Pavilion on Pico: Social Worker Asked "When Are You Leaving?" - CA
The resident felt like she was being kicked out. She told inspectors she felt bad that staff were trying to send her elsewhere because of her demands. Her requests were getting up at 6 a.m., having her laundry done daily, and keeping her belongings in boxes in her room.
Federal inspectors found that Pavilion on Pico Healthcare & Wellness Centre failed to provide proper social services to the resident, who had been admitted with type II diabetes, chronic lung disease, and major depressive disorder. The facility's approach to her needs violated her rights and caused psychological distress.
The resident required maximum assistance for daily activities like bathing and dressing. She needed a mechanical Hoyer lift to transfer from place to place. Her assessment showed she experienced moderate depression more than half the days while at the facility, though she could understand and make her own medical decisions.
Her psychiatrist noted in March that the primary goal was to explore and improve her interactions with nursing home staff. The psychiatrist wrote that addressing her mood and emotional state was crucial because it influenced her behavior toward others. The resident was in current episodes of depression.
The Social Services Director wrote in his progress notes on March 25 that he advised the resident "unfortunately, we cannot accommodate her needs due to her demands." He listed her requests: getting up by 6 a.m., daily laundry service, and having all her belongings brought to her room. He wrote that the facility had tried to find another facility that would meet her needs, but she had declined every single one that accepted her.
When inspectors interviewed the resident the next day, she said the Social Services Director was very rude when he approached her. She said she understood she could be demanding, but it was because she was particular about where she wanted to stay. She didn't want to go elsewhere and wanted to remain at the facility.
Nobody had developed a care plan for what staff called her "unrealistic demands and requests."
A nursing assistant who worked with the resident told inspectors the resident liked to be up early in the morning after breakfast around 9:30 a.m. The assistant said the resident was nice to her and friendly with staff. The assistant said the resident was particular about her likes and dislikes, but she understood "because it is residents' rights."
The Social Services Director told inspectors he inquired with other skilled nursing facilities because they couldn't accommodate her high demands. When asked what residents' rights were regarding freedom of choice, he couldn't answer. He said no interdisciplinary team meeting was conducted to prepare for discharge planning. He didn't know the facility's policy on discharge and transfer of residents.
The director said there was nothing wrong with how he approached the resident about transferring her to other facilities because of her high demands.
A registered nurse who reviewed the Social Services Director's notes disagreed. She told inspectors that the facility could accommodate the resident's needs and "they should not transfer Resident 1 because of high demands." The nurse said if the resident requested to get out of bed early, staff needed to accommodate her needs or explain why they couldn't.
The nurse explained that the resident understood she couldn't store all her belongings in her room for safety reasons. The resident also understood they couldn't wash her clothes daily because facility laundry was done only twice a week. But the nurse said if staff talked to the resident in a way that made her feel insecure and disrespected, the resident might feel unwanted and neglected.
This was concerning given the resident's major depressive disorder diagnosis.
The facility's own policy stated it would provide "person-centered, comprehensive and interdisciplinary care" to meet residents' health, safety, psychological, behavioral, and environmental needs. The policy required licensed nurses to assess residents' mood and behavior changes using a formal process.
The Social Services Director's job description required good interpersonal skills and ensuring that residents' psychological needs were identified and met. It required him to present a professional image through behavior and speech, adhere to company standards for resolving concerns, and ensure all resident rights were protected.
The administrator told inspectors that follow-up training with a Social Services Consultant would be provided to ensure the facility properly accommodated all residents' needs.
The resident's care plan for her major depression had set a goal of improved mood state with "happier, calmer appearance, no signs and symptoms of depression." Instead, she was left feeling kicked out by staff who couldn't answer basic questions about resident rights while pushing her toward facilities she didn't want.
The nursing assistant understood that being particular about preferences was a resident's right. The registered nurse understood the facility could accommodate the requests. But the Social Services Director, whose job required protecting resident rights, asked "when are you leaving?" without any formal discharge planning or team consultation.
The resident remained at Pavilion on Pico, still wanting to get up at 6 a.m., still wanting daily laundry, still feeling like staff wanted her gone.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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 resident felt like she was being kicked out.
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.