Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Panorama Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy and federal crime reporting requirements when an allegation of staff-to-resident sexual abuse was relayed to staff by law enforcement. A resident with intact cognition reported that a male CNA had inappropriately touched a cognitively intact, functionally dependent roommate. Nursing staff and law enforcement interviewed the alleged victim, who denied the allegation and reported no pain or discomfort, and a head-to-toe assessment showed no injuries. Despite being notified by an RN the same evening, the ADM did not report the allegation to CDPH, LLE, or the Ombudsman within the required two-hour timeframe, contrary to facility policy requiring immediate internal reporting and timely external reporting of all abuse allegations.
A resident with cognitive and physical limitations was allowed to self-administer Imodium and probiotic tablets without an interdisciplinary team assessment or documentation, contrary to facility policy. Staff confirmed that no evaluation was performed to determine if self-administration was clinically appropriate, and the medications were stored at the bedside with unsupervised access.
A resident with cognitive decline and physical limitations was permitted to self-administer Imodium and probiotic tablets stored at bedside, per physician order. However, the facility did not develop a care plan addressing this self-administration, despite policy requiring assessment and documentation by the IDT. The DON confirmed the absence of such a care plan during record review.
A resident with a history of aggressive behavior intentionally made physical contact with another cognitively impaired resident, causing a skin injury to the face. The incident occurred despite staff presence and intervention attempts, and was acknowledged by facility leadership as abuse and a failure to follow abuse prevention policy.
A resident with intact cognition and multiple mental health diagnoses expressed uncertainty about wanting a shower, but a CNA proceeded without consulting the charge nurse, violating the facility's policy on resident rights. The facility's procedure requires confirmation from the charge nurse when a resident's consent is unclear.
A facility failed to notify a physician that a UA was not collected for a resident with multiple diagnoses, including diabetes and sepsis. Despite a stat order, the urine sample was not obtained, and the physician was not informed, contrary to the facility's policy. Interviews revealed that the charge nurse was aware of the issue but did not report it, and the DON confirmed the policy was not followed.
A facility failed to inform a resident's responsible party about dental treatment recommendations, violating the right to make informed decisions. The resident, lacking decision-making capacity, had dental visits with recommendations for extractions, but there was no documentation of communication with the responsible party. Staff confirmed the oversight, which posed a potential risk for delayed care.
A resident with moderate cognitive impairment and physical limitations was unable to reach their call light, preventing them from requesting assistance. The resident, who required substantial assistance with personal care, was observed in a wheelchair without the call light within reach. Both a Licensed Vocational Nurse and the Director of Nursing confirmed the importance of call light accessibility, as outlined in the facility's policy.
A resident with diabetes and end-stage renal disease experienced a significant hyperglycemia episode, but the facility failed to update the care plan accordingly. Despite the facility's policy requiring care plan revisions with significant changes in condition, the care plan was not reviewed or revised, potentially leading to inadequate care and supervision.
The facility failed to provide communication devices in the languages understood by two residents, leading to a deficiency. One resident, primarily Armenian-speaking with severe cognitive impairment, had no communication board at her bedside. Another resident, primarily Shanghainese-speaking, also lacked a communication board, despite facility policy requiring such tools to be accessible. The DON confirmed the absence of these devices, which were kept at the nursing station instead.
A facility failed to accurately assess a resident with an indwelling catheter upon admission and readmission, leading to potential inadequate care. The resident's initial assessments incorrectly indicated the absence of a catheter, despite physician's orders and care plans requiring it. Interviews with the TN and DON confirmed the errors, highlighting the importance of thorough assessments as per facility policy.
The facility failed to complete social services assessments for two residents within the required timeframe, leading to potential delays in care. One resident, with multiple diagnoses including dementia, was observed without hearing aids, affecting communication. Another resident, with major depressive disorder and dementia, lacked an initial assessment in their record. The facility's policy required assessments within seven days, which was not followed.
The facility did not post the actual hours worked by nursing staff, only the projected hours, due to the Payroll staff arriving late. This failure was observed during a survey, and interviews confirmed the oversight. The facility's policy mandates daily posting of staffing numbers to ensure adequate staffing and transparency.
A resident in an LTC facility did not receive their prescribed medications, Gabapentin and Buspirone, within the required one-hour window of the scheduled time. The medications were administered by an LVN at 3:44 p.m., instead of the scheduled 1:00 p.m., violating the facility's policy. Interviews with the LVN and DON confirmed the breach of protocol.
A medication error occurred when a student nurse, unsupervised by an instructor, administered medications intended for one resident to another. The resident who received the wrong medications had a history of metabolic encephalopathy, COPD, and CHF, while the medications were meant for a resident with parkinsonism and hypertension. The error was discovered when the student nurse reported it, highlighting a failure to follow proper identification procedures.
Failure to Timely Report Allegation of Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime under Section 1150B of the Act by not reporting an allegation of staff-to-resident sexual abuse within the required two-hour timeframe to CDPH, local law enforcement, or the Ombudsman. Law enforcement officers arrived at the facility and informed nursing staff that a resident had reported an incident in which a male CNA allegedly entered the shared room and inappropriately touched the roommate two days earlier. The roommate, identified as Resident 2, had intact cognition per a recent MDS and was dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility. A head-to-toe assessment of Resident 2 by nursing staff revealed no injuries, bruising, redness, or other abnormal findings, and Resident 2 denied the allegation and any pain, discomfort, or concerns. Resident 1, who made the report to law enforcement, also had intact cognition and was similarly dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility, according to their MDS and admission records. After law enforcement notified facility staff of Resident 1’s report of sexual abuse toward Resident 2, the RN notified the Administrator by phone the same evening. The Administrator acknowledged that the allegation of sexual abuse was not reported to CDPH, law enforcement, or the Ombudsman because Resident 2 denied the allegation and reported no injury or discomfort, and because the LVN caring for both residents over the following three days had not received any related concerns. This inaction conflicted with the facility’s abuse prevention policy, which requires all allegations of abuse, neglect, misappropriation of resident property, or exploitation to be reported immediately to the Administrator and to appropriate state or federal agencies within applicable regulatory timeframes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in determining whether self-administration of medications was clinically appropriate for a resident. Specifically, a resident with diagnoses including a right foot fracture, age-related cognitive decline, and constipation was not assessed for self-administration of Imodium and probiotic oral tablets, which were stored at the resident's bedside. The resident's Minimum Data Set indicated some cognitive and physical limitations, including the need for assistance with eating, hygiene, and transfers. Despite this, physician orders allowed for unsupervised self-administration of these medications, and documentation in the Medication Administration Record (MAR) reflected this practice. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that no assessment was completed to determine the resident's suitability for self-administration, and no documentation of such an assessment could be found in the resident's records. The facility's policy required the IDT to assess and periodically re-evaluate residents for self-administration, considering cognitive, communication, visual, and physical abilities, and to document the assessment in the chart. This process was not followed for the resident in question, resulting in a deficiency related to medication management and resident safety.
Failure to Develop Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who was self-administering Imodium and probiotic oral tablets, both of which were stored at the resident's bedside. The resident had been admitted with diagnoses including a right foot fracture, age-related cognitive decline, and constipation. According to the Minimum Data Set, the resident was able to make herself understood, required assistance with eating and hygiene, and was dependent on staff for transfers. Physician orders specified that the resident could self-administer these medications, with the family providing the Imodium and both medications being kept at the bedside. During a review of the resident's records, including the Medication Administration Record and care plans, the Director of Nursing confirmed that there was no care plan addressing the resident's self-administration of medications. The facility's own policies required the interdisciplinary team to assess and document a resident's ability to self-administer medications and to include this information in the care plan. Despite these requirements, no such care plan was found for the resident, resulting in a failure to meet the facility's policy and regulatory standards for comprehensive care planning.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident deliberately made physical contact with another resident, resulting in a skin injury. On the date of the incident, one resident, who had intact cognition and a history of behavioral symptoms including physical and verbal aggression, approached another resident seated outside a room and began shouting and behaving aggressively. The second resident, who had impaired cognition and lacked decision-making capacity due to dementia and epilepsy, responded verbally, after which the first resident used his right hand to graze the second resident's left cheek. The incident was witnessed by the Director of Staff Development, who was present and attempted to intervene by standing between the two residents with her arms extended. Despite this, the aggressive resident was able to make physical contact with the other resident's face with the intent to cause injury. Documentation and interviews confirmed that the contact was intentional and met the facility's definition of abuse, as it was a purposeful act intended to inflict harm. The facility's policy clearly states that each resident has the right to be free from abuse, and both the Director of Nursing and the Administrator acknowledged that the incident constituted abuse and was not unavoidable. The facility did not follow its own policy and procedure for the prevention of abuse, resulting in a failure to protect the resident from harm while under the facility's care.
Failure to Confirm Resident's Consent for Shower
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by not confirming if the resident wanted to have a shower on a specific date. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, had the capacity to understand and make decisions, as indicated by their History and Physical and Minimum Data Set assessments. Despite this, the resident expressed uncertainty about wanting a shower, but the Certified Nursing Assistant (CNA) proceeded with the shower without consulting the charge nurse, as required by the facility's procedure. Interviews with the CNA, Director of Staff Development, and Director of Nursing revealed that the CNA did not follow the correct process when the resident was unsure about having a shower. The facility's policy requires that if a CNA is unable to confirm a resident's desire for a shower, the charge nurse should be notified to confirm with the resident. The CNA admitted to not consulting the charge nurse, which was a deviation from the facility's policy and procedure on resident rights, which emphasizes treating residents with consideration, respect, and recognition of their dignity and individuality.
Failure to Notify Physician of Uncollected Urinalysis
Penalty
Summary
The facility failed to adhere to its policy and procedure for Change of Condition Reporting by not notifying the physician that a urinalysis (UA) was not obtained for a resident as ordered. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus, sepsis, Parkinson's disease, and major depressive disorder, had a physician order for a UA to be done immediately. However, the nursing staff did not collect the urine sample, and the physician was not informed of this failure, which was against the facility's policy. Interviews with the nursing staff revealed that the charge nurse was aware of the uncollected UA but did not notify the physician, as required by the facility's policy. The Director of Nursing confirmed that the physician should have been notified within 24 hours if the urine could not be collected, and a change of condition report should have been completed. The facility's policy mandates timely communication of any change in a resident's condition to the physician, which was not followed in this instance.
Failure to Inform Responsible Party of Dental Treatment Recommendations
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident was informed about dental treatment recommendations, which violated the resident's and RP's right to make informed decisions regarding dental care. Resident 85, who was admitted with multiple diagnoses including Type II diabetes mellitus, major depressive disorder, and schizophrenia, was determined to lack the capacity to make decisions. Despite this, there was no documentation indicating that RP 1, the designated responsible party, was informed about the dental treatment recommendations made during visits on two separate occasions. Interviews with facility staff, including the Social Worker, Social Service Director, and Director of Nursing, confirmed the absence of documentation and communication with RP 1 regarding the resident's dental care. The facility's policy required that medically related social service needs, including informing residents and their designated representatives about health status and healthcare choices, be documented. The failure to inform RP 1 about the dental treatment recommendations posed a potential risk for delay in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for Resident 87, which resulted in the resident being unable to call for assistance when needed. Resident 87, who was admitted with diagnoses including Type II diabetes mellitus, required assistance with personal care, and had a contracture of an unspecified joint, was observed in a wheelchair without the call light within reach. The resident expressed a desire for more coffee but was unable to call staff due to the inaccessible call light. During an observation and interview, a Licensed Vocational Nurse confirmed that the call light was not within reach and acknowledged the importance of having it accessible to prevent potential injuries. The Director of Nursing also emphasized the necessity of having the call light within reach to allow residents to communicate their needs. The facility's policy, revised in January 2024, mandates that the call device be placed within the resident's reach before leaving the room, which was not adhered to in this instance.
Failure to Update Care Plan After Resident's Hyperglycemia Episode
Penalty
Summary
The facility failed to review and update the care plan for a resident after a significant change in condition, specifically an episode of hyperglycemia. The resident, who was admitted with diagnoses including diabetes mellitus Type II and end-stage renal disease, experienced an elevated blood sugar level of 446 mg/dl, which was documented on an SBAR Communication Form. Despite this change in condition, the resident's care plan, which was last revised several months prior, was not updated to reflect the new health status. Interviews with the facility's RN and DON confirmed that the care plan was not reviewed or revised following the hyperglycemia episode. The facility's policy requires care plans to be updated quarterly and with any significant change in condition, but this was not adhered to in this case. The failure to update the care plan could potentially result in inadequate care and supervision for the resident, as the effectiveness of the care plan interventions could not be evaluated.
Failure to Provide Communication Devices in Residents' Languages
Penalty
Summary
The facility failed to provide communication devices in the language that residents could understand, affecting two residents. Resident 105, who was primarily Armenian-speaking, had severe cognitive impairment and was receiving hospice care. Despite the resident's need for an interpreter being documented in social service assessments, there was no communication board or device available at her bedside. The Director of Nursing (DON) acknowledged that a communication board with pictures could have been beneficial for Resident 105 to communicate her needs to the staff. Resident 107, who was admitted with a need for assistance with personal care and difficulty walking, primarily spoke Shanghainese. The resident's Minimum Data Set (MDS) indicated intact cognitive skills, but the History and Physical (H&P) noted that she could not make her own decisions and was Korean-speaking. The social service assessment confirmed the need for an interpreter, and the care plan included providing a translator as necessary. However, during an observation, it was noted that there was no communication board at Resident 107's bedside, and the DON confirmed that communication boards were not accessible to the resident. The facility's policy on communication for non-English and aphasic residents required that communication boards be supplied and kept at the resident's bedside, with an additional copy attached to the resident's wheelchair if needed. Despite this policy, the communication boards were kept at the nursing station and not provided to or accessible by Residents 105 and 107, leading to a deficiency in ensuring effective communication for these residents.
Inaccurate Assessment of Resident with Indwelling Catheter
Penalty
Summary
The facility failed to accurately assess a resident with an indwelling catheter upon both admission and readmission, leading to potential inadequate care. The resident, who was admitted with diagnoses including bladder calculus and obstructive and reflux uropathy, was documented incorrectly in the Licensed Nurse-Initial Admission Record as not having urinary retention or an indwelling catheter. This discrepancy was noted on two separate occasions, with the initial assessments on both admission and readmission failing to reflect the presence of the catheter, despite physician's orders and care plans indicating its necessity. Interviews with the Treatment Nurse and Director of Nursing confirmed that the assessments were completed incorrectly, which could result in providing wrong information about the resident's status. The facility's policy required a thorough nursing assessment within 24 hours of admission to gather vital information for maintaining the resident's well-being. However, the failure to document the indwelling catheter in the initial assessments compromised the ability to provide appropriate care and services to the resident.
Failure to Complete Social Services Assessments
Penalty
Summary
The facility failed to ensure that the Social Services department completed their admission assessments for two residents, leading to potential delays in care and services. Resident 301 was admitted with multiple diagnoses, including metabolic encephalopathy, COVID-19, pneumonia, and dementia, and had moderate cognitive impairment. Despite having hearing difficulties and requiring hearing aids, the social services initial assessment was not documented within the required timeframe, and the resident was observed without hearing aids, unable to communicate effectively. The Licensed Vocational Nurse confirmed that the resident came with hearing aids, and the Social Worker acknowledged the lack of documentation and the importance of timely assessments to address potential issues. Resident 29 was admitted with diagnoses such as difficulty in walking, dysphagia, major depressive disorder, and unspecified dementia. The resident required substantial assistance with personal care and had fluctuating capacity to understand and make decisions. The social services assessment was not completed within the required seven days, and the resident's electronic health record lacked the initial assessment documentation. The Social Worker and Social Services Director confirmed the absence of the assessment and the necessity of completing it to understand the resident's needs and discharge plan. The facility's policy required social service assessments to be completed within seven days of admission, but this was not adhered to for both residents. The Director of Nursing confirmed the policy and emphasized the importance of completing the assessments to avoid delayed care and unknown resident needs. The failure to complete these assessments as per the facility's policy resulted in a deficiency in providing medically-related social services to help residents achieve the highest possible quality of life.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that staffing information, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily. On the date in question, the posted document at the nurses' stations and next to the staff time clock only included projected hours for each shift, leaving the actual hours worked blank. This oversight was observed during a survey, and it was confirmed that the actual hours had not been calculated or posted due to the Payroll (PR) staff arriving late to work. Interviews with the PR and the Director of Nursing (DON) revealed that the Director of Staff Development (DSD) or the Scheduler is responsible for posting projected hours, while the PR is tasked with verifying and calculating the actual hours worked. The PR admitted to being unable to complete this task on the day of the survey due to her late arrival. The facility's policy requires daily posting of staffing numbers to ensure transparency and adequate staffing based on the facility's census, but this was not adhered to on the specified date.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications within the required time frame for a resident, which is a deficiency in pharmaceutical services. The resident, who was admitted with diagnoses including osteoarthritis, major depressive disorder, anxiety, and type 2 diabetes, was prescribed Gabapentin for neuropathy and Buspirone for anxiety. According to the facility's policy, medications should be administered within one hour before or after the scheduled time. However, on a specific date, both medications were administered by an LVN at 3:44 p.m., which was beyond the one-hour window for the scheduled 1:00 p.m. administration time. Interviews with the LVN and the DON confirmed the deviation from the facility's medication administration policy. The LVN acknowledged administering the medications late, and the DON reiterated the facility's policy of adhering to the one-hour window for medication administration. The facility's policy on medication administration emphasizes that medications should be given as prescribed and within the specified time frame, which was not followed in this instance.
Medication Error Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a student nurse administered medications intended for another resident. On the specified date, the student nurse, under the supervision of an instructor, prepared medications for one resident but mistakenly administered them to another resident. This error was not immediately corrected because the supervising instructor did not accompany the student nurse during the medication administration, which was against the facility's policy. The resident who received the wrong medications had a medical history that included metabolic encephalopathy, chronic obstructive pulmonary disease, and congestive heart failure. The resident was cognitively intact and required moderate assistance with daily activities. The medications administered in error were intended for another resident with a diagnosis of parkinsonism and hypertension, and included Carbidopa-Levodopa, Pramipexole, and Sodium Chloride. The error was discovered when the student nurse reported the mistake to the instructor, who then informed the Director of Nursing. The facility's policy required that residents be properly identified before medication administration, using methods such as checking identification bands and photographs. The failure to follow these procedures led to the medication error, which posed a risk of adverse reactions for the resident who received the incorrect medications.
Removal Plan
- Resident 1 was assessed by the DON for any adverse effects from the significant medication error.
- Resident 1's Physician (MD 1) was notified of the significant medication error and ordered STAT laboratory tests of Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) for Resident 1.
- Resident 1 was placed on 72 hours Change of Condition (COC) monitoring and supervision. Resident 1 was monitored for medication adverse effects which may include nausea, dizziness, headache, hallucinations, and orthostatic hypotension.
- The Administrator (ADM) cancelled the contract with the affiliated nursing school.
- The ADM and designee interviewed all residents and or resident representative to identify any concern with medication administration.
- The DON and designee ensured that identification of residents based on facility policy, such as wristband and resident photo in the electronic medical records are in place.
- The facility's Pharmacy Consultant provided an in-service training to licensed nurses regarding the policy and procedure (P&P) for Medication Administration.
- The facility's Pharmacy Consultant conducted skills and competency check to licensed nurses and verified through return demonstration and discussion.
- The Interdisciplinary Team (IDT) will conduct room rounds to ensure each resident will have wristbands in place four to five times a week.
- The Director of Staff Development (DSD) or designee will perform random medication pass observation twice a week to ensure compliance with the facility's P&P on Medication Administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Panorama City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center Of North Hills | 1.2 mi | — | 8 | 0 |
| The Meadows Post Acute | 1.6 mi | — | 23 | 1 |
| Granada Hills Convalescent | 2.3 mi | — | 19 | 0 |
| Providence Holy Cross Med Ctr D/p Snf | 2.6 mi | — | 17 | 2 |
| Ararat Nursing Facility | 2.7 mi | — | 14 | 1 |
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