Pavilion on Pico: Mood Assessment Failures - Los Angeles, CA
The citation, one of several deficiencies recorded during the inspection of the facility at 5916 W. Pico Boulevard, focused on the facility's own internal process for recognizing and responding to residents in distress. When a resident's mood or behavior shifts, a licensed nurse is supposed to conduct an assessment using what the facility calls its Change of Condition process. Inspectors found that process was not being followed consistently.
CMS rated the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. Those words, "minimal harm," appear in the formal deficiency record as a regulatory classification. They do not mean nothing happened.
The Change of Condition process exists precisely because behavioral and mood shifts in nursing home residents are often the first visible sign of something more serious. A resident who becomes suddenly withdrawn, agitated, or confused may be experiencing pain, infection, medication side effects, or the early stages of a medical crisis. The assessment is the mechanism that catches those possibilities before they become emergencies. When it doesn't happen, the window for early intervention closes.
Pavilion on Pico is a licensed skilled nursing facility operating in the mid-city section of Los Angeles. The inspection was conducted in late March 2025, with the formal statement of deficiencies printed months later in August 2026. The facility's CMS identification number is 055160.
The inspection report, as provided, does not name the residents whose assessments were missed, does not describe what mood or behavioral changes they exhibited, and does not state how many times the lapse occurred or over what period. It establishes that the failure happened, that licensed nursing staff were responsible for the assessment, and that the facility's own written policy described exactly what should have been done.
That gap between a written policy and what actually occurs on a floor at night, or on a weekend, or during a shift when staff are stretched, is where inspection reports like this one live. A facility can document its protocols in detail. The documentation does not perform the assessment.
CMS requires facilities to submit a plan of correction for each cited deficiency. The inspection report notes that anyone seeking information about Pavilion on Pico's correction plan should contact the facility directly or reach the California state survey agency. No correction details were included in the materials reviewed for this report.
The citation carries a harm level that, in the formal regulatory language, sits near the lower end of the scale. Immediate jeopardy, the most serious designation, was not cited here. But the residents described as "few" are people whose nurses did not complete the step designed to catch what was wrong with them. Whether anything was wrong, and whether it was caught through some other means, the inspection report does not say.
What it says is that the process failed. A resident changed. The assessment did not follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion On Pico Healthcare & Wellness Centre, Lp from 2025-03-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 5, 2026 · Our methodology
PAVILION ON PICO HEALTHCARE & WELLNESS CENTRE, LP in LOS ANGELES, CA was cited for violations during a health inspection on March 26, 2025.
The citation, one of several deficiencies recorded during the inspection of the facility at 5916 W.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.