Miracle Mile Healthcare Center LLC in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH made an unannounced visit on December 9, 2025, to investigate a facility-reported incident. According to the citation, Resident 1 was admitted on September 26, 2025, with dementia. Nursing notes from October 11, 2025, describe her trying to leave the facility twice, setting off a fire door alarm, and becoming aggressive. Her care plan stated she was not an elopement risk (a risk of leaving the facility unsupervised) and listed no safety interventions.

CDPH found the facility did not complete a wandering and elopement screening when she was admitted, and the screening form dated October 20, 2025, was blank. Inspectors found staff did not update her elopement risk assessment after her exit-seeking behavior on October 11 and November 4, and did not develop a care plan addressing elopement. The citation also states LVN 1 and LVN 2 did not step in right away and keep watching her on November 4, 2025, while she was on 1:1 monitoring and kept kicking a window.

The 2567 report states that around 6:30 PM that evening she climbed on her bed and kicked the window beside it. A nurse practitioner ordered Haldol and Benadryl injections and 1:1 care, but she kept kicking the window with her knees until it broke, and staff called 911. According to the citation, she was taken to an acute care hospital and diagnosed with a fracture of the top of the right shinbone and a shattered fibula near the knee. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689, covering accident hazards and supervision, at severity G (actual harm).

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CDPH made an unannounced visit on October 8, 2025, to investigate a facility-reported incident involving an allegation of a fall with injury. According to the citation, the investigation focused on events during the night of September 21, 2025, when Resident 1 showed aggressive behavior, worsening psychosis (a loss of touch with reality) and impulsive, risky behavior that continued from the evening shift into the night shift.

CDPH found the facility did not protect Resident 4 from Resident 1, who became combative and deliberately pulled and disconnected the drainage bag from Resident 4's indwelling urinary catheter (a tube that drains urine from the bladder). Inspectors found staff did not move residents to another location when Resident 1's behavior escalated, as the facility's abuse prevention policy required, and did not stop Resident 1 from barricading herself inside a room with Resident 2 and Resident 4. The citation also states the facility did not promptly tell a physician about Resident 1's aggression or the disconnected catheter bag, and did not start and document an incident report for the events involving Resident 1, Resident 2 and Resident 4.

The department issued a Class A citation with a $25,000 penalty. The full narrative, including any resulting injury, is in the linked report.

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CDPH made an unannounced visit on November 6, 2024, to investigate a complaint about resident safety and a death. According to the citation, Resident 1 was a 79-year-old man admitted on September 29, 2024, with delirium (sudden confusion), metabolic encephalopathy (a brain problem caused by a chemical imbalance in the blood), diabetes and kidney failure. An elopement evaluation on September 30 rated him as not at risk of leaving.

CDPH determined the facility did not identify him as an elopement risk under its own wandering policy and did not carry out his care plan to monitor and report changes in his thinking when he showed confusion on November 4, 2024. Inspectors found staff did not assess him or notify his physician about his aggression and confusion that day. The citation states CNA 3 saw him near the elevator around 1 PM on November 5 wearing two gowns and a sweater and carrying a black bag of belongings, and staff did not monitor or supervise him. The department also found the facility had no system to track his whereabouts.

According to the 2567 report, he left the facility between about noon and 2 PM on November 5, after the last smoke break, and the exact time is unknown. Police found him dead in a park on November 7, 2024. CDPH issued a Class AA citation with a $100,000 penalty. The federal report cites F689, the accident hazards and supervision rule, at severity J (immediate jeopardy). The report states the immediate jeopardy was removed on November 14, 2024, after the facility submitted a removal plan that included reassessing residents at risk of elopement.

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CDPH made an unannounced visit on September 10, 2024, to investigate a complaint alleging resident neglect, falls and accidents. According to the citation, Resident 1 was admitted on September 19, 2023, with dementia with behavioral disturbance, aphasia (trouble communicating) after a stroke, impulse disorder, epilepsy and metabolic encephalopathy (a brain condition caused by a chemical imbalance in the blood). A fall risk assessment at admission rated him at high risk, and team notes described him as impulsive and getting up without help.

CDPH determined the facility did not monitor whether the interventions in his fall care plans were working and did not change them to prevent repeat falls. Inspectors found staff did not revise his fall risk care plan after a fall on May 24, 2024. The citation states the facility did not follow its own fall policy by adding new or different interventions after several falls with injury, and did not follow its 1:1 supervision policy to provide added supervision or a sitter.

According to the citation, Resident 1 fell on October 10, 2023, November 20, 2023, February 25, 2024, May 24, 2024, July 5, 2024, and August 21, 2024. After the August 21 fall at 5:25 PM he was taken by 911 to an acute care hospital and diagnosed with a traumatic head injury with a left subdural hematoma (bleeding between the brain and skull) and fractures of the left third through sixth ribs. He was admitted to the intensive care unit. CDPH issued a Class A citation with a $20,000 penalty. The federal 2567 report cites F689, accident hazards and supervision, at severity G (actual harm).

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According to the federal 2567 report, Resident 1 had a seizure disorder and a psychiatric diagnosis and was prescribed Keppra (a seizure medication) and Risperdal (a psychiatric medication). The report states he had increased episodes of paranoia and refused to take both medications.

Inspectors found the facility did not notify his attending physician or psychiatrist about the increased paranoia, or about refusals of Risperdal and Keppra two or more times in a row, as the facility's change of condition policy required. The report states staff also did not tell the physician about his last Keppra blood level after a seizure on January 9, 2024. Under the psychotropic medication rule, inspectors found he did not receive Risperdal as prescribed, the pharmacist did not do monthly medication reviews of his Risperdal, and no quarterly gradual dose reduction review was done.

According to the 2567 report, Resident 1 was hospitalized in April 2024 for an altered level of consciousness, and a hospital test on April 20 showed his Keppra level below the therapeutic range. The facility was cited under F580, notification of changes, and F758, freedom from unnecessary psychotropic medications, both at severity J, which means immediate jeopardy. Inspectors identified immediate jeopardy on April 26, 2024, and the report states it was removed on May 1, 2024, after the facility submitted a removal plan that included notifying the physician, rechecking Keppra levels and training licensed nurses on reporting refused medications.

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CDPH made an unannounced visit on August 15, 2023, to investigate a facility-reported incident about Resident 1 jumping from a second-floor window. According to the citation, Resident 1 was admitted on August 8, 2023. An elopement risk assessment rated him at high risk of leaving, and his care plan called for a 1:1 sitter starting August 9.

CDPH found the facility did not make sure Resident 1, who was on 1:1 supervision, was never left unattended on August 13, 2023. The citation states the facility knew he had left a hospital before, had tried to open his room window twice at the facility, had shown increased agitation, and had been verbally and physically threatening staff for the prior two days. Nursing notes from that day describe him pacing the halls faster than his sitter could keep up, refusing his medications and throwing them at a nurse. That evening he was placed on a 72-hour involuntary psychiatric hold for danger to others while staff waited for a hospital bed.

According to the citation, Resident 1 got out through a second-floor window that day and fell 11.5 feet onto asphalt. He had fractures of the right leg, right wrist, right hip and ribs, and was admitted to an acute care hospital at 11:30 PM. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689, accident hazards and supervision, at severity J (immediate jeopardy). The report states the immediate jeopardy was removed on August 18, 2023, after the facility's removal plan, which included inspecting resident room windows.

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According to the federal 2567 report, Resident 2 was admitted on January 9, 2023, after lower back spine fusion surgery, with an abscess and cellulitis (skin infection) of the mouth. She was cognitively intact. Her physician ordered oxycodone (an opioid pain medicine) every three hours as needed and carisoprodol (a muscle relaxer).

The 2567 report states Resident 2 told inspectors that around 8 AM on January 23, 2023, she asked LVN 2 for oxycodone for pain of nine out of 10, and LVN 2 did not respond. When she asked again around 8:30 AM, she said LVN 2 told her "wait a *d* minute" because the nurse was busy with a dialysis resident, and later said no. The report states that when Resident 2 said she would report the nurse, LVN 2 replied, "I don't give a *d* if you tell the president. I do what I want to do." She reported LVN 2 to RN 1, who told her to wait.

Inspectors found these failures left Resident 2 in pain and caused stress, humiliation and frustration. Under the pain management rule, the report states she stayed at a pain level of nine out of 10 and left for an outside appointment between 1:30 and 2 PM without receiving oxycodone. The facility was cited under F600, freedom from abuse and neglect, and F697, pain management, both at severity G (actual harm), and F609, reporting of alleged violations, at severity D. The F609 narrative is in the linked report.

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