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Deficiency Records for Miracle Mile Healthcare Center, LLC
A list of the most recent deficiencies for Miracle Mile Healthcare Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Miracle Mile Healthcare Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-19 | 2024-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-01 | 2024-07-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-20 | 2024-07-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-17 | 2024-06-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-17 | 2024-06-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-01 | 2024-05-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-01 | 2024-05-30 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-01 | 2024-05-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-01 | 2024-05-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-28 | 2024-04-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-28 | 2024-04-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-29 | 2024-04-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-26 | 2024-04-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-08 | 2024-03-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-03-08 | 2024-03-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-19 | 2024-02-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-19 | 2024-02-11 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-19 | 2024-02-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-10 | 2024-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-10 | 2024-02-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-22 | 2024-01-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-22 | 2024-01-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-20 | 2024-01-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-20 | 2024-01-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-14 | 2024-01-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-14 | 2024-01-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-14 | 2024-01-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-14 | 2024-01-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-14 | 2024-01-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-14 | 2024-01-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-14 | 2024-01-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-14 | 2024-01-13 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-12-14 | 2024-01-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-14 | 2024-01-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2024-01-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-14 | 2024-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-01-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-12-14 | 2024-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2024-01-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-19 | 2024-01-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-16 | 2023-12-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-16 | 2023-12-08 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-10-26 | 2023-11-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-21 | 2023-07-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-21 | 2023-07-20 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-21 | 2023-07-20 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-21 | 2023-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-06-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-26 | 2023-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-29 | 2023-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-29 | 2023-04-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-29 | 2023-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-04-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-04-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-09 | 2023-03-08 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-02-08 | 2023-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-10 | 2023-02-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-08 | 2022-11-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-17 | 2022-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-26 | 2022-06-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-26 | 2022-06-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-19 | 2022-06-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-19 | 2022-06-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-17 | 2022-05-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-12 | 2022-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-10 | 2022-03-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-30 | 2021-12-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-20 | 2021-11-04 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-16 | 2021-10-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-16 | 2021-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-16 | 2021-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-08-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-16 | 2021-08-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-16 | 2021-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-16 | 2021-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-16 | 2021-08-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-18 | 2019-05-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-04-19 | 2019-05-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-19 | 2019-05-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-19 | 2019-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-19 | 2019-05-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-19 | 2019-05-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-19 | 2019-05-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-19 | 2019-05-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-04-19 | 2019-05-10 | N |
| Post nurse staffing information every day. | Health | 2019-04-19 | 2019-05-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-19 | 2019-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-19 | 2019-05-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-19 | 2019-05-10 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-19 | 2019-05-10 | N |
| Keep all essential equipment working safely. | Health | 2019-04-19 | 2019-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | Not Fixed | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-16 | Not Fixed | N |
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