East Los Angeles Doctors Hosp

Based on observation, interview, and record review, the facility failed to ensure the can opener was maintained in a sanitary manner in the kitchen. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in two of two residents who received food from the kitchen.Findings: During the initial kitchen tour observation on 1/5/2026 at 8:30 a.m., a can opener attached to the food preparation table was observed to be blackened, covered with black stains and dried residue. The area surrounding the can opener blade and gear were heavily stained with dark, hardened food debris. During a concurrent observation and interview on 1/5/2026 at 8:40 a.m. in the kitchen, with the Dietary Supervisor (DS), the DS stated the can opener was dirty and had food stains attached to the can opener blade. The DS stated the can opener should be cleaned and kept in sanitary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the prescribing provider obtained informed consent for the administration of psychotropic medication (drugs that alter brain chemistry to affect mood, thoughts, perceptions, and behavior) for three of three sampled residents (Residents 4, 14, and 5), and failed to renew the psychotropic informed consents every six months for one of three sampled residents (Resident 5). These deficient practices removed Residents 4, 14, and 5's responsible parties right to make an informed decision to consent to, or continue, administration of psychotropic medications. Findings: 1a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on 3/11/ 2024. Resident 4's diagnoses included anoxic brain injury (when the brain is completely deprived of oxygen, causing brain cells to die) and convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to elevate the head of bed (HOB) during the administration of enteral feeding ( tube feeding, liquid nutrition delivered directly into the gastrointestinal tract via a soft tube), and perform daily behavioral monitoring for residents receiving psychotropic medications (drugs that alter brain chemistry to affect mood, thoughts, perceptions, and behavior), as indicated in the care plan, for five of 12 sampled residents (Residents 9, 13, 16, 4, and 14), These deficient practices placed Residents 9, 13, and 16 at risk for aspiration (the accidental inhalation of foreign material into the airways/lungs, causing issues like pneumonia [an infection/inflammation in the lungs]) and death. These deficient practices also placed Residents 4 and 14 at risk of not receiving adjustments to their psychotropic medication dosages if needed.Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) was elevated for three of seven sampled residents (Residents 9, 13, and 16) during the administration of enteral feeding (liquid nutrition delivered directly into the gastrointestinal tract via a soft tube). This deficient practice placed Residents 9, 13, and 16 at risk for aspiration (the accidental inhalation of foreign material into the airways/lungs, causing issues like pneumonia [an infection/inflammation in the lungs]) and death.Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), pneumonia (infection of the lungs), and presence of a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Resident 9's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control measures by not ensuring the phlebotomist (health worker trained in drawing venous blood) donned (to put on) personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to performing blood collection, and by not ensuring the phlebotomist did not place phlebotomy supplies on another resident's bedside dresser and disinfect after use for two of 12 sampled residents (Residents 4 and 6). These deficient practices placed Residents 4 and 6 at risk for cross contamination and increased the risk for spread of infection.Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included pneumonia (an infection/inflammation in the lungs), respiratory failure (a condition where there's not enough oxygen or too much…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure RNA services were performed daily for five out of six sampled residents (Resident 5, Resident 8, Resident 21, Resident 22 and Resident 23). This deficient practice had the potential to decline in functional mobility and contractures. Findings: a. During a review of Resident 5's face sheet, the face sheet indicated Resident 5 was admitted to the facility on [DATE]. The face sheet indicated Resident 5 had diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), hypocapnia (a decrease of carbon dioxide in the blood) and hypercapnia (a increase of carbon dioxide in the blood). During a review of the Resident's 5 Minimum Date Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 5's cognitive skills were severely impaired. The MDS also indicated Resident 5 was dependent on staff member with toileting hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review the facility's staff failed to: 1. Ensure one out of two sampled residents (Resident 13) rights were not violated by not explaining medications that were given. This deficient practice had the potential of the resident lower the resident self-esteem. Findings: During a review of Resident 13's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnosed was dysfunctional uterine bleeding (a condition heavy or prolonged vaginal bleeding from the uterus). During a review of Resident 13's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/19/2024 the MDS indicated, Resident 13's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 13's had a gastronomy (a surgical procedure that creates an opening in the stomach to help with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had a revised care plan for outside food. This deficient practice of not revising the care plan for outside food had the potential to place Resident 12 at risk for aspiration (the act of breathing in a foreign object). Findings: During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS indicated, Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was moderate impairment. The MDS indicated Resident 12's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had physician orders that were not updated for the diet plan. This deficient practice of not updating physician orders for Resident 12's diet had the potential to cause a delay in care. Findings: During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS indicated, Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was moderate impairment. The MDS indicated Resident 12's nutritional approaches…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that involves testing a sample of blood, urine, or other substance from the body) of phenobarbital level (a test that measures the amount of phenobarbital-a medicine used to treat seizure, in the blood) for the month of October 2024, was completed for one of one sampled resident (Resident 20). This deficient practice had the potential for Resident 20's to have abnormal values or drug toxicity (accumulation of an excessive amount of any medication in the bloodstream) that would result in delay of treatment and services. Findings: During a review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 20's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had accurate documentation to have food from home. This deficient practice of not accurately documenting food brought in by Resident 12's family and friends which had the potential for Resident 12 to aspirate (the act of inhaling food, liquids, or other material into the lungs). Findings: During an observation on 11/9/2024 at 5:45 p.m., Resident 12 refused to eat his meal. During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Complete the Revised McGeer Criteria (minimum set of signs and symptoms which when met, indicate that a resident likely has an infection and that an antibiotic (a drug used to treat infections caused by bacteria) might be needed) for Infection Surveillance Checklist for two out of two sampled residents (Resident 17 and 20). This deficient practice had the potential to result in the development of multi-drug resistant organisms ([MDRO] - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) from inappropriate antibiotic use. Findings: During a review of Resident 17's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included pneumonia (an infection/inflammation in the lungs) and respiratory failure (a serious condition that makes it difficult to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that food items were labeled and expired food was not stored in the kitchen accessible to be used in preparing foods for one of 22 sampled residents (Resident 17) on the Sub-Acute unit. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses. Findings: During the initial tour of the kitchen, on 11/18/23 at 10:15 a.m., with Dietary Staff A, Refrigerator 9 was observed to have mandarin oranges in a clear storage container with a use by date of 11/17/23, two turkey sandwiches with a used by date of 11/17/23. Also, noted in Refrigerator 9, jalapenos were stored in a small, black storage container with a use-by date of 11/15/23, feta cheese and shredded carrots was separated in two clear storage containers with no labels noted. The technician proceeded to throw away the expired and unlabeled food. During an observation of walk-in refrigerator # 4, on 11/18/23 at 10:30 a.m. with Dietary Staff A, refrigerator 4 was noted to have expired Romaine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.