Other·August 20, 2020

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 California Department of Public Health during an investigation of a complaint. Complaint Number: CA00690376 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 42040 The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint Number: CA00690376.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established 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: KBEZ11 Facility ID: CA920000054 If continuation sheet 1 of 4 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 07/23/2020 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 procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the State Agency (the Department) two incidents of elopements (resident leaving facility without the facility knowing), which occurred on 3/1/20 and 5/24/20 for one of three sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department to ensure the safety of the other residents and to ensure the elopement allegation was investigated. Findings: A review of Resident 1's Admission Record, dated 6/3/20, indicated the resident was originally admitted on 9/23/17 and readmitted on 1/30/20 with diagnoses hemiplegia (a condition that causes inability to move half of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (area of dead tissue in the brain caused by blocked and/or narrowed arteries that carry blood and oxygen to the brain) affecting the right dominant side, and vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage caused by problems with supply of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KBEZ11 Facility ID: CA920000054 If continuation sheet 2 of 4 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 07/23/2020 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 blood to the brain). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/1/20, indicated the resident has ability to usually understand others and usually understood. A record review of Resident 1's Elopement Risk Assessment, dated 1/31/20, indicates that the resident had elopement risk score of 10 (high risk for potential elopement from the facility). A record review of the facility's investigation report, dated 3/1/20, indicates they were unable to locate Resident 1 inside the facility. When the facility contacted Resident 1's family regarding the status of Resident 1's elopement, the family informed the facility that the resident came to their house. Resident was brought back to facility. A record review of the facility's investigation report, dated 5/24/20, indicates they were unable to locate Resident 1 inside the facility. When the facility contacted Resident 1's family regarding the status of Resident 1's elopement, the family informed the facility that the resident came to their house. Resident was brought back to facility. During an interview and concurrent record review on 6/3/20 at 10:50 a.m., the Director of Nursing (DON) verified that Resident 1 had eloped from the facility on 3/1/20. During a follow up interview on 7/8/20 at 3:40 p.m., the DON stated there were no records to indicate the elopement on 3/1/20 was reported to the State agency. DON stated she does not know why it was not reported. During an interview on 7/6/20 at 3:30p.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KBEZ11 Facility ID: CA920000054 If continuation sheet 3 of 4 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 07/23/2020 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 DON stated that on 5/24/20, after Resident 1 left the facility, Resident 1 was found by the police and taken to his family's home. DON stated the facility arranged to have the resident brought back to facility thereafter. DON was unable to explain how come the incident was not reported again to the Department. During an interview on 7/6/20 at 2:30p.m., the Administrator (Admin) confirmed that the facility did not report Resident 1's elopement incident that occurred on 5/24/20 to the State agency because there was a lot going on at the facility. The Admin further stated the facility should have reported the incident to the Department. A review of the facility's policy and procedure titled "Elopement/Unsafe Wandering" dated 6/2018, indicates "the facility will notify the appropriate State Agency in accordance with state requirement". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KBEZ11 Facility ID: CA920000054 If continuation sheet 4 of 4