Miracle Mile Healthcare Center, LLC

In the surveyor’s words

From the most serious findings on record at Miracle Mile Healthcare Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 19, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision during wandering behavior and follow their policy and procedure titled, Nursing-Wandering and Elopement, to ensure four of six sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) did not elope from the facility. The facility failed to identify the risk of elopement, failed to care plan for the risk of elopement for Resident 1, 2, 3 and 4 and failed to ensure the exit alarms were working properly. As a result, Resident 1 eloped from the facility on 5/7/2022 and remains missing. Resident 1 did not receive the physician ordered medications needed for her condition which could lead to serious injury, serious harm, serious impairment and/or death. […]

• Immediate jeopardy, isolatedF689Nov 14, 2024

  Based on interview and record review the facility failed to ensure a resident, who had periods of confusion, did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Implement the care plan to Monitor/document/report PRN (whenever necessary) any changes in cognitive (of, relating to, being, or involving conscious intellectual activity (such as thinking, reasoning, or remembering) function when Resident 1 exhibited periods of confusion on [DATE]. 2. Monitor and supervise Resident 1 when Certified Nursing Assistant (CNA 3) observed Resident 1 on [DATE] at around 1 pm close to the elevator. […]

• Immediate jeopardy, isolatedF580May 1, 2024

  Based on observation, interview, and record review, the facility failed to notify the physician when there is a significant change in resident's health condition for one of five sampled residents (Resident 1) by failing to: 1. Notify the attending physician and/or the Psychiatrist (PSYCH 1) when Resident 1 (R1) had increased paranoia (the unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition) episodes. Resident 1 stating, I was being poisoned, and refusing to take prescribed Risperdal (used to treat certain mental/mood disorders such as schizophrenia) and Keppra (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain]). 2. […]

• Immediate jeopardy, isolatedF758May 1, 2024

  Based on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 1[R1]) received Risperdal (medication used to treat certain mental and or/mood disorders such as schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) as prescribed by the attending physician (MD1). Resident 1's diagnoses included schizophrenia. 2. Ensure the MD1 were made aware that one of five sampled residents (R1) was refusing to take Risperdal as ordered and was exhibiting increased paranoia episodes manifested by (m/b) R1 stating, I was being poisoned, and hearing voices. 3. […]

• Immediate jeopardy, isolatedF689Aug 18, 2023

  Based on observation, interview, and record review the facility failed to ensure, for one of seven residents (Resident 1), who was on 1:1 (an observation whereby a patient/person at no time is left alone) supervision for safety while on 5150 (is the Welfare and Institutions Code number, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for danger to others and elopement (a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety), was not left unattended on 8/13/2023. […]