Health inspection·January 30, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4), had a wound care consultation follow up for pressure injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) prevention initiated in a timely manner. Residents Affected - Few This failure resulted Resident 4 ' s wound care treatments to be ordered 10 days after admission to the facility which, had the potential to result in Resident 4 ' s pressure injury on the sacrum (bony structure at the base of the spine) and bilateral (both sides) lateral (outer) ankle arterial ulcers (wound located on lower leg or foot due to poor circulation) to worsen. Findings: During a review of Resident 4's admission Record, dated 1/31/24, indicated, the resident was admitted to the facility on [DATE] with diagnoses including essential (primary) hypertension (high blood pressure), hemiplegia (muscle weakness on one side of the body) and hemiparesis (muscle paralysis on one side of the body) following cerebrovascular disease (a condition affecting the blood vessels and blood supply to the brain) of the left non-dominant side, pressure injury to sacrum and arterial ulcers to bilateral lateral ankles. During a review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/2/24, the MDS indicated, Resident 4 had major cognitive (ability to remember, understand, make decisions, and learn) problems and was dependent on staff for bed mobility, nutrition, bathing, toileting and personal hygiene. Further review of the same MDS indicated, Resident 4 was admitted with one unstageable (full thickness tissue loss, where the depth of the ulcer is obscured by slough [yellow, tan, gray, green or brown] and /or eschar [tan, brown, or black] in the wound bed) pressure injury and two arterial ulcers. During a review of Resident 4 ' s order summary report dated 1/30/24, the report indicated, an order for Wound consultation with follow-up treatment as indicated entered on 12/26/23. During a concurrent interview and record review on 1/30/24 at 1:45 pm with Director of Nursing (DON), Resident 4 ' s physician ' s orders and treatment administrator records for December and January were reviewed. The DON verified there were no treatment orders for any of the resident ' s wounds entered before 1/5/24. The DON further verified there were no treatments documented for any of the wounds until 1/5/24. The DON stated if a resident has wounds on admission then there should have been treatments ordered for them. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055160 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 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)