Health inspection·November 17, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity in full recognition of his or her individuality when two (2) of 13 sampled residents (Resident 2 and Resident 42) did not get their meals at the dining table at the same time. This failure had the potential to result in psychosocial distress and frustration for Resident 2 and Resident 42. Findings: During a review of Resident 2's admission Record, the admission record indicated the facility admitted Resident 2 on 12/12/2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe, dysphagia (difficulty swallowing) and type 2 diabetes (a common condition that occurs when the body does not use insulin properly, resulting in high blood sugar levels.) During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 2 was severely cognitively impaired (process of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 2 required set-up and cleaning assistance when eating. During a review of Resident 2's Order Summary Report, dated 11/11/2024, the order summary report indicated Resident 2 was ordered a no added salt([NAS] no salt packet served on the tray), soft mechanical chopped texture (diet consist of soft, chopped foods) with thin liquid (fluids with no restriction) consistency. During an observation on 11/17/2024 at 12:33 p.m. in the residents' dining room, the first food cart arrived in the dining room. Observed that there were 13 residents were seated in the dining room. Observed seven (7) residents got their meals while six (6) residents waited. During an interview on 11/17/2024 at 12:34 p.m. with Resident 2, Resident 2 stated she has been waiting and she was hungry. During an observation on 11/17/2024 at 12:35 p.m., the next cart arrived but did not have the trays for three (3) residents. During an interview on 11/17/2024 at 12:45 p.m. with Licensed Vocation Nurse 3 (LVN 3), LVN 3 Page 1 of 34 055160 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0550 Level of Harm - Minimal harm or potential for actual harm stated they (facility) did not serve the trays at the same time today and it was not their usual process. LVN 3 stated there was a mix up with some of the tray and they were looking for the resident's tray. LVN 3 stated they could do better and communicate with the kitchen so they could serve the residents at the same time. LVN 3 stated resident's food could be unhappy for not getting their food at the same time and their food could be cold. Residents Affected - Some During an observation on 11/17/2024 at 12:48p.m., Resident 2 was served food. During an observation on 11/17/2024 at 12:51 p.m., Resident 42 was served food. During an interview on 11/17/2024 at 12:54 p.m. with Director of Nursing (DON), DON stated she expected the food cart to be in the dining room for lunch at 12:15 and she saw some residents did not get their food hence she tried to figure out where the trays were. DON stated their process was to distribute the food to the residents at the same time so that residents would not feel deprived of something or felt neglected. During a review of the facility's Policies and Procedures (P&P) titled Resident Rights - Personal Property, dated 6/28/2024, the P&P indicated, Purpose: To ensure the quality of life of all residents by allowing residents to create a home-like environme. 055160 Page 2 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0637 Assess the resident when there is a significant change in condition 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 document in the resident's medical record a change in the resident's condition in accordance with the facility's policy and procedure (P&P) titled Change of condition Notification revised 6/28/2024 for one of ten sampled residents (Resident 2). Residents Affected - Few This deficient practice resulted in Resident 2's attending physician and resident representative not being promptly notified of Resident 2's change of condition. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (when the thyroid gland [a small butterfly shaped gland in front of the neck that produces hormones that regulate many of the body's functions] does not produce enough thyroid hormone), generalized muscle weakness (a decrease in muscle strength), and hypertension (HTN -blood pumping with more force than normal through your arteries). During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/17/2024, indicated Resident 2 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required maximal assistance and dependent on staff for activities of daily living. During a review of Resident 2's lab results report dated 8/23/2024, indicated thyroid stimulating hormone (TSH -a hormone that is produced by the pituitary gland [small pea size gland found at the base of the brain] releases to trigger the thyroid to produce and release its own hormone) 27.71 micro-internation units (uIU -metric unit of measurement for volume) per milliliter (ml -metric unit of measurement for volume, normal range is 0.45 % to 5.33 %). During a review of Resident 2's care plan, dated 12/15/2022, the care plan indicated, the focus as Resident 2 has hypothyroidism and one of the interventions indicated obtain and monitor lab/diagnostic work as ordered. Report results to the medical doctor and follow up as indicated. During a concurrent interview and record review, on11/16/2024, at 5:18 P.M., with Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN), Resident 2's medical records were reviewed. RNS/MDSN stated Resident 2 had a laboratory test result of 27.71 uIU of her TSH. RNS/MDSN stated the facility process for an abnormal lab result or a deviation from the residents' baseline is to notify the doctor and the resident representative, including completing a change of condition (COC). RNS/MDSN stated there is no coc that was completed for the TSH increase level, and there is no documented evidence that the resident's doctor or their representative was notified of the elevated TSH. RNS/MDSN stated there is nowhere else that this documentation would be found than the resident's medical record. During a concurrent interview and record review, on11/17/2024, at 4:35 P.M., with RNS/MDSN, Resident 2's medical records were reviewed. RNS/MDSN stated Resident 2 on 8/29/2024 had an order to redraw the TSH in six weeks (10/10/2024). RNS/MDSN stated Resident 2 refused to have the blood draw for TSH done, there is no documented evidence that the facility notified the doctor of Resident 2's refusal to get the blood work for TSH done. RNS/MDSN stated the doctor needs to be notified do that so that he can be aware of the clinical status of the resident to determine if there needs to be a change in the treatment plan of care or not. 055160 Page 3 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/17/2024, at 6:01 P.M., with the Director of Nursing (DON), the DON stated anything that out of baseline with the patient we need to have a coc. The coc is done to monitor the resident, notify the doctor and the resident representative of the change of condition. The doctor needs to be notified so that the facility can know the next step to be done for the resident, DON states lab results need to be relayed to the doctor as soon as the results are received, this is done so that there is no lapse in time or delay in the interventions needed for the resident that could potentially harm the resident if not given on time. During a review of the facility's P&P titled, Change of Condition Notification, revised 6/28/2024, indicated, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner . Policy I. The facility will promptly inform the resident, consult with the resident's attending physician, and notify the residents legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: . B. A significant change in the resident's physical, mental or psychosocial status; and/or II. Change of Condition related to the attending physician notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the residents condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. 055160 Page 4 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bases on interview and record review, the facility failed to notify the physician of the laboratory testing finding in accordance with the facility's policy and procedure (P&P) titled Laboratory Services revised 6/28/2024 for one of ten sampled residents when: Residents Affected - Few 1. Resident 2's lab results report dated 8/23/2024, indicated thyroid stimulating hormone (TSH -a hormone that is produced by the pituitary gland [small pea size gland found at the base of the brain] releases to trigger the thyroid to produce and release its own hormone) 27.71 micro-internation units (uIU -metric unit of measurement for volume) per milliliter (ml -metric unit of measurement for volume, normal range is 0.45 % to 5.33 %) 2. Resident 2's refused to have the TSH laboratory draw done on 10/10/2024 that was ordered on 8/29/2024. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (when the thyroid gland [a small butterfly shaped gland in front of the neck that produces hormones that regulate many of the body's functions] does not produce enough thyroid hormone), generalized muscle weakness (a decrease in muscle strength), and hypertension (HTN -blood pumping with more force than normal through your arteries). During a review of the physician's orders dated 8/29/2024, indicated TSH in 6 weeks. During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/17/2024, indicated Resident 2 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required maximal assistance and dependent on staff for activities of daily living. During a review of the laboratory log, indicated date specimens drawn: 10/10/2024; Resident 2 refused. During a concurrent interview and record review, on 11/16/2024 at 5:18 P.M., with Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN), Resident 2's medical records were reviewed. RNS/MDSN stated Resident 2 had a laboratory test result of 27.71 uIU of her TSH. RNS/MDSN stated the facility process for an abnormal lab result or a deviation from the residents' baseline is to notify the doctor and the resident representative, including completing a change of condition (COC). RNS/MDSN stated there is no coc that was completed for the TSH increase level, and there is no documented evidence that the resident's doctor or their representative was notified of the elevated TSH. RNS/MDSN stated there is nowhere else that this documentation would be found than the resident's medical record. During a concurrent interview and record review, on 11/17/2024 at 4:35 P.M., with RNS/MDSN, Resident 2's medical records were reviewed. RNS/MDSN stated Resident 2 on 8/29/2024 had an order to redraw the TSH in six weeks (10/10/2024). RNS/MDSN stated Resident 2 refused to have the blood draw for TSH done, there is no documented evidence that the facility notified the doctor of Resident 2's refusal to get the blood work for TSH done. RNS/MDSN stated the doctor needs to be notified do that so that he can be aware of the clinical status of the resident to determine if there needs to be a change 055160 Page 5 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0684 in the treatment plan of care or not. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/17/2024, at 6:01 P.M., with the Director of Nursing (DON), the DON stated anything that out of baseline with the patient we need to have a coc. The coc is done to monitor the resident, notify the doctor and the resident representative of the change of condition. The doctor needs to be notified so that the facility can know the next step to be done for the resident, DON states lab results need to be relayed to the doctor as soon as the results are received, this is done so that there is no lapse in time or delay in the interventions needed for the resident that could potentially harm the resident if not given on time. Residents Affected - Few During a review of the facility's Policy and Procedure titled, Laboratory Services, revised 6/28/2024, indicated, II Reporting Laboratory Results . C. The Licensed Nurse promptly notifies the Attending Physician of the laboratory yest findings and report the results according to the following guidelines: . II. Results abnormal -Telephone/page Attending Physician and fax to attending physician with date and time noted on results . D. The nurse documents the time when laboratory results were reports along with the Attending Physician's response in the resident's medical record. 055160 Page 6 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

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 observation, interview and record review, the facility failed to ensure that the Low air loss (LAL -a pressure relieving mattress for the management or prevention of pressure sores) Mattress setting was appropriately set for one of ten sampled residents (Resident 205). Residents Affected - Few This deficient practice had the potential to result in the redevelopment of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence due to pressure, or pressure in combination with shear) and possible hospitalization. Findings; During a review of Resident 205's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and generalized muscle weakness (a decrease in muscle strength). During a review of Resident 205's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/28/2024, indicated Resident 205 was cognitively intact (when a person is able to remember, learn new things, concentrate, or make decision that affect their everyday life), required maximal assistance and dependent on staff for activities of daily living. During an observation on 11/15/2024, at 5:50 P.M., in Resident 205's room, Resident 205's LAL mattress pump light bar was lit on bar number10 for 400 pounds (lbs -unit of measurement for mass/weight). During a review of Resident 205's Monthly weight report dated 11/2024, indicated, Resident 205's weight was 187 lbs, During a concurrent observation and interview on 11/15/2024, at 7:25 P.M., with the Licensed Vocation Nurse 1 (LVN 1), in Resident 205's room, Resident 205's LAL mattress pump was observed with light bar was lit on bar number10 for 400 lbs. LVN 1 stated the lit bar is what the LAL mattress is set on. LVN stated the third bar should have been lit for Resident 205 because he weighs 187 lbs currently. LVN 1 stated if the LAL mattress is set to a different setting than what it should be, it (setting) may increase the risk of Resident 205 for developing pressure ulcers. During a review of Resident 205's care plan, dated 10/25/2024, the care plan indicated, the focus as skin integrity management, at risk or potential for pressure development, history of ulcers. Resident 205's interventions included follow facility policies/protocols for the prevent/treatment of skin breakdown. During an interview on 11/17/2024, at 6:01 P.M., with the Director of Nursing (DON), the DON stated LAL mattress settings are based on the resident's weight. The wrong LAL mattress setting may lead to high risk of skin breakdown. During a review of the facility's Policy and Procedures titled, Mattresses revised 1/1/2012, indicated, . Purpose: To provide a mattress appropriate to the residents needs .Policy: 055160 Page 7 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0686 Level of Harm - Minimal harm or potential for actual harm A.To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. During a review of the facility's undated Training titled, Therapy Bed Training Checklist indicated .The comfort control LED displays the patient's comfort pressure level depending on the patient weight. Residents Affected - Few During a review of the undated manufactures guidelines indicated .Weight settings .The weight settings buttons .can be used to adjust the pressure of the inflated cells based on the patient's weight. 055160 Page 8 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 16) received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder, and urethra) by failing to: 1. Place a securement device/anchor on Resident 16's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to always provide continuous urinary drainage) to secure the catheter below the level of the bladder at all times. 2. Assess and monitor the catheter for proper placement and drainage, and to ensure no leaking was present as per the resident's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) titled Assess urinary drainage created on 4/28/2024. These deficient practices had the potential to result in urine backflowing up into Resident 16's bladder and blood stream resulting in a catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]), skin breakdown, systemic infection, organ failure, and death. Findings: During a review of Resident 16's admission Record indicated the facility admitted the resident on 4/18/2024, with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure (a sudden and often reversible reduction in kidney function), and artificial opening of urinary tract (a urostomy is a stoma, or opening, in the abdomen that connects the urinary tract to allow urine to drain freely from the body). During a review of Resident 16's History and Physical (H&P) dated 4/18/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 16's Order Summary Report dated 4/18/2024, indicated change urinary catheter bag as needed when the indwelling catheter is changed and if clogged, leaking or dislodgement, excessive sedimentation leading to obstruction. an order for [CATHETER] secure suprapubic catheter tubing (a thin, flexible rubber or plastic tube that healthcare providers use to drain urine from the urinary bladder when unable to urinate) with anchor every shift (to minimize dislodging of catheter). During a review of Resident 16's Care Plan titled, Assess urinary drainage created on 4/28/2024, indicated assess for signs and symptoms of infection noting cloudiness, color, sediments (small pieced or fragments of tissue), blood, and odor. Change foley as needed if clogged or excessive sediments leading to obstruction. The care plan indicated an intervention (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) of foley catheter care (keeping the catheter and the area around it clean to prevent infection) every shift or as needed. Maintain proper alignment of the indwelling catheter to promote proper drainage. 055160 Page 9 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation inside Resident 16's room and interview on 11/15/2024 at 11:07 a.m., surveyor and Certified Nursing Assistant 1 (CNA 1) observed the suprapubic catheter of Resident 16 without a securement device or anchor in place. CNA 1 stated the suprapubic catheter should have had a securement device/anchor to prevent the resident from pulling out the tube causing trauma and eventually infection. CNA 1 confirmed the urine bag had not been draining urine for a week and the resident's diaper was always wet. During a review of Resident 16's situation background assessment and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) dated 11/15/2024., indicated the Resident was transferred to the Hospital non-emergency due to in dwelling cathter leakage and reinsertions by urology follow up and evaluation. During a concurrent observation and interview on 11/16/2024, at 11.30 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 noted the indwelling catheter bag empty and noted the Resident diaper was wet. LVN 1 stated the suprapubic catheter should be draining urine into the bag and not in the resident diaper. LVN 1 Stated she will call the Doctor and have a securement device/anchor to prevent pulling out the tube causing trauma and eventually infection. CNA 1 also confirmed that the urine bag has not been draining urine for a week and the resident diaper is always wet. During an interview on 11/17/2024 at 12:10 p.m., the Director of Nursing (DON), stated the suprapubic catheter should have had a securement device or an anchor to prevent pulling of Resident 16's foley catheter. The DON stated if the foley catheter was pulled out it could cause trauma and bleeding to the site that could cause infection. The DON confirmed the resident was taken to the hospital on [DATE] at 11.45 p.m., where the foley catheter was changed and now the urine was draining into the urinary bag with no leaking. During a review of the facility's recent policy and procedures titled, Indwelling Catheter. last reviewed on 4/17/2024, indicated to secure catheter and/or bag to resident with approved catheter securement device. 055160 Page 10 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the Licensed Vocational Nurse (LVN) 4 failed to hold a Amlodipine (blood pressure medication) per the physician's order for one of two sampled residents (Resident 32). Residents Affected - Few This deficient practice placed Resident 1 at risk for a further decrease in heart rate. Findings: During a review of Resident 32's admission Record indicated the facility originally admitted Resdent 32 on 5/19/2022 and more recently on 12/21/2022 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of hglucose/sugar in the blood and the kidneys make a large amount of urine), essential hypertension (HTN-high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), hyperlipidemia (high fat in the blood), morbid obesity (severely overweight), and epilepsy (seizures). During a review of Resident 32's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/25/2024 indicated Resident 32's cognition (mental ability to make decisions for daily living) was intact. Resident 32 requires supervision (helper provided verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to wheelchair. During a review of Resident 32's physician order dated 8/30/2024 indicated Amlodipine Besylate 5mg (mg-milligrams), give 5mg by mouth in the morning for Hypertension Hold if SBP (systolic blood pressure: top number) less than (>) 100 or Pulse Rate (PR-heart rate/beats per minute [BPM]) <60. During a review of Resident 32's Medication Administration Record (MAR) dated 11/16/2024 indicated vitals outside of parameters for administration of Amlodipine. During an observation on 11/16/2024 at 7:49 a.m. of Licensed Vocational Nurse 4 (LVN) 4 at Medication cart in front of Resident 32's room, LVN 4 measured Resident 32's blood pressure (BP) at 144/73 milliliters of mercury (mmHg-unit of measurement) and the pulse rate at 58 BPM. During at concurrent observation and interview on 11/16/2024 at 7:52 a.m. with LVN 4, LVN 4 placed Amlodipine 5mg tablet in a medication cup and attempted to hand the cup to Resident 32 to take the Amlodipine. The surveyor stopped LVN 4 and asked LVN 4 to review BP and PR parameters for Resident 32. LVN 4 stated, The heart rate is less than 60. I have to hold your Amlodipine because the heart rate is outside of the parameter. During a review of the facility policy and procedure titled, Medication Administration revised 1/2012, indicated, Medication and biological orders will be received by a licensed Nurse prior to administration. i. Orders will be reviewed for allergies, food/drug interactions. ii. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. 055160 Page 11 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the correct temperature in one of two medication storage rooms, Medication storage room [ROOM NUMBER]. This deficient practice put the medications at risk of losing their efficacy before they expire. Findings: During a concurrent observation and interview on 11/16/2024 at 2:43 p.m. with Registered Nurse Supervisor (RNS), inside of the Medication Storage room [ROOM NUMBER] the thermostat indicated 90 degrees. The RNS stated, I think it's supposed to be 68°F-77°F (degrees Fahrenheit-Unit of measurement). During a concurrent observation and interview on 11/16/2024 at 3:59 p.m. with the [NAME] President of Operations (VPO), the Medication Storage room [ROOM NUMBER] door was open with a large fan on the floor blowing air into the room. The VPO stated the light switch in the room also controls the fan located in the ceiling; when the light is turned off so is the fan and that is the cause of the elevated temperature inside the room. During a concurrent observation and record review on 11/16/2024 at 4:10 p.m. with the Licensed Vocational Nurse 3 (LVN 3), the Room Temperature log sheet on the door of medication storage room [ROOM NUMBER] was reviewed. The Room Temperature Log dated 11/1/2024 -11/15/2024 timed at 7:00 a.m. indicated temperatures ranging between 73°F to 76°F. The entry dated 11/16/2024 was blank. LVN 3 stated the log should be completed daily at 7:00 a.m. During a review of the facility policy and procedures titled. Medication Storage in the Facility revised 1/2018, indicated, All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC-A federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability). 1) Room Temperature 59°F to 77°F (15° to 25°C) 2) Controlled room temperature (the temperature maintained thermostatically) 68°F to 77°F(20° to 25°C). 3) Refrigerated 36°F to 46°F (2°C to 8°C) with a thermometer to allow temperature monitoring. [ .] The facility should maintain a temperature log in the storage area to record temperatures at least once a day. 055160 Page 12 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of five of 54 residents on puree texture diets (diets consisted of food with smooth and pudding like consistency) received scrambled eggs instead of Florentine torta per facility menu spreadsheet. This failure had the potential to result in decrease of nutrient intake resulting to unintended (not done on purpose) weight loss. Findings: During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/16/2024, the spreadsheet indicated residents on pureed International Dysphagia Standardization Initiative ([IDDSI] global framework that provides standardized descriptors and testing methods for texture-modified foods and thickened liquids for people with difficulty in swallowing) 4 included the following foods on the tray: Grape juice four (4) ounces ([oz] unit of measurement) Puree oatmeal 3/4 cup ([c] household measurement) Puree Florentine Torta 2 ½ x 3 inches - 4 oz. Puree wheat toast 2 oz. Margarine 1 teaspoon (tsp) Milk 8 oz. During an observation on 11/16/2024 at 7:13 a.m. at the trayline area (an area where foods were assembled on the trays), [NAME] 1 prepared scrambled eggs for puree diets. During a concurrent observation and interview on 11/16/2024 at 11:16 a.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of puree diet with Dietary Supervisor (DS), DS stated they used scrambled eggs because the Florentine torta recipe was not smooth when cooked hence they used scrambled eggs for a smoother product; however, DS stated the spreadsheet indicated puree diet would be getting puree Florentine torta. DS stated it was important to follow the spreadsheet to ensure residents would receive the calories they need. DS stated residents on puree diet would get less nourishments or nutrients and it would change the flavor of the food that would lead to low food intake and weight loss. DS stated he was not sure if Registered Dietitian (RD) was aware of the change and there was no menu substitution noted on the menu spreadsheet. During an interview on 11/16/2024 at 8:20 a.m. with DS, DS stated it was important to follow standardized recipe to ensure residents were getting the nutrition they need. During a review of the facility's Policies and Procedures (P&P) titled Menu Planning, dated 6/28/2024, the P&P indicated, Is the menu service, which provides the seasonal menus with corresponding 055160 Page 13 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recipes. These will be provided to the facility at least two weeks in advance. Menu and cook's spreadsheets are to be dated and posted in the kitchen and on the consumer bulletin board in the entrance of the facility by the FNS Director two weeks in advance. All menu changes with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook maybe kept. Only the facility Registered Dietitian of FNS Director can make permanent changes. The facility Registered Dietitian is to sign and date spreadsheet when changes are made. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. During a review of the facility's standardized recipe titled RECIPE: Florentine Torta, dated 6/28/2024, the standardized recipe indicated Pureed/Dsyphagia: Puree #12. Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. During a review of the facility's standardized recipe titled RECIPE: Pureed (IDDSI Level 4) Eggs, dated 6/28/2024, the standardized recipe indicated Prepared eggs per recipe. (1) Complete regular recipe. Measure out total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets. (2) Puree on low speed to a paste consistency before adding any liquid. 055160 Page 14 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when: Residents Affected - Some a. Residents on pureed International Dysphagia Standardization Initiative ([IDDSI] global framework that provides standardized descriptors and testing methods for texture-modified foods and thickened liquids for people with difficulty in swallowing) level 4 (diet consisted of food that are soft with pudding like consistency) received oatmeal with lumps. b. Residents on soft mechanical diet (diet consisted of food that are soft and chopped) received toasted bread with hard bread edges. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for six (6) of 54 residents on puree diet and 16 of 54 residents on soft mechanical diet. Findings: a. During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/16/2024, the spreadsheet indicated residents on puree level 4 diet would include the following foods on the tray: Grape juice four (4) ounces ([oz] unit of measurement) Puree oatmeal 3/4 cup ([c] household measurement) Puree Florentine Torta 2 ½ x 3 inches - 4 oz. Puree wheat toast 2 oz. Margarine 1 teaspoon (tsp) Milk 8 oz. During an observation on 11/16/2024 at 7:03 a.m., [NAME] 2 started dishing out oatmeal from a pot to individual bowls. During an interview on 11/16/2024 at 7:13 a.m. with [NAME] 1, [NAME] 1 stated everybody would get the same oatmeal from the same pot. During an observation on 11/16/2024 at 7:20 a.m. at the trayline (an area where foods were assembled on the trays), puree oatmeal looked creamy and lumpy. During a concurrent observation and interview on 11/16/2024 at 8:01 a.m., of the test tray (a process of tasting, temping, and evaluating the quality of food) with Dietary Supervisor (DS), DS stated puree diet should be smooth, palatable, and easy to swallow. DS stated the oatmeal had lumps and it would be a potential choking hazard for residents on puree diet. 055160 Page 15 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0805 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedures (P&P) titled Menu Planning, dated 6/28/2024, the P&P indicated, Procedures: The facility's diet manual and diet ordered by the physician should mirror the nutritional care provided by the facility. Menus are written for regular and therapeutic diets in compliance with the diet manual. Standardized recipes adjusted to appropriate yield shall be maintained and used for food preparation. Residents Affected - Some During a review of the facility's Diet Manual titled Regular Pureed Diet, dated 6/28/2024, the diet manual indicated Description: The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes, etc. Foods avoided included: lumpy cereal (oatmeal), dry cereal, unless pureed. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Hot Cereal, dated 6/28/2024, the recipe indicated, Hot cereal of choice. (4) The finished puree item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. b. During a review of the facility's daily spreadsheet titled Fall Menus dated 11/16/2024, the spreadsheet indicated residents on soft mechanical diet would include the following foods on the tray: Grape juice 4 oz Oatmeal ¾ c Florentine Torta 2 ½ x 3 inches (ground sausage, soft vegetables) Wheat toast 1 piece (pc) Milk 8 oz. During an observation on 11/16/2024 at 7:36 a.m., soft mechanical diet trays got wheat toast with hard bread edges. During a concurrent interview and record review on 11/16/2024 at 8:14 a.m. with DS, the facility's standardized recipe titled Breads, dated 6/28/2024 was reviewed. The standardized recipe indicated, Mechanical Soft: All breads must be soft, no nuts, no seeds, or added texture. No hard crust. Can remove the crust before serving. DS stated soft mechanical diet was used for residents having problems with chewing and difficulty swallowing. DS stated residents on soft mechanical diets received toasted bread today and it was okay if it's soft enough however, the residents were served hard bread crust. DS stated it was not okay for residents on soft mechanical diet to have gotten hard crust of bread because it could be a possible choking hazard to the residents. During an interview on 11/16/2024 at 8:20 a.m. with DS, DS stated, It was important to follow the 055160 Page 16 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0805 recipes to make sure the textures were correct to prevent the possibility of resident's choking. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Diet Manual titled Regular Mechanical Soft Diet, dated 6/28/2024, the diet manual indicated, Description: The Mechanical Soft diet is designated for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Foods avoided included: breads with hard crust. Bread with whole or chopped nuts. Toasted English muffins (exception- soft chopped in casseroles.) Grainy or hard crackers such as Triscuits or wheat thins, bagels. Residents Affected - Some 055160 Page 17 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Some a. Trash can in the handwashing sink room was not covered when it was not actively used. b. Staff did not perform hand hygiene. 1. Staff did not wash their hands after touching the lids of the garbage can then touched the clean resident's tray. 2. Staff loaded the dirty dishes in the dishmachine then proceeded to putting away the clean plates without washing their hands nor changing their gloves. c. Frozen raw chicken was stored on top of ground beef and cooked chicken was stored on the bottom of the raw fish. d. [NAME] racks had dust and rust in Refrigerator 2. 2. Freezer 3's gasket had dirt debris and buildup. 3. Freezer 4's gasket was torn and had dust buildup. 4. Preparation table roof had food dried buildup. 5. Ice machine spout had calcium buildup. e. There were chipped, cracked, and rusted kitchen utensils and equipment. 1. Refrigerator 5's shelves were chipped. 2. Eight (8) of 12 resident's trays were cracked. f. Three (3) dented cans were stored with the non-dented cans. g. Steam table cover, domes and lids were wiped using a cloth to dry and not air dried. h. Scoops were not stored in the same orientation. Staff touched the scoop head with their bare hands. i. Staff food was stored in the resident's refrigerator. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 53 of 54 medically compromised residents who received food and ice from the kitchen. 055160 Page 18 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Findings: Level of Harm - Minimal harm or potential for actual harm a. During an observation on 11/15/2024 at 5:09 p.m. in the handwashing area, the trash can was not in active use and did not have the lid. Residents Affected - Some During a concurrent observation and interview on 11/15/2024 at 6:02 p.m. with Dietary Supervisor (DS), DS stated the trash in the handwashing area was not actively being used and did not have a cover. DS stated it was not an okay practice due to transport of bacteria from one area to another. DS stated residents could get sick of foodborne illnesses as a potential outcome of this practice. During an observation on 11/16/2024 at 7:18 a.m. of the handwashing station, it was observed that the trash can was not covered. During a review of facility's Policy and Procedures (P&P) titled Waste Management, dated 6/28/2024 the P&P indicated, VI. Food waste will be placed in covered garbage and trash cans. (A) Waste will be disposed in a garbage can following local city codes. During a review of Food Code 2022, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. b.1. During an observation on 11/15/2024 at 5:12 p.m. in the trayline (an area where foods were assembled on the trays) area, [NAME] 3 touched the lid of the white trash can then touched the clean tray of the resident without handwashing. During an interview on 11/15/2024 at 5:57 p.m. with DS, DS stated staff should wash their hands every time they touched foods, before and after using cutting boards, before and after they entered the kitchen, after using the restroom, before and after changing tasks and after touching dirty surfaces. DS stated it was important for staff to wash their hand to avoid cross-contamination of the food. DS stated residents might acquire food borne illnesses if there was contamination of foods. During an interview with 11/15/2024 at 6:03 p.m. with DS, DS stated it was not okay for staff to touch the lid of the trash then went back to the clean area because the trash was not sterile (completely clean and free of germs). DS stated [NAME] 3 should wash her hands before putting on new gloves or touching resident's clean trays. 2. During a concurrent observation and interview on 11/15/2024 at 6:49 p.m. with DS, Dietary Aide 2 loaded the dirty dishes to the dishwashing machine then started putting the clean dishes away without washing hands and not changing the gloves. DS stated DA 2 did not wash his hands or changed his gloves. DS stated DA 2 was crossing from dirty task to clean task and he should have washed his hands and changed his gloves to prevent cross-contamination. During a review of the facility's P&P titled Hand Hygiene, dated 6/28/2024, the P&P indicated, Purpose: To establish the use of appropriate hand hygiene for all facility staff, healthcare personnel (HCP), residents, volunteer, and visitors while at the facility. Policy: The facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel). 055160 Page 19 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 During a review of the facility's P&P titled Dietary Department-Infection Control, dated 6/04/2024, the P&P indicated Proper Handwashing: Level of Harm - Minimal harm or potential for actual harm After handling soiled equipment or utensils. Residents Affected - Some Before initially donning gloves for working with food. After engaging in any other activities that contaminate the hands. During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single- service and single-use article and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils;(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; G) When switching between working with raw food and working with ready-to eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. c. During an observation on 11/15/2024 at 5:15 p.m. in the reach-in freezer, the raw chicken was stored on top of the frozen ground beef and the cooked chicken was stored on the bottom of the raw fish. During a concurrent observation and interview on 11/15/2024 at 6:08 p.m. with DS, DS stated the raw meats was on top of cooked chicken and the raw chicken was on top of the raw ground beef. DS stated raw chicken should be at the bottom shelves and cooked foods should be on top. DS stated they needed to follow the hierarchy of storing food to avoid cross contamination. During a review of the facility's P&P titled Food Storage and Handling, dated 6/4/2024, the P&P indicated, Policy: Food items will be stored, thawed, and prepared in accordance with the standard sanitary practices. All items will be correctly labeled and dated. Purpose: To properly store, thaw, and prepare food to avoid foodborne illnesses. 1. Raw Meat/Poultry/Seafood Storage. (a) Raw meat is to be stored at a temperature below 41°F and separately from cooked meats and raw foods. (b) Raw meat, poultry, and seafood should be labeled, dated, and stored in refrigerators/freezers in the following top to bottom order: [Top] Ready to eat food. Seafood Whole cuts of beef and pork Ground meat and ground fish. [Bottom] Whole and ground poultry. 055160 Page 20 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d.1. During an observation on 11/15/2024 at 5:18 p.m. of the Refrigerator 2, it was observed that the green racks had dust and rust. During a concurrent observation and interview on 11/15/2024 at 6:10 p.m. with DS, DS stated the Refrigerator 2 was cleaned within this week, but he was not sure exactly when. DS stated it was important to maintain the cleanliness and orderliness of the refrigerator to prevent slip and fall of the staff and to prevent contamination. DS stated shelves had dust and rust and it was not acceptable due to contamination. 2. During an observation on 11/15/2024 at 5:24 p.m. of the reach-in Freezer 3 by the trayline, the gasket had dirt debris. During a concurrent observation and interview on 11/15/2024 at 6:13 p.m. of the reach-in Freezer 2, DS stated the gasket had dust, but it was just cleaned within this week. DS stated this was an issue of cross-contamination for the residents. 3. During an observation on 11/15/2024 at 5:27 p.m. of the reach-in Freezer 4, the gasket was torn and had dust buildup. During a concurrent observation and interview on 11/15/2024 at 6:15 p.m. of Freezer 4 with DS, DS stated the gasket was torn and there was dust buildup around the gasket. DS stated gasket should not be torn to ensure maintenance of temperature of the freezer. DS stated if the freezer was not in the acceptable temperature, food would easily get spoiled and food borne illnesses was the potential outcome for the residents consuming spoil food. 4. During an observation on 11/15/2024 at 7:08 p.m. of the preparation table, the preparation table roof had food splatters. During an observation on 11/16/2024 at 6:10 a.m. of the preparation table, the preparation table roof had dry food splatters. During a concurrent observation and interview on 11/16/2024 at 10:19 a.m. of the preparation table roof with DS, DS stated the staff cleaned the preparation table roof daily however he did not think it was cleaned last night as there was dirt. DS sated everything should be cleaned in the kitchen for cross-contamination prevention. 5. During an observation and interview on 11/15/2024 at 7:27 p.m. of the ice machine with DS, the ice machine had hard water buildup. DS stated the maintenance staff was the one maintaining and cleaning the ice machine. DS stated there was a hard water buildup on the ice machine spout and it was not okay due to cross-contamination of ice. During an interview on 11/15/2024 at 7:34 p.m. with Maintenance Director (MD), MD stated the ice machine spout had calcium build up and the last time it was cleaned by an outside company was on 10/28/2024. MD stated the residents used ice and ice could get bacteria if the ice machine was dirty. MD stated residents could get sick of stomach issues as a potential outcome of dirty ice machines. During a review of the facility's P&P titled Cleaning Schedule, dated 6/28/2024 the P&P indicated, Purpose: To establish guidelines for maintaining a routine cleaning schedule. Policy: The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine 055160 Page 21 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 cleaning schedule developed by the dietary manager. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled Sanitation of Reach-In-Refrigerator, dated 6/28/2024, the P&P indicated, Policy: The reach in refrigerator will be maintained in a sanitary condition. Purpose: To establish guidelines for sanitation of the reach-in refrigerator. Daly task: Residents Affected - Some a. Wipe up spills on shelves, sides, and floor of refrigerator by using clean sanitizing solution and a clean cloth. b. Wash the inside and outside of the door frame, the front of the door and the gaskets using detergent solution and a clean cloth. During a review of the facility's P&P titled Freezer Operation and Cleaning, dated 6/28/2024, the P&P indicated, Purpose: To establish guidelines for the operation and cleaning of the freezer. Policy: The dietary staff will use the freezer according to the manufacturer's guidelines. The freezer will be cleaned periodically, as necessary. II. Sanitation of equipment: a. Clean the outside of the freezer with detergent solution. b. Rinse the outside of the freezer using clean water and a clean cloth. c. Sanitize the outside of the freezer using sanitizing solution. During a review of the facility's P&P titled Ice Machines and Ice Storage Chests, dated 6/28/2024, the P&P indicated, To ensure safe and sanitary provision of ice to residents. Ice machines and ice storage/distribution containers are used and maintained in a manner that provides a safe and sanitary supply of ice. During a review of the facility's P&P titled Ice Machine-Operation and Cleaning, dated 6/28/2024, the P&P indicated The ice machine will be cleaned routinely. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. e.1. During an observation on 11/15/2024 at 5:35 p.m. of the Refrigerator 5, it was observed that the shelves had chips. During a concurrent observation and interview on 11/15/2024 at 6:17 p.m. of the Refrigerator 5 with DS, DS stated the shelves in Refrigerator 5 had chips and it was not okay as it could go to the food as contaminant. 055160 Page 22 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled Food Storage and Handling, dated 6/4/2024, the P&P indicated Shelving should be sturdy with a surface which is smooth and easily cleaned. 2. During an observation on 11/15/2025 at 7:06 p.m. of the resident's trays, there were 8 of 12 trays cracked and chipped. Residents Affected - Some During a concurrent observation and interview on 11/15/2024 at 7:20 p.m. with DS, DS stated the blue trays had chips and it's lost its smoothness. DS stated the trays would be hard to clean so bacteria could grow in it. During a review of facility's P&P titled Discarding of Chipped/Cracked Dishes and Single Service Items, dated 6/28/2024, the P&P indicated, Purpose: To establish guidelines for service ware and single service items. Policy: The dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. Procedure: The dietary staff will discard chipped or cracked dish or glassware. During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. f. During an observation on 11/15/2024 at 5:43 p.m. at the dry storage area, the was two (2) three-bean salad cans and one (1) pork and beans dented and were stored with the undented cans. During a concurrent observation and interview on 11/15/2024 at 6:20 p.m. with DS, DS stated they have a dented can section as staff were not supposed to use dented cans. DS stated there were 3 dented cans mixed with the non-dented cans and it should be separated. DS stated staff could accidentally use the dented cans and residents could get food poisoning from the meal as a potential outcome after consuming the food coming from the dented cans. During a review of facility's P&P titled Receiving Food and Supplies dated 6/28/2024, the P&P indicated Do not accept and return to the supplier, any items that are dented, rusted, damaged cans. During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. g. During an observation on 11/15/2024 at 5:52 p.m. of the dishwashing process, Dietary Aide 1 (DA 1) wiped the steam table cover with a towel to dry. During an interview on 11/15/2024 at 6:38 p.m. with DS, DS stated dishwashing process included, 055160 Page 23 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scraping, washing, rinsing, sanitizing and air drying. DS stated it was important to air dry to allow the sanitizer to dry and wiping it with cloth was not acceptable. DS stated the cloth residue might stick to the pot and growth of bacteria could occur as sanitizer was not air dried and wiped. During a concurrent observation and interview on 11/15/2024 at 6:49 p.m. of the dishwashing process with DS, DS stated the domes and lids were stacked wet and staff was supposed to air dry them to prevent bacterial growth. During a review of the facility's P&P titled Pot and Pan Cleaning, dated 6/28/2024, the P&P indicated 10. Allow the items to air dry. Do not use a towel. During a review of Food Code 2022, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. h. During an observation on 11/16/2024 at 6:35 a.m. of the scoop storage, observed the scoops were stored in a different direction. [NAME] 2 touched the head of the scoop with her bare hands. During an interview on 11/16/2025 at 10:27 a.m. with DS, DS stated the scoops and utensils should be stored in the same direction for staff not to touch the lip of the scoop to lessen the chances of cross contamination from the hands to the scoop. During a review of the facility's P&P titled Dietary Department-Infection Control dated 6/4/2024, the P&P indicated To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and growth of disease producing organisms and toxins. During a review of Food Code 2022, the Food Code 2022 indicated, 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented. i. During a concurrent observation and interview on 11/16/2024 at 10:42 a.m. in the activity room with the Activity Staff (AS), there was a plastic of food in the resident's refrigerator. AS stated, the plastic of food belongs to her. During an interview on 11/16/2024 at 10:45 a.m. with Registered Nurse 1 (RN 1), RN 1 stated staff member's food should not be stored in the resident's refrigerator because it could get mixed up with the resident's food. RN 1 stated the staff food could be given to the residents. RN 1 stated staff food would not be complaint with resident's diet and food allergies and could potentially caused residents to have an allergic reaction and choke if they have dysphagia (difficulty swallowing). RN 1 stated staff food should be separated from the resident's food to prevent contamination of food. During a review of the facility's P&P titled Food Brought in by Visitors dated 6/28/2024, the P&P indicated B. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold holding, and handling of leftovers. During a review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of 055160 Page 24 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0812 Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055160 Page 25 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by Residents Affected - Some a. Not maintaining the garbage area free from dirty, plastics, mask on the floor and surroundings. b. Not maintaining one (1) of the dumpster's (a large trash metal container designed to be emptied into a truck) lid close and not overflowing with trashes. This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 53 of 54 facility residents. Findings: a. During a concurrent observation and interview on 11/16/2024 at 8:22 a.m. at the dumpster area with the Dietary Supervisor (DS), there were masks, dog poop bags, boxes and dirt on the floor and surroundings of the dumpster. DS stated the trash area should be cleaned from trash on the floor for infection control purposes. During a concurrent observation and interview on 11/16/2024 at 10:36 a.m. with Maintenance Director (MD), MD stated there were boxes, poop bags, mask on the floor and it was coming from the people walking by. MD stated dumpster area should always be clean for infection control and to prevent contamination. b. During an observation on 11/17/2024 at 8:23 a.m. in the dumpster area, the black dumpster was overflowing with trash and the lid was not closed. During an observation on 11/17/2024 at 9:27 a.m. in the dumpster area, the black dumpster was overflowing with trash. During a concurrent observation and interview on 11/17/2024 at 9:29 a.m. in the dumpster area with MD, MD stated the schedule for trash pick up was Mondays through Saturdays only and the trash vendor was not scheduled on Sundays. MD stated the bin was open because of a lot of trash and it was not okay due to contamination. MD stated he could call the trash vendor to pick up the trash to prevent the spread of infection. During a review of facility's Policy and Procedures (P&P) titled Garbage and Trash Can Use and Cleaning, dated 6/28/2024 the P&P indicated, Purpose: To establish guidelines for the use and cleaning of garbage and trash can. Policy: The dietary staff will use garbage and trash can according to the manufacturer's guidelines. Garbage and trash cans will be cleaned routinely. During a review of the facility's P&P titled Waste Management, dated 6/28/2024, the P&P indicated Purpose: To reduce a risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. Close and dispose regulated waste according to state and federal regulations. VIII. Maintain safe, secure, and clean holding area for waste. (B) Clean area once daily whenever spill occur. 055160 Page 26 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Food Code 2022, indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. During a review of Food Code 2022, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. 055160 Page 27 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the requirements of no more than four residents per room for two of 20 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents. Findings: During a tour of the facility for an unannounced recertification survey visit on 11/15/2024, rooms [ROOM NUMBERS] were observed to have five residents per room. The residents in rooms [ROOM NUMBERS] were observed with enough space for residents to move freely inside the room. rooms [ROOM NUMBERS] had adequate space for the residents in the rooms to operate and use their wheelchairs, walkers, and canes. The room variance did not affect the care and services provided by nursing staff. During the resident council meeting on 11/16/2024, at 11:30 A.M., residents were asked if they had any concerns regarding their room space, residents in attendance did not appreciate any concerns or issues regarding their livable space. During a review of the facility's client accommodation analysis form completed on 11/16/2024, indicated rooms [ROOM NUMBERS] housed five beds per room. On 11/16/2024, the administrator (ADM) submitted a letter requesting for a waiver for rooms with more than four residents per room for the following rooms: room [ROOM NUMBER] with five residents room [ROOM NUMBER] with five residents. During the recertification Survey on 11/15/2024, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the resident's rooms from 11/15/2024-11/17/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient spaces for bedside tables, side tables and resident care equipment. During an interview on 11/16/2024, at 1:24 P.M., the ADM stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care. 055160 Page 28 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms for 17 of 20 resident rooms, (Rooms 4, 5, 6, 7, 8, 9, 10,11, 14, 15, 16, 17, 18, 19, 20, 21, and 22). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the quality of life for the residents. Findings: During a review of the Request for Room Size Waiver letter submitted by the Administrator, dated 11/16/2024 indicated 17 resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter indicated the rooms do not pose anyu kind of risk to the care and services the facility provides to the residents. Each room has access ti he outside and provides ample sunlight and ventilation. The following rooms provided are less than 80 sq.ft. pr resident: Room Room Size Floor Area #of beds 4 14x 10 140 2 5 14x 10 140 2 6 14x 10 140 2 7 055160 Page 29 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0912 14x 10 Level of Harm - Potential for minimal harm 140 2 Residents Affected - Some 8 14x 10 140 2 9 14x 10 140 2 10 20x 10 200 3 11 20x 10 200 3 14 20x 10 200 3 15 20x 10 055160 Page 30 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0912 200 Level of Harm - Potential for minimal harm 3 16 Residents Affected - Some 20x 10 200 3 17 20x 10 200 3 18 20x 10 200 3 19 20x 10 200 3 20 20x 10 200 3 21 20x 10 200 055160 Page 31 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0912 3 Level of Harm - Potential for minimal harm 22 20x 10 Residents Affected - Some 200 3 According to the federal regulation, the minimum square footage for a two bedroom is at least 160 sq. ft and three bedroom is at least 240 sq. ft. During the recertification Survey on 11/15/2024, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the resident's rooms from 11/15/2024-11/17/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient spaces for bedside tables, side tables and resident care equipment. During a concurrent observation and interview on 11/16/2024, at 8:36 A.M., with the maintenance Director (MD) using tape measurer to measure the size of the room from the window to the door for the length, then measuring from wall to the start of the closet horizontally for the width. The MD stated, this is how I measure to verify the size of the rooms. During an interview on 11/16/2024 at 2:47 P.M., the administrator (ADM) stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care. 055160 Page 32 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when six (6) flies (a type of insect) were observed in the kitchen. Residents Affected - Some This deficient practice had a potential to result in 53 of 54 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 11/15/2024 at 5:43 p.m. one (1) fly was flying around the preparation area. During an observation on 11/16/2024 at 6:15 a.m. 1 fly was flying around the preparation table. During an observation on 11/16/2024 at 6:54 a.m. 1 fly was flying round the trayline (area where food was assembled) and the preparation area During a concurrent observation and interview on 11/16/2024 at 7:42 a.m. with [NAME] 1, there was two (2) flies flying around the preparation area. [NAME] 1 stated there was a fly in trayline. During a concurrent observation and interview on 11/16/2024 at 8:17 a.m. with Dietary Supervisor (DS), DS stated there was 1 fly in the preparation area and it was his first time seeing it in the kitchen. DS stated he did not know where it is coming from. During an interview on 11/16/2024 at 8:22 a.m. with DS, DS stated the flies did not belong in in the kitchen and the kitchen should be free from flies because it could transmit diseases to the residents. DS stated he was not sure when was the last pest control visit and would double check with the maintenance director. During a review of facility's Policy and Procedures (P&P) titled Pest Control, dated 6/28/2024, the P&P indicated, To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors. The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. During a review of the facility's pest control report dated 10/23/2024, the pest control report indicated, large flies' treatment was applied in the garbage area-exterior, and no other areas noted. During a review of Food Code 2022, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies. (B) Routinely inspecting the premises for evidence of pests. 055160 Page 33 of 34 055160 11/17/2024 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0925 Level of Harm - Minimal harm or potential for actual harm (C) Using methods, if pests are found, such as trapping devices or other means of pest control specified under §§ 7-202.12, 7-206.12, and 7-206.13. (D) Eliminating harborage conditions. Residents Affected - Some 055160 Page 34 of 34