Cycle 1
Health 2024-11-10 · Fire 2024-11-10
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Los Angeles, CA
East Los Angeles Doctors Hosp
5-star overall rating with 5-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4060 E. Whittier Blvd., Los Angeles, CA
(323) 260-4230
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
23
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.75
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
3.59
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.34
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
8.68
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.34
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
7.78
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
3.35
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 38% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 23.17% |
8.2%
15 pts better
|
Numerator 19 · Denominator 82 |
| Staff flu vaccination coverage | 66.14% |
42%
24.1 pts better
|
Numerator 84 · Denominator 127 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
98.5%
7.2 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 91.3% · Q3 91.3% · Q4 95.7% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
4.1%
3 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
13.7%
7.2 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.0% · Q3 8.7% · Q4 4.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.2%
14.2 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 3.3% |
0.4%
2.9 pts worse
|
0.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 4.3% · Q4 4.3% · 4Q avg 3.3% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.0%
0.8 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 0.0% · Q4 2.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
10.9%
10.9 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
4.7%
3.5 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.7% · Q3 3.7% · Q4 8.1% · 4Q avg 8.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-19 · Fire 2023-11-19
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-30
D · Potential for more than minimal harm
2023-11-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-11-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-01-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-10
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-30
D · Potential for more than minimal harm
2023-11-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-05-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-27
E · Potential for more than minimal harm
2023-01-26
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-02-27
E · Potential for more than minimal harm
2023-01-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-02-27
E · Potential for more than minimal harm
2023-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-27
E · Potential for more than minimal harm
2023-01-26
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-27
Penalties and ownership
What sits behind the stars
Ownership
Avanti Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Avanti Hospital Holdings I LLC
5% Or Greater Indirect Ownership Interest · Organization
Avanti Hospitals LLC
5% Or Greater Indirect Ownership Interest · Organization
Bell, Mark
5% Or Greater Indirect Ownership Interest · Individual
Bell, Mark
Corporate Officer · Individual
Carrasco, Victor
Contracted Managing Employee · Individual
Deerfield Private Design Fund Iv, LP
5% Or Greater Indirect Ownership Interest · Organization
Dfp Opco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Edwards, Irv
5% Or Greater Indirect Ownership Interest · Individual
Eladh Management LLC
General Partnership Interest · Organization
Healthplus Holdings LLC
Limited Partnership Interest · Organization
Hernandez, Hector
Operational/Managerial Control · Individual
Hollister Health Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Macpherson, James
5% Or Greater Indirect Ownership Interest · Individual
Macpherson, James
Corporate Officer · Individual
Pipeline Health System Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pipeline Health System, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pipeline Hospital Holdings,llc
5% Or Greater Indirect Ownership Interest · Organization
Scr Healthcare Investments I, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Costa Del Sol Healthcare
Los Angeles, CA
3-star overall rating with 2-star inspections with $38,181 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Los Angeles Comm Hospital
Los Angeles, CA
3-star overall rating with 4-star inspections with $4,938 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Infinity Care Of East Los Angeles
Los Angeles, CA
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $65,583 in total fines with 37 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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