Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 The Meadows Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, heart failure, and type 2 DM was seated on a patio interacting with other residents when another cognitively intact resident in a wheelchair suddenly stood up and struck the resident in the right eye area with a closed hand, causing a laceration, bruising, and mild pain. Documentation on SBAR and skin assessments described the wound characteristics and discoloration, and interviews with the resident and staff confirmed that the contact was willful and non-consensual. The facility’s abuse policy defined such resident-to-resident contact as abuse and affirmed residents’ right to be free from abuse, neglect, misappropriation, and exploitation.
A resident with osteoarthritis and immunodeficiency reported unclean shower rooms, including mold odor and visible black discoloration in a shower booth. Facility staff confirmed the presence of black spots in multiple areas of the shower, and the janitor responsible for cleaning lacked a set schedule or checklist for deep cleaning. Facility policy required regular cleaning and a homelike environment, but these standards were not met.
A resident with impaired cognition and multiple chronic conditions attended an IDT care conference without the responsible party being notified or invited, despite facility policy and regulatory requirements. Interviews and record reviews confirmed the lack of notification and documentation, resulting in the responsible party not being able to participate in care planning and treatment decisions.
A resident with rheumatoid arthritis and other chronic conditions did not receive a scheduled Remicade IV infusion after an RN failed to promptly communicate an outpatient clinic's notification to the DON. The RN only notified the physician and assumed the resident would receive the infusion after discharge, resulting in a delay of treatment and not meeting the facility's policy for timely care.
A resident with multiple respiratory diagnoses was not provided with continuous oxygen therapy as ordered by the physician. During an observation, the resident was found without oxygen or related supplies, and both an LVN and the DON confirmed that the resident should have been receiving continuous oxygen at the prescribed rate.
A LTC facility failed to administer a prescribed medication for itchiness to a resident with prurigo nodularis, missing doses on two occasions. Additionally, the facility did not obtain physician orders before administering the COVID-19 vaccine to two residents with severe cognitive impairments, using an outside pharmacy without securing necessary documentation. These actions violated the facility's medication administration policy.
A facility failed to provide coordinated hospice services to a resident admitted to hospice care. There was no documented evidence of hospice staff presence, and the facility lacked a designated coordinator to manage hospice care. The resident, with severe cognitive impairment and multiple diagnoses, did not receive well-coordinated hospice services due to these deficiencies.
The facility failed to implement its infection control program by not ensuring a resident's oxygen tubing was labeled and off the floor, and by transporting clean laundry uncovered. The oxygen tubing for a resident with respiratory issues was found touching the floor and undated, contrary to facility policy. Additionally, laundry staff transported clean clothes uncovered, risking contamination, which was against the facility's guidelines.
A facility failed to complete a resident's Quarterly MDS assessment on time, as required by CMS guidelines. The resident, with neuropathy and difficulty walking, was admitted in 2021 and readmitted in 2022. The assessment, due 14 days after the ARD, was completed late, contrary to the facility's policy.
The facility failed to document non-pharmacological interventions before administering PRN opioid pain medication to two residents. Despite care plans outlining non-pharmacological strategies, hydrocodone-acetaminophen was frequently given without prior attempts at these interventions. Interviews confirmed the lack of documentation, contrary to the facility's policy emphasizing non-pharmacological approaches to pain management.
The facility failed to maintain safe food storage and preparation practices, as observed during a survey. Unlabeled wheat bread and English muffins were found in the kitchen, and a resident's food from home lacked a label and received date in the resident's refrigerator. The Dietary Manager and a Registered Nurse confirmed the importance of labeling to prevent foodborne illnesses, as per the facility's policies.
A facility failed to conduct a required quarterly rehabilitation screen for a resident with severe cognitive and physical impairments, as confirmed by the DOR. The resident, admitted with vascular dementia and cerebral palsy, was supposed to have a rehab screen quarterly, but no screen was conducted in August 2024. This oversight was against the facility's policy, which mandates timely and complete documentation in the EMR.
A facility failed to establish a policy for the POLST form, resulting in an incomplete form for a resident with decision-making incapacity. The resident's POLST form lacked the necessary signature from the resident or their legal decision maker, as confirmed by a registered nurse. The administrator acknowledged the absence of a specific policy, which could lead to confusion and delays in care.
The facility failed to document COVID-19 vaccine eligibility screening for two residents before administering the vaccine. Both residents had severely impaired cognition and required assistance with daily activities. The Infection Preventionist did not complete the eligibility screening section on the consent forms, contrary to the facility's policy.
A facility failed to implement proper infection control when an LVN did not wear an isolation gown and face shield before entering a resident's room under novel respiratory precautions for suspected COVID-19. Despite signage indicating the need for full PPE, the LVN entered with only an N-95 mask and gloves, potentially risking the spread of infection. The DON confirmed the requirement to follow posted precautions, as outlined in the facility's infection control plan.
A resident's call light was found out of reach, potentially delaying care. The resident, who required maximum assistance, was unable to call for help. Staff confirmed the call light's improper placement and acknowledged the oversight.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The facility failed to protect a resident from physical abuse when one cognitively intact resident struck another in the face while on the facility patio. Resident 3, who had COPD, heart failure, and type 2 diabetes and was assessed as cognitively intact with the capacity to make decisions, was seated on a patio chair interacting with other residents, including Resident 4. At approximately 10:55 a.m., while Resident 3 was conversing with the group, Resident 4, who was seated in a wheelchair in front of Resident 3, suddenly stood up and used a closed fist/hand to hit Resident 3 in the right upper eye area without warning. Resident 3’s assessments indicated that cognition was intact and that the resident required supervision or touching assistance for most ADLs. Following the incident, documentation on an SBAR form and a skin assessment described a linear cut above the right eye, initially measured at 0.5 cm in length by 0.1 cm in width and depth, with small bleeding and reddish discoloration. Subsequent observation by the ADON noted purplish discoloration around the right eye and a laceration approximately 1.0 cm in length by 0.1 cm in width and depth, covered with steri-strips. Resident 3 reported aching pain in the right eye area, rating it 2 out of 10, and expressed being shocked that the incident occurred. Resident 4’s records showed that this resident was also cognitively intact, had decision-making capacity, and required setup or clean-up assistance for most ADLs. On the date of the incident, Resident 4 was on the patio interacting with other residents, including Resident 3, in the presence of an activity staff member (ACS 1). The SBAR for Resident 4 and ACS 1’s interview indicated that Resident 4 suddenly stood up, raised a hand toward Resident 3, and, despite ACS 1’s attempt to intervene, struck Resident 3 in the right eye area. In a subsequent report to the state agency, Resident 4 stated that he felt his hand make contact with Resident 3’s face. The facility’s abuse policy stated that residents have the right to be free from abuse and that willful non-consensual contact between residents is considered abuse and is never to be deemed unavoidable.
Failure to Maintain Clean and Homelike Shower Facilities
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not maintaining cleanliness in the shower rooms. The resident, who had diagnoses including osteoarthritis of the left hip and immunodeficiency, reported that the shower rooms were not always clean and described smelling mold and observing black spots in the shower area during use. The resident expressed discomfort with the condition of the shower facilities, specifically noting black discoloration on the corners of the floors and around the soap rest in one of the shower booths. Multiple observations by facility staff, including maintenance assistants, the maintenance supervisor, the administrator, and the DON, confirmed the presence of black discolorations in the shower booth. These areas included around the soap rest, the cracks where the mosaic tile floors met the tile walls, and the corner edge of the tiled wall near the grab bar. Staff acknowledged that these areas were dirty and required cleaning, and the DON stated that the shower rooms should have been in better condition. Further interviews revealed that the janitor responsible for cleaning the shower rooms did not have a set schedule or checklist for deep cleaning and performed deep cleaning based on perceived need. The janitor was unable to remove the black spots and had not reported the issue to supervisors due to their absence. Facility policies reviewed indicated that residents should be provided with a clean, sanitary, and orderly environment, and that environmental surfaces should be disinfected regularly and when visibly soiled.
Failure to Notify Responsible Party of Care Conference
Penalty
Summary
The facility failed to inform the responsible party (RP) of a resident with moderately impaired cognition and multiple chronic conditions, including Parkinson's disease, rheumatoid arthritis, and type 2 diabetes, about an Interdisciplinary Team (IDT) Care Conference. The resident, who was dependent on staff for most activities of daily living and unable to make medical decisions, attended the care conference without the RP being notified or invited to participate. Review of the resident's records confirmed the absence of documentation showing that the RP was informed of the meeting. Interviews with the RP, Social Services Director (SSD), and Director of Nursing (DON) confirmed that the RP was not notified prior to the care conference, despite facility policy and federal and state regulations requiring such notification and involvement. The facility's policies emphasized the importance of including residents' families or legal representatives in care planning, but this was not followed in this instance, resulting in the RP not being able to participate in decisions regarding the resident's care, treatment, and services.
Failure to Provide Timely Remicade IV Treatment Due to Communication Breakdown
Penalty
Summary
The facility failed to provide timely intervention after being notified by an outpatient infusion clinic that a resident could not receive their scheduled Remicade (infliximab) IV treatment due to their admission to the facility. The resident, who had diagnoses including Parkinson's Disease, rheumatoid arthritis, and type 2 diabetes mellitus, was dependent on staff for multiple activities of daily living and had moderately impaired cognition. On 5/5/2025, RN 1 received a call from the outpatient clinic indicating they could not administer the Remicade IV. RN 1 notified the resident's physician but did not inform the Director of Nursing (DON) or take further steps to ensure the resident received the necessary treatment while admitted. The resident expressed concern to RN 1 on multiple occasions about the timing of the Remicade IV therapy, stating that the treatment improved mobility and ease of movement. RN 1 did not inform the DON of the situation until nearly a month later, after the resident inquired again about the therapy. The DON confirmed that timely notification would have allowed the facility to coordinate and provide the treatment. The facility's policy required timely, integrated, and efficient care, but the lack of communication and follow-up resulted in a delay of the resident's Remicade IV treatment.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident received continuous oxygen therapy as ordered by the physician. The resident, who had diagnoses including cerebral palsy, chronic pulmonary edema, and bronchopneumonia, was admitted with a physician's order for oxygen at two liters per minute via nasal cannula to be administered continuously. The resident's care plan also specified the need for continuous oxygen therapy and outlined interventions to maintain the prescribed oxygen setting. During an observation in the activities room, the resident was found sitting without oxygen in place and no oxygen administration supplies nearby. The resident was unsure why the oxygen was not being used. A Licensed Vocational Nurse confirmed that the resident was not receiving oxygen at that time, despite being aware of the physician's order. The Director of Nursing also confirmed that the resident should have been receiving continuous oxygen according to the order and facility policy.
Medication Administration and Physician Order Deficiencies
Penalty
Summary
The facility failed to administer a physician-prescribed medication for itchiness to a resident diagnosed with prurigo nodularis, a chronic skin condition causing itchy bumps. The resident, who was moderately impaired cognitively and dependent on staff for personal care, did not receive the prescribed Triamcinolone cream on two occasions during the evening shift. This oversight was confirmed by a registered nurse who acknowledged the potential for discomfort and skin breakdown due to the missed medication. Additionally, the facility did not adhere to its medication administration policy by failing to obtain a physician's order before administering the COVID-19 vaccine to two residents. Both residents had severe cognitive impairments and were dependent on staff for daily activities. The facility used an outside pharmacy to administer the vaccine but did not secure the necessary physician's orders, as confirmed by the Infection Preventionist and the Director of Nursing. This lapse was attributed to a misunderstanding that the vaccine administration by an outside entity did not require a physician's order. The facility's policy on administering medications, which mandates adherence to prescribers' orders, was not followed in these instances. The lack of physician orders for the COVID-19 vaccine and the missed administration of the prescribed cream highlight deficiencies in the facility's medication management practices.
Failure to Provide Coordinated Hospice Services
Penalty
Summary
The facility failed to provide appropriate hospice services to a resident, identified as Resident 30, who was admitted to hospice care. The deficiency was identified through interviews and record reviews, which revealed that there was no documented evidence of hospice staff being physically present in the facility to provide hospice-related services to the resident. The resident, who had been admitted to the facility with diagnoses including dementia, psychotic disturbance, mood disturbance, Parkinson's disease, and heart failure, was severely impaired in cognition and dependent on assistance for daily activities. Despite an order to admit the resident to hospice on 10/23/2024, there was no record of hospice staff signing in to confirm their presence in the facility. Additionally, the facility lacked a designated staff member to coordinate care and services between the hospice provider and the facility. Interviews with the MDS Nurse and the Social Services Director revealed that there was no specific hospice coordinator, and any nursing staff or the Social Services Director would contact the hospice agency directly if needed. This lack of coordination was contrary to the facility's policy, which required a designated Social Service or Nursing Designee to coordinate care and communication between the facility and hospice staff. The facility's policy and procedure for the Hospice Program outlined the responsibilities of the designated coordinator, including collaborating with hospice representatives, coordinating facility staff participation in hospice care planning, and ensuring communication with hospice representatives and other healthcare providers. However, the absence of a designated coordinator led to a failure in ensuring well-coordinated and comprehensive hospice services for Resident 30.
Infection Control Deficiencies in Oxygen Tubing and Laundry Transport
Penalty
Summary
The facility failed to implement its infection control and prevention program in two key areas. Firstly, the facility did not ensure that a resident's nasal cannula oxygen tubing was properly labeled and kept off the floor. During an observation, it was noted that the oxygen tubing for a resident with chronic pulmonary disease and respiratory failure was touching the floor and was not dated. The Director of Nursing confirmed that the tubing should be changed weekly and labeled with the date of change to prevent contamination and infection. The facility's policy requires oxygen cannula and tubing to be changed every seven days, and the CDC guidelines highlight the risk of contamination from floors. Secondly, the facility did not adhere to its policy regarding the transportation of clean laundry. An observation revealed that laundry staff transported a cart of clean clothes uncovered, contrary to the facility's policy that mandates clean laundry to be covered during transport to prevent contamination. The Infection Preventionist confirmed that clean laundry should always be covered to maintain cleanliness and prevent infection. The facility's policy specifies that clean linen must be protected from dust and soiling during transport and storage.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a Quarterly Minimum Data Set (MDS) assessment for a resident, which is a standardized assessment and care screening tool. This deficiency was identified during a review of the resident's records and interviews with the facility's MDS Nurse. The resident in question was originally admitted to the facility in May 2021 and readmitted in May 2022, with diagnoses including neuropathy and difficulty in walking. The resident was noted to have intact cognition and required supervision for most activities of daily living. The deficiency was discovered when reviewing the Centers for Medicare and Medicaid Services (CMS) Submission Report, which indicated that the assessment was completed more than 14 days after the assessment reference date (ARD). The ARD was set for October 18, 2024, and the assessment should have been completed by November 1, 2024. However, it was not completed until November 20, 2024. The facility's policy, last reviewed and revised in November 2024, requires that the resident assessment coordinator ensures timely assessments, with Quarterly Assessments not conducted less frequently than three months following the most recent OBRA assessment.
Failure to Document Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid pain medication to two residents, leading to a deficiency in pain management. Resident 7, who was admitted with chronic obstructive pulmonary disease and a history of falling, had a care plan that included assisting with positions of comfort. However, the facility's records showed that hydrocodone-acetaminophen was administered multiple times without documentation of non-pharmacological interventions being attempted first. Similarly, Resident 8, who was admitted with bilateral osteoarthritis of the knees, had a care plan that included non-pharmacological interventions such as repositioning and relaxation techniques. Despite this, the facility's records indicated that hydrocodone-acetaminophen was administered on several occasions without any documented evidence of non-pharmacological interventions being attempted first. Interviews with the Director of Nursing and Registered Nurse 1 confirmed the lack of documentation for non-pharmacological interventions prior to administering opioid medications. The facility's policy, which was last reviewed and revised on 11/6/2024, emphasized the importance of attempting non-pharmacological interventions to alleviate pain without medication due to potential side effects. However, this policy was not adhered to, resulting in the deficiency.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. A bag of wheat bread and a bag of English muffins were found without an open date label, which is required to inform kitchen staff when to discard the bread. The Dietary Manager (DM 1) acknowledged that labeling is necessary to ensure food items remain safe for consumption and prevent potential foodborne illnesses. Additionally, a resident's food from home stored in the resident's refrigerator was found without a label or received date, which is against the facility's policy. Registered Nurse 1 (RN 1) confirmed that leftover food brought by visitors is stored in the resident's refrigerator and should be labeled with the resident's name and the date received to ensure it is discarded after 72 hours. The facility's policy, titled 'Food Receiving and Storage,' mandates that foods be received and stored in compliance with safe food handling practices. Another policy, 'Food Brought by Family/Visitors, Receiving and Storage,' requires that food brought by family or visitors be labeled and stored in a manner that distinguishes it from facility-prepared food, with perishable items stored in resealable containers labeled with the resident's name and use-by date.
Failure to Conduct Quarterly Rehabilitation Screen
Penalty
Summary
The facility failed to implement its policy on rehabilitation screening by not conducting a quarterly rehabilitation screen for one of the sampled residents, identified as Resident 68. The resident was originally admitted with diagnoses including vascular dementia, psychotic disturbance, and cerebral palsy, which significantly impaired their cognitive and physical abilities. According to the facility's order summary report, Resident 68 was supposed to have a rehabilitation screen upon admission and quarterly thereafter. However, a review of the Rehabilitation Screening Forms revealed that no quarterly screen was conducted for Resident 68 in August 2024, as required. During interviews, the Director of Rehabilitation (DOR) confirmed the absence of the required quarterly rehabilitation screen for Resident 68 and acknowledged the importance of these screens in assessing the need for rehabilitation services. The facility's policy on rehabilitation screening and the PCC-UDA Schedule Guide emphasized the necessity of accurate, complete, and timely entries in the electronic medical record, including the completion of quarterly Rehab Screening Forms. The failure to conduct the quarterly screen placed Resident 68 at risk of not maintaining, improving, or restoring their functional abilities.
Lack of POLST Policy Leads to Incomplete Resident Form
Penalty
Summary
The facility failed to develop a specific policy and procedure for the Physician Orders for Life-Sustaining Treatment (POLST) form, which is crucial for outlining a resident's end-of-life care preferences. This deficiency was identified during a review of Resident 101's records, who was admitted with diagnoses including hyponatremia, lung disease, and metabolic encephalopathy. The review revealed that Resident 101 lacked the capacity to make decisions, and their POLST form was incomplete, missing the signature of either the resident or their legally recognized health care decision maker. This oversight was confirmed during an interview with a registered nurse, who acknowledged the importance of having a completed POLST form to ensure the resident's safety and adherence to their care preferences. Further investigation revealed that the facility's administrator admitted to the absence of a specific policy for the POLST form. The facility's governing board is responsible for establishing and reviewing policies, as indicated in their administrative management policy. However, the lack of a POLST-specific policy could lead to confusion among staff and potential delays in care. The administrator's job description emphasizes the need to direct operations in compliance with regulations and to establish policies that reflect the facility's goals, yet this critical policy was not in place, contributing to the deficiency.
Failure to Document COVID-19 Vaccine Eligibility Screening
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy by not ensuring that residents were screened for eligibility before administering the vaccine. This deficiency was identified for two residents, Resident 30 and Resident 68, who were both administered the COVID-19 vaccine without documented evidence of eligibility screening. The facility's policy requires screening for contraindications, medical precautions, and prior vaccinations before offering the vaccine. Resident 30, who has diagnoses including dementia, psychotic disturbance, and Parkinson's disease, was admitted to the facility in 2014. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for daily activities. Similarly, Resident 68, with diagnoses of vascular dementia and cerebral palsy, was admitted in 2022 and also had severely impaired cognition and dependence on assistance. In both cases, the Infection Preventionist (IP) failed to document the screening for vaccine eligibility, leaving the relevant section of the COVID-19 Vaccine Consent & Declination form blank.
Infection Control Breach by LVN
Penalty
Summary
The facility failed to implement proper infection control practices when a Licensed Vocational Nurse (LVN 1) did not wear an isolation gown and face shield before entering the room of a resident who was under novel respiratory precautions due to suspected COVID-19 infection. The resident, admitted with conditions including hemiplegia and atrial fibrillation, was placed on contact and droplet isolation as per physician's orders and care plan due to respiratory symptoms. Despite the presence of signage indicating the need for an isolation gown, N-95 mask, and face shield, LVN 1 entered the resident's room wearing only an N-95 mask and gloves. The Director of Nursing confirmed that staff should adhere to the posted novel respiratory precautions signage, which serves as a communication tool for the necessary isolation precautions. The facility's Infection Prevention Quality Control Plan, last reviewed in February 2024, outlines the requirement for personal protective equipment to prevent the spread of infection. The failure of LVN 1 to comply with these guidelines had the potential to result in the spread of infection, placing residents, staff, and visitors at risk of COVID-19.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach, which could delay resident care and assistance with activities of daily living. On 5/23/2024, Resident 2's call light was observed hanging behind the headboard frame, out of reach. Resident 2, who was admitted with a diagnosis of cerebral infarction and required maximum assistance with various activities, was unable to find or use the call light to call for help. This was confirmed during an interview with Resident 2, who stated he could not call staff for assistance. Certified Nursing Assistant 1 (CNA 1) confirmed that the call light was stuck behind the headboard and admitted she had not checked its placement since starting her shift. The Director of Nursing (DON) also stated that call lights should be within reach to promptly provide residents with needed assistance. The facility's policy, last reviewed on 2/1/2024, indicated that residents should have a means to call staff for assistance from their bed, toileting, and bathing facilities, and that the call system should remain functional at all times.
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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) |
|---|---|---|---|---|
| Terrace Post Acute | 1.2 mi | — | 24 | 0 |
| Panorama Gardens Nursing And Rehabilitation Center | 1.6 mi | — | 1 | 0 |
| The Rehabilitation Center Of North Hills | 1.8 mi | — | 8 | 0 |
| California Healthcare And Rehabilitation Center | 2.1 mi | — | 41 | 0 |
| The Care Center On Hazeltine, Llc | 2.2 mi | — | 12 | 0 |
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