Other·July 24, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an Abbreviated Standard Survey. Complaint Intake #: CA00492605 Substantiated. Representing the Department of Public Health: Surveyor ID #: 36203 RN, HFEN The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 Each resident must receive and the facility must provide the necessary 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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary care and services to attain optimal LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 1 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE improvement in condition and did not deteriorate outside the limits of normal processes. For Resident 1, who fell and had pain rated at 8 out of 10 (10 being the worst possible pain), the facility did not administer physician ordered pain medication. This deficient practice resulted in unnecessary and increased pain and suffering, rated at 9 out of 10, to Resident 1. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/21/15, with diagnoses of osteoporosis (a condition in which the bones become weak and brittle), dementia (decrease in the ability to think and remember great enough to affect a person's daily functioning), anxiety (feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome), and osteoarthritis (a joint disease that mostly affects cartilage, cartilage is the slippery tissue that covers the ends of bones in a joint) to left elbow. A review of the physicians order, dated 6/3/16, indicated Resident 1 was to receive Norco 5325 milligram (mg) tablet (a medication used to treat moderate to severe pain) as needed every six hours for moderate to severe pain. A review of the Minimum Data Set (an assessment and care screening tool), dated 6/10/16, indicated Resident 1 had an active diagnosis under musculoskeletal of arthritis, and was not steady, only able to to stabilize with staff assistance when moving from seated to standing position. The Care Area Assessment (CAA), dated 6/11/16, indicated Resident 1 had difficulty maintaining sitting balance and had impaired balance during transitions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 2 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of a progress note, dated 6/13/16, at 7:12 p.m., indicated the licensed vocational nurse (LVN 1) documented Resident 1 was reassessed after found laying on the floor and complained of discomfort to the right lower extremity when the area was touched. During an interview with Registered Nurse 1 (RN 1), on 6/28/16, at 9:15 a.m., she stated that on the day of incident, Resident 1 was anxious, attempted to get out of the wheelchair, and fell. On 7/7/16, at 7:41 a.m., RN 1 stated on the day of the fall, the physician was notified of the fall and increased the Ativan (act on the brain and nerves (central nervous system) to produce a calming effect) to 0.5 milligrams (mg) every 8 hours for anxiety and restlessness. During an interview, on 6/28/16, at 10:10 a.m., with the director of nursing (DON), she stated Resident 1 was in the hallway at Station 3. LVN 1 was with the resident initially, then left to see another resident. The DON stated Resident 1 was found on his left side, lying on the floor. The fall was unwitnessed. After the fall, the resident grimaced whenever his right hip was touched. A review of the care plan, dated 6/4/16, indicated Resident 1 had acute / chronic pain related to arthritis and osteoporosis. The goals included the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The care plan interventions indicated to follow the pain scale to medicate as ordered, monitor / document for probable cause of each pain episode, notify physician if interventions were unsuccessful, or if current complaint was a significant change from the residents past experience of pain, and to observe and report decrease in functional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 3 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE abilities, decreased range of motion, or withdrawal or resistance to care. A review of the medication record (MAR), dated 6/13/16, on the afternoon shift (3 - 11 p.m.), indicated Resident 1 had 8 out of 10 pain and did not receive the physician ordered Norco pain medication. During a phone interview, on 8/1/16, at 9:37 a.m., the DON stated Resident 1 had an unwitnessed fall at around 6 p.m., and left for the general acute care facility at 8:20 p.m. The DON stated, after the fall, the resident had a pain level of 8 out of 10, did not receive Norco (pain medication), and that "The resident should have received pain medication for 8/10 pain." A review of the ambulance run sheet, dated 6/13/16, indicated Resident 1 left the facility at 8:20 p.m., without any pain medication administration. Upon leaving the facility and during transport (over two hours after the fall), the ambulance run sheet indicated Resident 1 was experiencing 9 out of 10 pain. A review of the general acute care hospital (GACH) computed tomography (CT) scan, dated 6/14/16, indicated Resident 1 had a comminuted displaced right intertrochanteric femoral neck fracture (fracture to the upper part of the femur or thigh bone) with adjacent soft tissue swelling. A review of the GACH X-ray report of the right hip, dated 6/15/16, indicated Resident 1 had an intratrochanter fracture of the right hip (upper part of the femur or thigh bone). A review of the operating room note, dated 6/16/16, indicated Resident 1 went to surgery for a right hip fracture. The resident had an open reduction and internal fixation (ORIF, first, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 4 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the broken bone is reduced or put back into place, next an internal fixation device is placed on the bone). The facility's policy and procedure titled, "Pain Management," dated 5/2007, indicated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning. The facility was to develop and implement a plan, using pharmacologic and/or non -pharmacologic interventions to manage pain and/or try to prevent the pain consistent with the resident's goals.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor/ modify care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk, the facility failed to develop an appropriate care plan with risk for falls and failed to provide supervision to prevent the fall. This deficient practice resulted in Resident 1 suffering a fall with injuries, which included a fractured hip and required surgery. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 5 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/21/15, with diagnoses of osteoporosis (a condition in which the bones become weak and brittle), dementia (decrease in the ability to think and remember that is great enough to affect a person's daily functioning) and anxiety (feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome). The Minimum Data Set (an assessment and care screening tool), dated 6/10/16, indicated Resident 1 required total dependence during bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing with one person physical assistance. The Care Area Assessment (CAA), dated 6/11/16, indicated Resident 1 had difficulty maintaining sitting balance and had impaired balance during transitions. A review of the Fall Risk Assessment, dated 6/4/16, indicated Resident 1 was disoriented and had a high risk for falls due to the resident having a history of falls, poor vision, and a balancing problem while standing/walking. The fall risk assessment indicated a decrease in muscular coordination, change in gait pattern when walking, and Resident 1 required the use of assistive devices. A review of a progress note, dated 6/9/16, the licensed vocational nurse (LVN 2) documented Resident 1 was at risk for falls due to unsteady gait, imbalance, and poor safety awareness. The resident continued with episodes of unassisted transfers. A review of the progress notes documented by RN 1, dated 6/13/16, at 12:25 p.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 6 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 was up in a wheelchair, attempted to get up without assistance, and appeared anxious and restless. The resident was confused and unable to make needs known. RN 1 explained to the resident not to get up without assistance. The progress note indicated Ativan (act on the brain and nerves (central nervous system) to produce a calming effect) was given for the episode of restlessness. A review of a progress note, dated 6/13/16, at 7:12 p.m., documented by LVN 1 indicated Resident 1 was re-assessed after found laying on the floor and complained about discomfort to the right lower extremity when the area was touched. A review of the medication administration record (MAR) indicated Resident 1 received Ativan 0.5 mg for anxiety, and restlessness on 6/4, 6/5, 6/8, 6/9, 6/10, and 6/12/16. According to WebMD, 2015, the side effects of Ativan include drowsiness, dizziness, loss of coordination, and blurred vision. A review of the MAR, dated 6/13/16, indicated Resident 1 received Ativan 0.5 mg at 8:50 a.m., for restlessness, which was ineffective. The MAR indicated resident received an additional dose of Ativan 0.5 mg, at 9:20 a.m. (thirty minutes later). During an interview with Registered Nurse 1 (RN 1), on 6/28/16, at 9:15 a.m., she stated on 6/13/16 Resident 1 was anxious and tried to get out of the wheelchair and fell. On 7/7/16, at 7:41 a.m., RN 1 stated Resident 1 had been restless, the physician was notified, and the Ativan order was increased to 0.5 milligrams (mg) every 8 hours for anxiety and restlessness. RN 1 stated Resident 1 should have been supervised due to repeated attempts of unassisted transfers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 7 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of a care plan, initiated on 6/4/16, indicated Resident 1 had a high risk for falls related to being unaware of safety needs, confusion, balance problems, and an increase of trying to get up unassisted. The goals of the care plan included the resident being free of falls and not sustaining serious injury. The interventions included to anticipate and meet the resident's needs and to be sure the call light was in reach and encourage to call for assistance as needed. The care plan did not include evidence of providing supervision to Resident 1. During an interview, on 6/28/16, at 10:10 a.m., with the director of nursing (DON), she stated Resident 1 was in the hallway at Station 3, LVN 1 was with the resident, but went to see another resident. A pad alarm was heard and Resident 1 was found on his left side, lying on the floor. The DON stated the fall was unwitnessed. After the fall, the resident grimaced whenever his right hip was touched. During an interview, on 7/7/16, at 8 a.m., RN 2 stated Resident 1 had a cognitive impairment (a slight but noticeable and measurable decline in memory and thinking skills), was at high risk for falls and should have been supervised while in the wheelchair. RN 2 stated supervision should have been added to the care plan. During an interview, on 7/7/16, at 8:30 a.m., the assistant DON stated Resident 1 was a high risk for falls. The resident was sitting at the nurse's station in his wheelchair, and, "unfortunately no one was supervising the resident at the time." The assistant DON stated supervision should have been added to the care plan. During a phone interview, on 7/7/16, at 8:45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 8 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., LVN 1 stated Resident 1 was more anxious than usual and the morning and received Ativan due to increased episodes and attempting to get up unassisted. The resident was up in a wheelchair at the nurse's station with a pad alarm. LVN 1 stated she went to pass medication to another resident and left Resident 1 in the hallway, leaving him unsupervised. When she came out of the room, she found the resident lying on the ground. LVN 1 stated the physician was called and a new order to transfer Resident 1 to the general acute care facility was received. LVN 1 stated the resident should have been supervised due to the increased episodes of being restless and getting up unassisted. A review of the physicians order, dated 6/3/16, indicated Norco (a combination medication used to relieve moderate to severe pain contains a narcotic pain reliever (hydrocodone) and a non-narcotic pain reliever (acetaminophen) 5-325 milligram (mg) tablet was to given as needed every 6 hours for moderate to severe pain. A review of the medication record (MAR), dated 6/13/16, indicated Resident 1 had 8 out of 10 pain and did not receive the pain medication that was ordered. During a phone interview, on 8/1/16, at 9:37 a.m., the DON stated after Resident 1's fall, the resident had a pain level rated at 8 out of 10 and did not receive Norco (pain medication). The DON stated, "The resident should have received pain medication for 8/10 pain." A review of the computed tomography (CT) scan, dated 6/14/16, indicated Resident 1 had a comminuted displaced right intertrochanteric femoral neck fracture (fracture to the upper part of the femur or thigh bone) with adjacent soft tissue swelling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 9 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the X-ray report of the right hip, dated 6/15/16, indicated Resident 1 had an intratrochanter fracture of the right hip (upper part of the femur or thigh bone). A review of the operating room note, dated 6/16/16, indicated Resident 1 went to surgery for a right hip fracture. The resident had an open reduction and internal fixation (ORIF - first the broken bone is reduced or put back into place, next an internal fixation device is placed on the bone). The facility's policy and procedure titled, "Fall Risk Assessment," dated 5/2007 indicated any resident identified as high risk for falls would have a prevention protocol initiated and documented on the care plan. Prevention protocol included providing supervision.

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 10 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement infection control practices for one of three sampled residents (Resident 1). For Resident 1, who was on contact isolation, facility staff did not wash their hands and observe infection control precautions. This deficient practice caused an increased risk in the spread of infection and cross contamination among residents. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/21/15, with diagnoses of dementia (decrease in the ability to think and remember that is great enough to affect a person's daily functioning) and anxiety (feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome). A review of the Minimum Data Set (an assessment and care screening tool), dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 11 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/10/16, indicated Resident 1 required total dependence during bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing with one person physical assistance. During an observation, on 6/28/16, at 8:51 a.m., Resident 1's Foley catheter (a tube inserted into the bladder to drain urine) tubing touched the floor. The urine was noted red in color with sediments present and the tubing was kinked with dependent loops (dependent loops cause backflow of urine, leading to increased risk for infection). During an observation, on 6/28/16, at 9 a.m. outside Resident 1's room, a color coded (green) stop sign was observed. The sign instructed staff and visitors to wash hands, wear gloves, and gown prior to entering Resident 1's room. Licensed vocational nurse 1 (LVN 1) was observed entering Resident 1's room without washing her hands before assisting the resident, and touched the curtains without wearing gloves or a gown. During an interview with the LVN 1, on 6/28/16, at 9 a.m. she stated Resident 1 was on isolation for wound infection around the gastrostomy tube (GT- a feeding tube inserted through the abdomen that delivers nutrition directly to the stomach). LVN 1 stated she should have followed the sign and should have worn a gown and donned gloves before entering Resident 1's room. During an observation, on 6/28/16, at 9:05 a.m., the registered nurse (RN 1) entered Resident 1's room and donned gloves without washing her hands. RN 1 stated, "I'm sorry I forgot. I'm nervous. I should have worn a gown and gloves before entering the resident's room." RN 1 proceeded to put on gloves and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 12 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gown to readjust the Foley catheter and stated there was bloody urine in the tubing. She further stated there should not be any kinks or dependent loops in the tubing. After repositioning the Foley catheter, RN 1 removed her gloves and gown, and exited the room, and did not wash her hands. RN 1 stated, "I'm so sorry. I forgot to wash my hands." A review of the care plan for indwelling catheters, dated 6/26/16, indicated Resident 1 had a catheter due to surgery status post right hip, with a goal of no signs and symptoms of infection and would remain free from catheter related trauma. The care plan interventions indicated to check for kinks each shift. The facility's undated policy and procedure titled, "Isolation Measures," indicated staff should wash their hands before and after duty, after patient contact, and before and after use of gloves. The facility's policy and procedure titled, "Catheter Drainage Bag," dated 5/07, indicated staff should wash hands properly before and after any manipulation of the drainage bag and/or tubing. Observe urine for color, consistency, odor, or foreign particles. To achieve free flow or urine, the catheter and drainage bag tubing should be free of kinking and the drainage bag tubing should be placed or coiled to facilitate straight drainage. The facility's undated policy and procedure titled, "Infection Control," undated, indicated color coded stop signs were used to identify that contact precautions (isolation) were in effect. This notified staff and visitors of the need for special precautions and/or to contact nursing staff for further instructions. The policy indicated gowns and gloves were to be worn when providing care of working with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 13 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056337 (X3) DATE SURVEY COMPLETED 09/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PANORAMA GARDENS NURSING AND REHABILITATION CENTER 9541 Van Nuys Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE environmental surfaces. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CPDH11 Facility ID: CA920000054 If continuation sheet 14 of 14