A
EAST LOS ANGELES DOCTORS HOSP
86/100 score
1.75 hrs RN staffing
7 deficiencies
PAVILION ON PICO HEALTHCARE & WELLNESS CENTRE, LP
5916 W. PICO BOULEVARD, LOS ANGELES, CA 90035
C
Facility Assessment
Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.53 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
42
Outstanding
0
Actual harm or worse (G–L)
1
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★★ (5/5)
Staffing: ★★★☆☆ (3/5)
|
|
NursingHomeGrade Score
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54/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 immediate jeopardy issue found among 42 total deficiencies. 42 corrected.
Most recent inspection (November 17, 2024)
B
No harm — pattern
F0911
Status: Corrected
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Environmental Deficiencies — Waiver has been granted, corrected December 3, 2024
B
No harm — pattern
F0912
Status: Corrected
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies — Waiver has been granted, corrected December 3, 2024
E
Potential harm — pattern
F0925
Status: Corrected
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
E
Potential harm — pattern
F0803
Status: Corrected
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
E
Potential harm — pattern
F0805
Status: Corrected
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
E
Potential harm — pattern
F0814
Status: Corrected
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
D
Potential harm — isolated
F0637
Status: Corrected
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
E
Potential harm — pattern
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2024
Inspection cycle 2 (October 20, 2023)
B
No harm — pattern
F0911
Status: Corrected
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Environmental Deficiencies — Waiver has been granted, corrected November 9, 2023
B
No harm — pattern
F0912
Status: Corrected
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies — Waiver has been granted, corrected November 9, 2023
D
Potential harm — isolated
F0740
Status: Corrected
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2025
D
Potential harm — isolated
F0745
Status: Corrected
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2024
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0685
Status: Corrected
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0645
Status: Corrected
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0624
Status: Corrected
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2025
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0578
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
Inspection cycle 3 (October 30, 2022)
B
No harm — pattern
F0911
Status: Corrected
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
B
No harm — pattern
F0912
Status: Corrected
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0732
Status: Corrected
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0801
Status: Corrected
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0814
Status: Corrected
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
J
Immediate jeopardy — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2023
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2024
E
Potential harm — pattern
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023
D
Potential harm — isolated
F0698
Status: Corrected
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 18, 2023
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
D
Potential harm — isolated
F0559
Status: Corrected
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
E
Potential harm — pattern
F0578
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2022
How We Stay Independent
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