Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Los Angeles Doctors Hosp during CMS and state inspections, most recent first.
The facility failed to keep a kitchen can opener in sanitary condition. During observation, the can opener attached to the food prep table was blackened and covered with black stains, dried residue, and hardened food debris around the blade and gear. The DS stated it was dirty and should be cleaned to prevent contamination and bacterial growth, and the facility policy required kitchen equipment to be cleaned after each use.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications: The facility did not ensure the prescribing provider obtained informed consent for psychotropic meds for three residents with severe cognitive impairment and dependence for ADLs, including residents receiving Zoloft, Zyprexa, and Ativan. For one resident, consent for Ativan and Olanzapine was also not renewed within the required six-month interval. Staff stated licensed nurses were obtaining consent, while the CNO said the process was not aligned with current AFL guidance and that RN staff were not within scope to obtain informed consent.
Failure to follow tube-feeding positioning and psychotropic behavior monitoring care plans: Staff did not keep the HOB at the ordered semi-Fowler's position during enteral feeding for three residents with gastrostomy tubes and respiratory diagnoses, despite care plans directing elevation to 30 to 45 degrees. Staff also did not document behavior monitoring every shift for two residents receiving psychotropic meds, including an antidepressant, an antipsychotic, and an anxiolytic, even though the care plans required shift-by-shift monitoring.
Failure to maintain HOB elevation during enteral feeding: Three residents with respiratory failure, pneumonitis/pneumonia, and gastrostomy tubes were ordered continuous tube feedings with the HOB in semi-Fowler's position. During observations, each resident was receiving enteral nutrition while the HOB was kept below 30 degrees, despite RN confirmation and facility policy requiring at least 30 degrees during continuous feeding.
A phlebotomist failed to follow infection control practices during a blood draw for a resident with trach and G-tube care needs and another resident with severe cognitive impairment and indwelling devices. The phlebotomist wore only gloves and a lab coat, touched the resident’s bed and linens, placed phlebotomy wrappers on the roommate’s bedside dresser, and did not disinfect the dresser after use; the IP stated EBP applied and required PPE during high-contact care.
The facility failed to provide daily RNA services as prescribed for five residents with severe cognitive impairments and dependency on staff for daily activities. Despite physician orders for daily treatments to maintain or improve range of motion, services were only provided five times a week. The DON confirmed the lack of weekend services, acknowledging the risk of contractures and other complications.
A resident with severe cognitive impairment was not informed about medications administered via gastrostomy tube, violating her rights. The LVN failed to explain the medications, which is against the facility's policy and standard procedure, as confirmed by staff interviews.
A resident with respiratory failure and moderate cognitive impairment was receiving outside food from family, but the care plan was not updated to reflect this change. The resident was on a mechanically altered diet with a gastronomy for nutrition, and the failure to revise the care plan increased the risk of aspiration. Facility staff acknowledged the need for care plan revision, but it was not completed, contrary to facility policy.
A resident with respiratory failure and moderate cognitive impairment was observed receiving an incorrect diet due to outdated physician orders. Despite the resident's need for a regular soft and bite-size diet, the orders still indicated enteral feeding. Registered nurses confirmed the orders should have been updated, as per facility policy, to prevent care delays.
A facility failed to complete a required phenobarbital level test for a resident with severe cognitive impairment and chronic respiratory failure. The resident had an active order for phenobarbital to prevent seizures, requiring monthly monitoring. The test for October was not completed, and there was no documentation of communication with the physician or follow-up on the missing test results, despite facility policies requiring ongoing drug therapy monitoring.
A facility failed to document a resident's intake of food brought from home, despite the resident's dietary restrictions due to respiratory failure and moderate cognitive impairment. The resident's family had been bringing food for several weeks without documentation in the medical records, posing a potential aspiration risk. Staff interviews revealed that the LVN was aware but did not document the food intake, and the RN confirmed the need for updated progress notes to educate the family and prevent choking.
The facility did not complete the Revised McGeer Criteria for Infection Surveillance Checklist for two residents receiving antibiotics, as required by their policies. The Infection Preventionist Nurse failed to validate the appropriateness of the antibiotics due to this oversight, and the Director of Pharmacy confirmed this as a standard practice. This deficiency could lead to inappropriate antibiotic use and the development of multi-drug resistant organisms.
Dirty Can Opener in Kitchen
Penalty
Summary
The facility failed to ensure a can opener in the kitchen was maintained in a sanitary manner. During an initial kitchen tour observation on 1/5/2026 at 8:30 a.m., the can opener attached to the food preparation table was observed to be blackened and covered with black stains and dried residue. The area around the can opener blade and gear was heavily stained with dark, hardened food debris. During a concurrent observation and interview on 1/5/2026 at 8:40 a.m., the Dietary Supervisor stated the can opener was dirty and had food stains attached to the blade. The Dietary Supervisor stated the can opener should be cleaned and kept in sanitary condition to prevent contamination and the growth of harmful bacteria. Review of the facility policy indicated kitchen equipment would be cleaned after each use, and review of the FDA Food Code indicated equipment food-contact surfaces and utensils shall be clean to sight and touch.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the prescribing provider obtained informed consent for psychotropic medications for three sampled residents, and failed to renew psychotropic informed consents every six months for one resident. Resident 4 had anoxic brain injury, convulsions, severe cognitive impairment, and was dependent on staff for all ADLs and mobility. Resident 4 received Zoloft, with facility verification forms showing informed consent obtained by a family member and verified by two nurses for earlier dose changes, but the record did not show provider-obtained informed consent for the later Zoloft order starting 8/27/2025. Resident 14 had encephalopathy, schizoaffective disorder, severe cognitive impairment, and was dependent on staff for all ADLs and mobility. Resident 14 received Zyprexa, and the record showed facility verification of informed consent obtained by a family member and verified by two nurses for the 5/14/2025 order and again for the 6/21/2025 dose change. The survey findings stated the prescribing provider did not obtain informed consent for the psychotropic medication administration. Resident 5 had schizophrenia, severe cognitive impairment, and was dependent on staff for all ADLs. Resident 5 received Zyprexa and Ativan, and the record showed informed consent forms obtained by family members and verified by two nurses. During interview, nursing staff stated licensed nurses were responsible for obtaining consent, while the CNO stated the facility did not have a current policy and was following AFL guidance, but that the process was not aligned with current guidance and that it was not within the licensed nurse's scope of practice to obtain informed consent. For Resident 5, the facility also did not renew informed consent within six months for Ativan and Olanzapine, with staff acknowledging the consents were 1 year and 14 months old, respectively, and the AFL cited in the report required written informed consent and renewal every six months.
Failure to follow tube-feeding positioning and psychotropic behavior monitoring care plans
Penalty
Summary
The facility failed to elevate the head of bed to the ordered semi-Fowler's position during enteral feeding for Residents 9, 13, and 16. Resident 9 had diagnoses including respiratory failure, pneumonia, and a gastrostomy, was fully dependent on staff for ADLs and mobility, and required enteral feeding 22 hours a day. The physician orders and care plan directed staff to maintain the head of bed at 30 to 45 degrees during feeding, but on three separate observations the resident was receiving tube feeding at 55 milliliters per hour while the head of bed remained below 30 degrees. Resident 13 had diagnoses including respiratory failure, pneumonitis, and a gastrostomy, was comatose, fully dependent on staff for ADLs and mobility, and required enteral feeding 22 hours a day. The physician orders and care plan directed staff to keep the head of bed in semi-Fowler's position and elevate it to at least 30 to 45 degrees during feeding. During observation, Resident 13 was receiving tube feeding at 65 milliliters per hour while the head of bed was maintained at less than 30 degrees. Resident 16 had diagnoses including respiratory failure, pneumonitis, and a gastrostomy, was comatose, fully dependent on staff for ADLs and mobility, and required enteral feeding 22 hours a day. The physician orders and care plan directed staff to maintain the head of bed in semi-Fowler's position and elevate it to at least 30 to 45 degrees during feeding. During observation, Resident 16 was receiving tube feeding at 55 milliliters per hour while the head of bed was maintained at less than 30 degrees. During interview, RN 2 stated the head of bed should be maintained at a minimum elevation of 30 degrees to prevent aspiration. The facility also failed to complete daily behavioral monitoring for Residents 4 and 14 as directed in their care plans for psychotropic medication use. Resident 4 had severe cognitive impairment and was dependent on staff for all ADLs and mobility. The resident received Zoloft for sad facial expressions and episodes of continuous crying, and the care plan directed staff to monitor behaviors and document the frequency every shift. The record did not show behavior monitoring during multiple night shifts in April, July, August, and November 2025. Resident 14 had severe cognitive impairment and was dependent on staff for all ADLs and mobility. The resident received Zyprexa for agitation and aggressive behavior and Ativan for restlessness and aggressive behavior. The care plans directed staff to monitor behaviors and document the frequency every shift. The psychotropic medication records did not show behavior monitoring during a morning shift in July 2025, a night shift in August 2025, and a day shift in October 2025. The CNO stated the behavior monitoring was intended to ensure treatment was effective, including the dose of the medication, and that the care plan was to be followed.
Failure to Maintain Head of Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure the head of bed was elevated to semi-Fowler's position during continuous enteral feeding for three sampled residents. Resident 9 had diagnoses including respiratory failure, pneumonia, and a gastrostomy, was fully dependent for ADLs and mobility, and had physician orders for enteral feeding 22 hours a day with the head of bed maintained in semi-Fowler's position. During observations on 1/5/2026, 1/6/2026, and 1/7/2026, Resident 9 was receiving enteral feeding at 55 mL per hour while the head of bed was maintained at less than 30 degrees. Resident 13 and Resident 16 also had diagnoses including respiratory failure, pneumonitis, and a gastrostomy, were comatose, fully dependent for ADLs and mobility, and had physician orders for enteral feeding 22 hours a day with the head of bed maintained in semi-Fowler's position during feeding. On 1/5/2026, Resident 13 was observed receiving enteral feeding at 65 mL per hour with the head of bed at less than 30 degrees, and Resident 16 was observed receiving enteral feeding at 55 mL per hour with the head of bed at less than 30 degrees. RN 2 stated the head of bed should be maintained at a minimum elevation of 30 degrees to prevent aspiration, and the facility policy required the head of bed to be elevated at least 30 degrees during enteral feeding and to remain elevated for continuous feeding.
Infection Control Lapses During Phlebotomy
Penalty
Summary
The facility failed to maintain infection control measures during blood collection for two residents. During an observation at one resident’s bedside, a phlebotomist was seen wearing a white lab coat and gloves, with the lab coat touching the resident’s bed and linens. The phlebotomist used gloved hands to reposition the resident’s arm before opening phlebotomy supplies, and empty wrappers were moved from that resident’s bed to the roommate’s bedside dresser. The phlebotomist then completed the blood draw while wearing the same gloves and later collected the wrappers from the other resident’s dresser and discarded them without disinfecting the dresser surface. One resident was admitted with pneumonia, respiratory failure with tracheostomy and gastrostomy, and gastrostomy infection, and was comatose and dependent on staff for all mobility. The roommate was admitted with respiratory failure and had a tracheostomy and gastrostomy; the MDS indicated severe cognitive impairment and dependence on staff for all ADLs and mobility. The Infection Preventionist stated enhanced barrier precautions applied to residents with indwelling medical devices, including these two residents, and that the phlebotomist should have worn the required PPE. The Infection Preventionist also stated items in contact with one resident should be discarded and should not touch another resident’s belongings, and that the roommate’s bedside dresser should have been disinfected immediately to prevent cross-contamination.
Failure to Provide Daily RNA Services as Prescribed
Penalty
Summary
The facility failed to ensure that Restorative Nurse Assistant (RNA) services were performed daily for five residents, as required by their physician orders. These residents, identified as Resident 5, Resident 8, Resident 21, Resident 22, and Resident 23, were all dependent on staff for various activities of daily living and had severe cognitive impairments. The RNA services were intended to maintain or improve their range of motion and prevent contractures, but the services were only provided five times a week instead of daily, as prescribed. Resident 5 had chronic respiratory failure and was supposed to receive RNA services that included the application of bilateral hand rolls and knee splints daily. However, the treatment record showed that these services were only completed five times a week. Similarly, Resident 8 and Resident 21 were prescribed the application of bilateral PRAFOS and resting splints daily, but their records also indicated that these treatments were only performed five times a week. Resident 22 had no treatment record of RNA services, despite having a physician order for passive and active range of motion exercises daily. During an interview, the Director of Nursing (DON) confirmed that RNA services were not provided on weekends, which was contrary to the physician orders that specified daily services. The DON acknowledged the potential risks of not adhering to the prescribed RNA services, which could lead to conditions such as wrist or foot drop and further contractures. The facility's policy on the Restorative Nursing Program required that treatment programs be carried out according to the written plan of care and documented daily, which was not followed in these cases.
Failure to Explain Medications to Resident
Penalty
Summary
The facility's staff failed to uphold a resident's rights by not explaining medications administered to her. The resident, who was admitted with diagnoses including dysfunctional uterine bleeding, respiratory failure, and anoxic brain injury, was observed to be alert and awake during medication administration. However, the Licensed Vocational Nurse (LVN) did not explain the medications being given via gastrostomy tube, which is a violation of the resident's rights to be informed and to refuse treatment. Interviews with the facility's staff, including a Registered Nurse (RN) and the LVN involved, confirmed that the standard procedure is to introduce oneself and explain medications to residents. The RN emphasized the importance of this practice to maintain the resident's dignity and informed consent. The LVN admitted to missing this step during the medication pass, acknowledging that the resident was alert and had the right to refuse the medications. The facility's policies on resident education and rights also support the necessity of informing residents about their medications.
Failure to Revise Care Plan for Resident Receiving Outside Food
Penalty
Summary
The facility failed to revise the care plan for a resident who was receiving outside food, which had the potential to place the resident at risk for aspiration. The resident, who was admitted with a diagnosis of respiratory failure and had moderate cognitive impairment, was on a mechanically altered diet and had a gastronomy for nutrition. Despite this, the resident reported that their family had been bringing them food from home for several weeks. The care plan, dated 10/26/2024, did not reflect this change, and the approaches were to provide the diet as ordered. Interviews with facility staff, including a registered nurse and a licensed vocational nurse, confirmed that the care plan needed to be revised to account for the resident receiving food from home. The facility's policy and procedure indicated that care plans should be updated in response to changes in the resident's condition to ensure continuity of care and safety. However, the care plan for this resident was not updated, increasing the risk of aspiration due to the unaddressed change in dietary intake.
Failure to Update Physician Orders for Resident's Diet
Penalty
Summary
The facility failed to ensure that a resident's physician orders were updated to reflect the correct diet plan, which had the potential to cause a delay in care. The resident, who was admitted with a diagnosis of respiratory failure and had moderate cognitive impairment, was observed receiving a regular soft and bite-size diet with thin liquid, despite physician orders indicating enteral feeding via gastronomy. This discrepancy was identified during a review of the resident's records and through interviews with registered nurses. The registered nurses acknowledged that the physician orders should have been updated to reflect the resident's current diet of regular soft with small bite size. The facility's policy and procedure for order clarification and medication reconciliation were reviewed, highlighting the importance of accurate and complete reconciliation of orders to prevent errors. The failure to update the physician orders for the resident's diet was noted as a deficiency, with the potential to cause a delay in care.
Failure to Complete Required Phenobarbital Level Test
Penalty
Summary
The facility failed to ensure that a laboratory test for phenobarbital levels was completed for a resident in October 2024. This resident, who was admitted with chronic respiratory failure and required a tracheostomy and gastrostomy tube, had severe cognitive impairment and was dependent on staff for daily activities. The resident had an active physician order for phenobarbital to prevent seizures and required monthly monitoring of phenobarbital levels. However, the facility did not complete the required test for October, and there was no documentation of communication with the physician regarding the missing test results. During an interview and record review, the Director of Nursing confirmed that the phenobarbital level test for October was not available and had not been completed. The facility's policies and procedures for drug therapy monitoring and physician order implementation were reviewed, indicating that drug therapy should be monitored continuously to ensure safety and effectiveness. Despite these policies, there was no evidence of follow-up or documentation regarding the missing phenobarbital level test, which was crucial for managing the resident's seizure condition and preventing drug toxicity.
Failure to Document Resident's Outside Food Intake
Penalty
Summary
The facility failed to ensure accurate documentation for a resident who was receiving food from home, which was not in accordance with accepted professional standards. The resident, who had been diagnosed with respiratory failure and had moderate cognitive impairment, was on a mechanically altered diet and had a gastronomy for nutrition. Despite these dietary restrictions, the resident's family had been bringing food from home for several weeks, which was not documented in the resident's medical records. This lack of documentation posed a potential risk for aspiration, as the resident refused to eat the facility-provided meal during an observation. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) was aware of the family bringing food but had not documented it in the progress notes. The Registered Nurse (RN) confirmed that the progress notes should have been updated to reflect the family's actions and to educate them about the resident's dietary needs to prevent choking. The facility's policy and procedure on charting required documentation to be completed for each shift and to include both normal and abnormal findings, which was not adhered to in this case.
Failure to Complete Infection Surveillance Checklist for Antibiotic Use
Penalty
Summary
The facility failed to complete the Revised McGeer Criteria for Infection Surveillance Checklist for two residents, which is necessary to determine if antibiotic use is appropriate. Resident 17, who was admitted with pneumonia and respiratory failure, had a physician's order for erythromycin ethyl succinate for high gastric residual. Resident 20, admitted with chronic respiratory failure and a tracheostomy, had orders for Zosyn and vancomycin to treat leukocytosis. Both residents were severely impaired cognitively and dependent on staff for personal hygiene. The Infection Preventionist Nurse (IPN) admitted to not completing the checklist within three days of the antibiotic order, which is part of her role in antibiotic stewardship. The Director of Pharmacy confirmed that completing the checklist is a standard practice for all licensed nurses. The facility's policies on infection prevention and antimicrobial stewardship emphasize the importance of surveillance and appropriate antibiotic use, but these were not followed, leading to the potential for inappropriate antibiotic use and the development of multi-drug resistant organisms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Costa Del Sol Healthcare | 0.1 mi | ★★★★★ | 5 | 0 |
| Los Angeles Comm Hospital | 0.7 mi | ★★★★★ | 15 | 1 |
| Infinity Care Of East Los Angeles | 2.1 mi | ★★★★★ | 11 | 0 |
| Hollenbeck Palms | 2.5 mi | ★★★★★ | 21 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.7 mi | ★★★★★ | 25 | 0 |
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