Pavilion On Pico Healthcare & Wellness Centre, Lp

F-F745

Findings:

During a review of the Resident 1's Admission Record, it indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 experienced moderate depression in half or more of the days while in the facility.

During a review of Resident 1's History and Physical (H&P) dated 2/2/2025, the H&P indicated, Resident 1 can understand and make own medical decisions.

During a review of Resident 1's Care Plan (CP) for mood problem related to major depression, initiated on 2/10/2025, the CP indicated a goal of, Resident (1) will have improved mood state happier, calmer appearance, no signs and symptoms (s/sx) of depression.

During a review of Resident 1's Medical Record as of 3/26/2025, there was no CP develop regarding Resident 1's behavior of unrealistic demands and requests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 055160 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055160 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 During a review of Resident 1's Psychosocial Note, dated 3/20/2025 by Psychiatrist 1 (PSYCH1), the Psychosocial Note indicated, The primary goal for the session was to explore and improve the client's Level of Harm - Minimal harm or (Resident 1) interpersonal interactions, particularly with the staff at the skilled nursing facility where she potential for actual harm resides. The client (Resident 1), diagnosed with bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), is in Residents Affected - Few current episodes of depression, and it is crucial to address her mood and emotional state, which influence her behavior towards others.

During a review of Resident 1's Progress Notes by Social Services Director (SSD), dated 3/25/2025, the Progress Notes indicated, I (SSD) advised patient (Resident 1) that unfortunately, we cannot accommodate her (Resident 1)'s needs due to her demands, she is max (maximum) assist with Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place), and she is demanding to be up by 6 a.m.

She (Resident 1) is also asking to have her laundry done on a daily basis, she also complains of having all her belongings brought to her room, which is a lot of boxes . We have tried to find a facility that will meet her needs, but she has declined every single facility that has accepted her based on her (Resident 1) needs.

During an interview with Resident 1 on 3/26/2025 at 12:03 p.m., Resident 1 stated, SSD was very rude when

he (SSD) approached her, and he (SSD) asked her, when are you leaving? . Resident 1 stated, she felt like

she was being kicked out . Resident 1 stated, she is particular on the place where she would like to stay, she does not want to go elsewhere and would like to stay in the facility. Resident 1 further stated, she understands that she can be demanding but it's because she is picky with the place she wanted to stay. Resident stated, she felt bad that they are trying to send her out elsewhere because of her demands.

During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/26/2025 at 12:18 p.m., CNA 1 stated, Resident 1 liked to be up early in the morning after breakfast at around 9:30 a.m. CNA 1 stated, Resident 1 is nice to her, and she (Resident 1) was friendly with staff. CNA 1 stated, Resident 1 are particular on her likes and dislikes, but she (CNA 1) understands because it is residents' rights.

During an interview with SSD on 3/26/2025 at 1:02 p.m., SSD stated, Resident 1 have high demands such as wanting to get out of bed early at 6 a.m., she (Resident 1) wanted her laundry to be done daily, and she (Resident 1) wanted all her belongings in her room. SSD stated, they are not able accommodate her needs because of her high demands so he (SSD) inquired into other skilled nursing facility (SNF) that may accommodate her needs. SSD stated, Resident 1 declined to be transferred to another SNFs. When asked what residents' rights are when it comes to their freedom of choice, SSD was not able to answer. SSD stated, there was no IDT meeting conducted in preparation of Resident 1's discharge planning. SSD stated,

he does not know about the facility's policy on discharge and transfer of residents. SSD further stated, there was nothing wrong on how he approached Resident 1 regarding transferring her (Resident 1) to other SNFs because of her high demands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 055160 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055160 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/26/2025 at 1:33 p.m., RN 1 stated, she explained to Resident 1, and Resident 1 understood about not being able to store all her Level of Harm - Minimal harm or belongings in her room for her safety and others. RN 1 stated, if Resident 1 requested to be out of bed early potential for actual harm in the morning, staff need to accommodate her needs and if they are not able to get Resident 1 up early, staff need to explain it to Resident 1. RN 1 stated, Resident 1 also understood that they are not able to wash Residents Affected - Few her clothes daily because the laundry is done in the facility for only twice a week. RN 1 reviewed SSD's notes on 3/25/2025 and stated, the facility can accommodate Resident 1's needs and they should not transfer Resident 1 because of high demands . RN 1 stated, if staff talked to Resident 1 in a manner where

they do not feel secured and disrespected, Resident 1 may feel that she is not wanted and neglected which Resident 1 may be very sensitive because of her diagnosis of major depressive disorder.

During a review of the facility's policy and procedures (P&P) titled, Behavior/Psychotropic Drug Management, reviewed and approved by facility on 6/28/2024, the P&P indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain

the highest physical, mental, and psychosocial well-being . If an in-house resident manifests a change in his/her mood or behavior symptoms, the licensed Nurse will conduct an assessment of the resident's mood and behavior status utilizing the Change of Condition process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055160 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055160 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454 potential for actual harm Based on interview and record review, the facility failed to provide medically-related social services to attain Residents Affected - Few or maintain the highest practicable physical, mental and psychosocial well-being to one out of four sampled residents (Resident 1), by failing to promote individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs.

This deficient practice placed Resident 1 in psychosocial distress.

Findings:

During a review of the Resident 1's Admission Record, it indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 experienced moderate depression in half or more of the days while in the facility.

During a review of Resident 1's History and Physical (H&P) dated 2/2/2025, the H&P indicated, Resident 1 can understand and make own medical decisions.

During a review of Resident 1's Care Plan (CP) for mood problem related to major depression, initiated on 2/10/2025, the CP indicated a goal of, Resident (1) will have improved mood state happier, calmer appearance, no signs and symptoms (s/sx) of depression.

During a review of Resident 1's Medical Record as of 3/26/2025, there was no CP develop regarding Resident 1's behavior of unrealistic demands and requests.

During a review of Resident 1's Psychosocial Note, dated 3/20/2025 by Psychiatrist 1 (PSYCH1), the Psychosocial Note indicated, The primary goal for the session was to explore and improve the client's (Resident 1) interpersonal interactions, particularly with the staff at the skilled nursing facility where she resides. The client (Resident 1), diagnosed with bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), is in current episodes of depression, and it is crucial to address her mood and emotional state, which influence her behavior towards others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055160 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055160 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 During a review of Resident 1's Progress Notes by Social Services Director (SSD), dated 3/25/2025, the Progress Notes indicated, I (SSD) advised patient (Resident 1) that unfortunately, we cannot accommodate Level of Harm - Minimal harm or her (Resident 1)'s needs due to her demands, she is max (maximum) assist with Hoyer Lift (a mechanical potential for actual harm device used to lift and/or transfer a person from place to place), and she is demanding to be up by 6 a.m.

She (Resident 1) is also asking to have her laundry done on a daily basis, she also complains of having all Residents Affected - Few her belongings brought to her room, which is a lot of boxes . We have tried to find a facility that will meet her needs, but she has declined every single facility that has accepted her based on her (Resident 1) needs.

During an interview with Resident 1 on 3/26/2025 at 12:03 p.m., Resident 1 stated, SSD was very rude when

he (SSD) approached her, and he (SSD) asked her, when are you leaving? . Resident 1 stated, she felt like

she was being kicked out . Resident 1 stated, she is particular on the place where she would like to stay, she does not want to go elsewhere and would like to stay in the facility. Resident 1 further stated, she understands that she can be demanding but it's because she is picky with the place she wanted to stay. Resident stated, she felt bad that they are trying to send her out elsewhere because of her demands.

During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/26/2025 at 12:18 p.m., CNA 1 stated, Resident 1 liked to be up early in the morning after breakfast at around 9:30 a.m. CNA 1 stated, Resident 1 is nice to her, and she (Resident 1) was friendly with staff. CNA 1 stated, Resident 1 are particular on her likes and dislikes, but she (CNA 1) understands because it is residents' rights.

During an interview with SSD on 3/26/2025 at 1:02 p.m., SSD stated, Resident 1 have high demands such as wanting to get out of bed early at 6 a.m., she (Resident 1) wanted her laundry to be done daily, and she (Resident 1) wanted all her belongings in her room. SSD stated, they are not able accommodate her needs because of her high demands so he (SSD) inquired into other skilled nursing facility (SNF) that may accommodate her needs. SSD stated, Resident 1 declined to be transferred to another SNFs. When asked what residents' rights are when it comes to their freedom of choice, SSD was not able to answer. SSD stated, there was no IDT meeting conducted in preparation of Resident 1's discharge planning. SSD stated,

he does not know about the facility's policy on discharge and transfer of residents. SSD further stated, there was nothing wrong on how he approached Resident 1 regarding transferring her (Resident 1) to other SNFs because of her high demands.

During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/26/2025 at 1:33 p.m., RN 1 stated, she explained to Resident 1, and Resident 1 understood about not being able to store all her belongings in her room for her safety and others. RN 1 stated, if Resident 1 requested to be out of bed early

in the morning, staff need to accommodate her needs and if they are not able to get Resident 1 up early, staff need to explain it to Resident 1. RN 1 stated, Resident 1 also understood that they are not able to wash her clothes daily because the laundry is done in the facility for only twice a week. RN 1 reviewed SSD's notes on 3/25/2025 and stated, the facility can accommodate Resident 1's needs and they should not transfer Resident 1 because of high demands . RN 1 stated, if staff talked to Resident 1 in a manner where

they do not feel secured and disrespected, Resident 1 may feel that she is not wanted and neglected which Resident 1 may be very sensitive because of her diagnosis of major depressive disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055160 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055160 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 During an interview with Administrator (ADM) on 3/26/2025 at 4:19 p.m., ADM stated, a follow-up in-services with a Social Services Consultant will be provided to the SSD to ensure that the facility is providing Level of Harm - Minimal harm or appropriate accommodation and needs of all residents. potential for actual harm

During a review of the facility's Job Description (JD) titled, Social Service Coordinator , date signed by SSD Residents Affected - Few on 4/20/2023, the JD indicated, Qualifications: Good written and verbal communication skills; Good interpersonal skill . Principal Responsibilities: Ensure the residents' psychosocial and concrete needs are identified and met in accordance with federal, state and company requirements. Customer Service:

Presents professional image to consumers through dress, behavior and speech.

Adheres to company standards for resolving consumer concerns.

Ensures that all consumer/ resident rights are protected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055160