Pavilion on Pico: Resident Threatened With Transfer - CA
That is what federal inspectors found when they surveyed Pavilion on Pico Healthcare & Wellness Centre in late March.
The resident, identified in inspection records only as Resident 1, had a diagnosis of major depressive disorder. She had preferences: she wanted to get up early, and she wanted her clothes washed. These were not unusual requests. They were the kind of things a person living somewhere expects to be able to ask for.
Staff told inspectors she was making "high demands."
The facility's own charge nurse, identified in the report as RN 1, reviewed the social services notes from the day before inspectors arrived and said plainly that the facility could accommodate Resident 1's needs. The nurse said the facility "should not transfer Resident 1 because of high demands."
But the nurse also acknowledged what had already happened. Staff had spoken to Resident 1 in a way that left her feeling "not secured and disrespected." The nurse told inspectors that if staff talked to her that way, "Resident 1 may feel that she is not wanted and neglected" — and that this mattered especially because of her depression diagnosis.
The nurse said it plainly. Then the inspection report moved on.
What the report captures, in the flat bureaucratic language of federal deficiency citations, is a sequence of events that tells its own story. A resident asked to get up early. Staff told her they needed to explain to her why that was a problem. She asked to have her clothes washed. Staff told her laundry only runs twice a week in the facility, not daily. Somewhere in those exchanges, the word "transfer" entered the conversation.
The facility's own discharge and transfer policy, reviewed and approved as recently as June 2024, lays out the narrow circumstances under which a resident can be moved out. A physician has to order it. The discharge has to be necessary for the resident's welfare, or the facility has to be genuinely unable to meet needs it cannot provide. The resident's health has to have improved to the point where the facility's services are no longer required.
None of those conditions applied to Resident 1. Her health had not improved in a way that made nursing home care unnecessary. The facility was not medically incapable of caring for her. The reason her transfer came up, according to the inspection record, was that staff found her difficult.
The facility's resident rights policy, also reviewed in June 2024, states that employees are to treat residents "with kindness, respect, and dignity." It states that residents have freedom of choice about how they wish to live their everyday lives and receive care.
Resident 1's everyday life included wanting to get up at a time she chose and having clean clothes. The inspection record does not indicate she was given either without friction.
What the record does indicate is that by the time inspectors arrived, the social services director had documented the situation on March 25, the day before the survey. RN 1 reviewed those notes during the inspection. The nurse's conclusion — that the transfer talk was wrong, that the manner in which staff had spoken to Resident 1 was wrong — came only after inspectors were already in the building asking questions.
The harm level assigned to this deficiency was "minimal harm or potential for actual harm." That is the lower end of the scale CMS uses to classify what inspectors find. It does not mean nothing happened. It means inspectors judged that the harm had not yet risen to the level of serious injury.
For a resident with major depressive disorder, being told she is too demanding, being spoken to in a way that makes her feel unwanted, being told she might be transferred — the inspection report itself flags these as the specific risks. RN 1 said so. The nurse connected the manner of the staff interactions directly to how Resident 1's diagnosis made her vulnerable to feeling "neglected."
That word, "neglected," appears in the nurse's own statement to inspectors. Not in an advocacy organization's press release, not in a family member's complaint. From the facility's own charge nurse, describing what Resident 1 might feel as a result of how her own colleagues had treated her.
Pavilion on Pico Healthcare & Wellness Centre sits at 5916 West Pico Boulevard in Los Angeles. The inspection covered in this report was completed March 26, 2025.
The inspection report does not say whether anyone sat down with Resident 1 after the survey and told her she was not going to be transferred. It does not say whether the staff members who spoke to her in the way RN 1 described faced any consequence. It does not say whether she got to choose her wake-up time after inspectors left, or whether her laundry situation changed.
What it says is that a woman with depression was made to feel she was not wanted in the place where she lived, because she asked for things that her facility's own nurse later confirmed the facility could provide.
The report identifies residents affected as "few." That is the smallest category on the scale. One person. Maybe a handful. The kind of number that, in a deficiency citation, can make something sound minor.
It was not minor to Resident 1.
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 11, 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.
That is what federal inspectors found when they surveyed Pavilion on Pico Healthcare & Wellness Centre in late March.
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.