpose of the procedure is to provide
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During a concurrent review of Resident 88's nurse's notes, RNS 2 stated there were no progress notes that indicated the nurse documented the post dialysis assessment in the resident's electronic health record.
During an interview on 1/5/2025 at 6:00 PM, the Director of Nursing (DON) stated the dialysis communication form was to monitor's the resident's vital signs prior to and after dialysis.
The DON stated not assessing the resident upon return from dialysis could result in the facility not addressing changes in the resident's health condition.
A review of the facility's policy and procedure titled, Hemodialysis Access Care, reviewed 1/25/2024, under the section Documentation indicated: The General Medical nurse should document in the resident's medical record every shift as follows:
- Location of catheter.
- Condition of dressing (interventions if needed).
- If dialysis was done during shift.
- Any part of report from dialysis nurse post dialysis is being given.
- Observations post dialysis.
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Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
family or friends, coordinating resources and services to meet the resident's needs);
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During a concurrent observation and interview on 01/04/25 at 8:07 a.m., of the facility's medication storage room with Registered Nurse Supervisor (RNS) 1, RNS 1 stated expired medications are being destroyed by two-night shift License Nurses. RNS 1 further stated the disposal of narcotics are to be destroyed by the Director of Nursing (DON) and stored in the DON's office.
During a concurrent observation and interview on 01/04/25 at 8:37 a.m., with the DON, it was noted that the storage container for the narcotics was not a locked permanently or locked affixed compartment. It was observed that the compartment was open and easily accessible to extract medication from.
The DON stated the medications should be in a locked container prevent diversion.
During an interview on 01/05/25 at 09:59 a.m., the DON stated the process of narcotics disposition starts with the charge nurses.
The DON stated the narcotics are first counted by two licenses before they remove the medication from the medication carts, the license nurse gives the medications to the DON and then the narcotics are double locked in the DON's office until the pharmacist comes in the facility to waste the medication.
The DON stated the pharmacist verified the medications with the DON and then it is put into an incinerator (an apparatus for burning waste material, especially industrial waste, at high temperatures until it is reduced to ash), and the pharmacist will seal the container to prevent diversion.
The DON further stated the company picks up the medication and signed that they picked up the medication.
The DON did not have a log/record of the dates, times, and contact pharmacist that comes to the facility to waste controlled medications, or of the company that pick up the controlled medications.
During a review of the facility's policy and procedures (P&P) titled Controlled Medication Disposal with an effective date of 4/2021, the P&P indicated, Procedures: e.Since Alliance Pharmacy only facilitates the destruction, all destruction logs will be performed and maintained at the facility.
The facility shall be responsible for all records and those records must be maintained for at least three years.
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During an observation in the prep sink area of the kitchen and interview on1/2/2025 at 5:04 PM, a cell phone and personal speaker were observed on the prep sink. [NAME] 1 stated the items belonged to [NAME] 1 and [NAME] 1removed the items from the area. [NAME] 1 stated personal items should not be in the kitchen area for infection control.
During a concurrent interview and observation in the dish machine area on 1/2/2025 at 5:17 PM Dietary Aide (DA1) was loading dirty pots and pans in the dish machine.
Then DA1 was removing the cleaned and sanitized dishes to air dry without washing hands between the two actions. DA 1 confirmed not washing hands after touching the dirty dishes and prior to putting away clean dishes.
DA 1 stated they should have washed hands to prevent cross contamination.
During a concurrent interview and observation on 1/2/2025 at 5:24 PM with the Dietary Services Supervisor (DSS) the kitchen's chest freezer was observed.
The DSS stated the hashbrowns inside the freezer were in open bags without open dates and should have been dated.
The DSS stated the date the hashbrowns were opened was unknown.
The DSS stated the not labeling the hashbrowns, having personal outside items on the prep sink, and the dietary aide not washing hands between touching dirty and clean dishes all could lead to foodborne illness.
During an interview on 1/5/2025 at 5:56 PM, the Director of Nursing (DON) stated food in the kitchen were to be labeled with opened date so that the residents didn't receive expired foods.
A review of facility policy titled Sanitization, reviewed 1/25/2024, indicated, The food service area shall be maintained in a clean and sanitary manner.
A review of facility Procedure for Refrigerated Storage, dated 2020, indicated individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated.
Freezer burn may occur before that and reduce the maximum shelf life.
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During a facility tour on 1/2/25 7:22 PM a bedside table was observed to have clean linen inside the bathroom of Resident room [ROOM NUMBER].
During concurrent interview, Certified Nursing Assistant (CNA2) stated she did not know who placed the bedside table, clean linen, and a wheelchair inside room [ROOM NUMBER]'s bathroom. CNA2 further stated the items are not supposed to be in the bathroom, because of infection control.
During a facility tour on 1/3/2025 6:35 PM Licensed Vocational Nurse (LVN 5) was observed walking out of room [ROOM NUMBER] and to a medication cart outside the room while wearing gloves with a topical medication cream Diclofenac sodium (pain medication) belonging to a resident in hand.
During a concurrent interview with LVN 5 stated she (LVN 5) is not supposed to have gloves and holding medication in the hallway because of infection control. room [ROOM NUMBER] was observed to have an enhanced barrier precaution sign at the entrance, LVN 5 stated she did not know which Resident in room [ROOM NUMBER] was on enhanced precaution.
During an interview on 1/5/2025 at 6 PM, Director of Nursing (DON) stated wheelchairs, bedside tables and clean linens should not be inside Resident's bathrooms because they can get contaminated and if used could pause an infection control issue for the Residents. DON further stated staff should doff personal protective equipment (PPE) and place it in the trash before exiting the Residents room to prevent spread of diseases.
A review of facility policy and procedure (P&P) titled infection control dated 1/25/2024 indicated, facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
revised date of 12/2009, the P&P indicated, Policy Interpretation and Implementation: 1.The
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
department is responsible for maintaining the building, grounds, and equipment in a safe and operable
guidelines. B. maintaining the building in good repair and free from hazards. D. maintaining the
in providing repair service. 3.
The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
555139 01/05/2025
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During an interview on 1/4/2025 at 1:16 PM, STR 1 stated he has been employed by the facility since June 2024. STR 1 stated received abuse training in December 2024 after a resident made an allegation of abuse.
During a concurrent interview and record review on 1/4/2025 at 5:56 PM, STR 1's employee file was reviewed with the facility's staffer (STFR - person that prepares the work schedule for the facility's employees).
The STFR stated there was no evidence STR 1 received abuse training upon his hire on 6/18/2024. STFR stated STR 1 was in-serviced on abuse on December 2024 after a resident made an allegation of abuse against STR 1. STFR stated employees were given abuse training upon hire.
The STFR stated not providing abuse training upon hire could lead to the abuse and neglect of residents due to the staff not knowing what constitutes abuse and neglect.
During an interview on 1/05/2025 at 5:58 PM, the Director of Nursing (DON) stated abuse in-services were to be completed upon hire.
The DON further stated abuse in-services were given to educate the staff and nurses on the types of abuse and to guide them when interacting with residents.
The DON stated not giving abuse in-service could lead to abuse.
The facility's policy and procedure titled, Abuse Prevention/Prohibition, reviewed 1/25/2024, indicated the facility conducts mandatory Facility Staff training programs during orientation, annually and as needed on: - Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. - Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident's property. - Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. - Reporting abuse, neglect, exploitation, and misappropriations of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal.
During an interview on 1/4/2025 at 4:13 pm with Assistant Maintenance Supervisor (AMS) and Assistant Laundry Supervisor (ALS), the ALS stated he was temporarily in charge of the laundry service as acting laundry services supervisor. AMS stated that the washing machine had been out of service for about a month. AMS stated the industrial washing machine needed a part that was being ordered. AMS was not familiar with how to install the ordered part, and someone will have to be sent to the facility to install the part on the machine. AMS stated until then there was only one machine used to wash the linen for the facility.
During observation on 1/5/2025 4:10 pm the laundry room had two industrial size laundry machines and one small commercial size washing machine; in addition, the laundry room had two industrial size drying machines.
One of two industrial washing machines was out of service.
The machine to the right side of the laundry room was empty and the electronic display read Error scrolling across the screen continually.
The laundry room had one bin full of dirty linen and the working industrial washer was washing a full load of facility linen.
The small commercial size washer was not in use at the time, however, according to laundry worker 1 (LW 1) the small commercial size washing machine was in working condition.
During an interview on 1/5/2025 at 4:12 LW 1 stated, the industrial size laundry machine had not been working for over three weeks. LW 1 stated that some time prior, someone went out to fix the industrial washing machine, however, they stated that a part needed to be ordered and someone needed to install the part before the machine could be used again.
During an interview on 1/5/2025 4:23 pm the Director of Nursing (DON) was not sure if the part to fix the machine had been ordered, or an appointment for a repair person was scheduled.
The DON stated he would check to see if a technician was scheduled to come out to fix the machine or if the part was ordered.
The DON stated, if there was only one machine, it could cause a delay in delivering clean linen to the staff in the resident care area.
The DON stated the shortage of clean linen could cause the residents to feel some frustration due to a delay in having their linen changed.
555139
Form Approved OMB
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 01/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
During observation in Resident 3's room on 01/02/25 at 7:02 pm, Resident 3 was observed laying on the bed with no blanket or linen, aside from the fitted sheet that was on the bed.
During an interview on 01/02/25 at 7:02 pm, Resident 3 stated the certified nursing assistant (CAN) on day shift removed the resident's linen to change the linen for the day, however there was no clean linen available, so the CNA took the used linen and did not return. Resident 3 did not remember the time the CNA took the linen; however, stated the CNA took the linen in the morning and the resident had not had any linen on the bed since early that morning.
During an interview on 01/02/25 at 7:28 pm, CNA 1 Stated, Linen was changed in the morning, and as needed. CNA 1 stated residents should always have a top sheet and a blanket along with pillowcases. CNA 1 stated she (CNA1) was not able to replace the linen for Resident 3 because the linen had not been delivered to the floor for staff.
During an interview on 1/5/25 at 4:23 pm, the Director of Nursing (DON) stated all residents had the right to have a homelike environment to the extent possible while living in the facility.
The DON stated having a homelike environment meant the resident's beds were to be completely made with clean linen daily.
The DON stated linen included a fitted sheet, cover sheet with pillowcases and a blanket.
The [NAME] stated if the beds were not clean and with all the linen on the bed, then the resident would experience the discomfort of not having a homelike environment.
555139
Form Approved OMB
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 01/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Miracle Mile Healthcare Center, LLC 1020 South Fairfax Ave Los Angeles, CA 90019
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.