Health inspection·March 26, 2025

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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 provide a sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: Residents Affected - Few 1. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting regarding Resident 1's discharge planning. 2. Ensure the discharge planning was necessary, not because Resident 1 demanded of wanting to get up early and requested of laundry services. 3. Honor Resident 1's rights to be treated with kindness, respect and dignity. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care after discharge. Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] 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. Page 1 of 9 055160 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 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 a review of Resident 1's Medical Record as of 3/26/2025, there was no IDT team meeting in preparation of Resident 1's discharge planning. 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 else where and would like to stay in the facility. Resident 1 further stated, she wanted to see where they put her belongings that was sent from her previous facility where she resided, but she was told it was placed somewhere else, and they (facility) can not store it in her room. 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 055160 Page 2 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. During a review of the facility's policy and procedure (P&P), titled, Discharge and Transfer of Residents, reviewed and approved by facility on 6/28/2024, the P&P indicated that, To ensure that discharge planning is complete and appropriate, and that necessary information is communicated to the continuing care provider . The Facility may transfer or discharge a resident with an order from the resident's physician for: The discharge is necessary for the welfare of the resident, and needs cannot be met in the facility; The Resident's health has improved significantly and services provided by the facility are no longer required . A. Prior to discharging the resident, Nursing Staff/IDT will prepare a Discharge Summary/Post Discharge Plan of Care and will document the summary in the resident's medical record. During a review of the facility's P&P titled, Resident's Rights , reviewed and approved on 6/28/2024, the P&P indicated, The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety . Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. 055160 Page 3 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of four sampled resident (Resident 1), by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 unrealistic demands according to facility's policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management . This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Cross Reference F745 Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] 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. 055160 Page 4 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 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. 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 055160 Page 5 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0740 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 055160 Page 6 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 provide medically-related social services to attain 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. Residents Affected - Few 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] 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. 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 055160 Page 7 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 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. 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 appropriate accommodation and needs of all residents. During a review of the facility's Job Description (JD) titled, Social Service Coordinator , date signed by SSD 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. 055160 Page 8 of 9 055160 03/26/2025 Pavilion on Pico Healthcare & Wellness Centre, LP 5916 W. Pico Boulevard Los Angeles, CA 90035

F 0745 Customer Service: Level of Harm - Minimal harm or potential for actual harm · Presents professional image to consumers through dress, behavior and speech. · Adheres to company standards for resolving consumer concerns. Residents Affected - Few ·Ensures that all consumer/ resident rights are protected. 055160 Page 9 of 9