Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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.
Failure to Respect Resident Communication, Privacy, and Dignity: A CNA lowered a resident’s HOB and provided bedside care without first informing or speaking with the resident, who had encephalopathy, morbid obesity, reduced mobility, and severely impaired decision-making. In a separate event, housekeeping entered another resident’s room without knocking or introducing herself; that resident had blindness, seizures, and severely impaired cognitive skills. Interviews confirmed staff did not follow expected communication and privacy practices.
Improper Use of Low Air Loss Mattress: A resident with severe cognitive impairment, morbid obesity, and reduced mobility was observed lying on a low air loss mattress with multiple layers of linen between the resident and the mattress. CNA and MDSN both stated there were six layers present, while the MDSN and DON stated the mattress should have only one or two layers to function properly and support pressure ulcer prevention and treatment.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
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 DM, hemiplegia, and limited mobility developed a left heel blister that worsened to an open, painful wound after staff failed to consistently float the heels and did not obtain an APP mattress. In another case, a resident with severe left-hand ROM loss and a closed-fist contracture had no device in place to protect the palm from the fingernails or prevent skin injury, and the hospice MD was not informed of the decline in ROM.
Failure to Provide ROM and Restorative Services: A hospice resident with multiple joint ROM limits did not receive ordered ROM exercises for months, and worsening left-hand stiffness progressed to a closed fist with contractures and skin cuts while staff failed to report the decline. Hospice aide notes left exercise sections blank, the OT did not notify nursing of the worsening hand ROM, and no device was in place to protect the palm. A second resident also missed an ordered restorative sit-to-stand program, with the RNA stating it was forgotten.
A facility failed to notify the MD and/or resident representative about significant changes in condition for three residents. One resident had repeated blood glucose readings above the ordered call parameters without physician notification, another had persistent hyperglycemia over several weeks with incomplete communication to the MD, and a hospice resident’s decline in left-hand ROM and later finger injury were not promptly reported to the primary physician and family. Staff interviews and record review confirmed missing or delayed communication and documentation.
A facility failed to develop comprehensive care plans for several residents with identified needs. One resident with hospice status and progressive ROM loss developed a left-hand contracture without care plan interventions for ROM decline or the RNA program, another resident’s PT/OT Sign-in Sheet intervention was not included in the care plan and was not completed for every therapy session, a resident with a new UTI diagnosis had no care plan for the change in condition, and two residents who refused influenza, pneumococcal, and COVID vaccines had no care plans addressing the refusals.
Failure to include pain interventions in the care plan for a resident with a left heel Stage 2 fluid-filled blister. The resident had DM, hemiplegia/hemiparesis, dysphagia, and significant ADL and mobility dependence. The COC documented the heel blister, but the pain assessment was marked not clinically applicable, the physician order did not address pain, and the care plan lacked pain interventions. During wound care, the resident cried and stated the heel hurt a lot, and the TN and DON acknowledged the care plan had not been updated to address pain.
Missed Required Physician Visits for a Resident with DM and Stroke: A resident with DM and stroke did not receive face-to-face MD visits at the required intervals. Record review showed telephone-only encounters during the required period, and after hospital readmission the next in-person visit was not documented until well after the expected timeframe. The DON and ADM confirmed the visit schedule requirements during interview, and the report stated this had the potential for the physician to miss the beginning of the resident’s elevated blood sugars.
Failure to Follow Clear Diabetes Monitoring and Physician Notification Guidance: A resident with DM had repeated elevated blood sugars and unclear physician-notification guidance in the chart and facility policies. The DON verified multiple high glucose readings and stated the physician should have been notified when the first reading was 454 mg/dL, while the facility’s diabetes-related policies lacked clear parameters for when to call the MD. The DON, ADM, and MDir all acknowledged the need for clearer notification criteria and physician visit guidance.
A resident with CHF was observed sleeping with the HOB flat despite a care plan intervention to keep it elevated. In another case, an LPN failed to document notifying the MD when a resident’s accuchecks were above the ordered threshold. A third resident with DM had persistent hyperglycemia for weeks, with repeated blood sugars in the 200s, 300s, and 400s, while staff documented attempts to contact the physician and requests to restart diabetes medication but did not show timely clarification or effective follow-through on the blood sugar management orders.
A resident with psychosis and PTSD was started on buspirone for anxiety, but the record did not show an assessment or clinical rationale supporting the medication. The DON confirmed the physician note lacked documentation of anxiety assessment, psych notes listed no psychiatric meds, and the IDT review did not document anxiety or non-pharmacological interventions before the psychotropic was initiated.
Failure to provide nail care and personal hygiene assistance. A resident with HTN, type 2 DM, impaired cognition, and need for moderate assistance with personal hygiene was observed with long fingernails and black substances under the nails. The DON stated the nails needed cleaning and trimming, and CNA documentation showed the resident had not refused care. The facility policy stated residents will be well groomed.
Bedside rail use and padding were not maintained as required for two residents. One resident with severe cognitive impairment was observed with quarter rails up even though there was no care plan for rail use, and staff stated the rails posed a risk of limb entrapment. Another resident with seizures had an order and care plan for padded upper side rails, but observations showed the padding had slipped down and exposed the hard rails; the ADON and DON acknowledged the padding was not fully covering the rails.
A resident with PTSD, anxiety, dementia, psychosis, and COPD had episodes of uncontrolled anxiety and yelling, including an event requiring EMS transfer after he shouted that he could not breathe. Staff and records showed his PTSD triggers were not adequately assessed, and his care plan did not include person-centered interventions specific to his triggers. The resident reported that people coming into or passing through his room and seeing paramedics upset him, while the SCD stated his assessments did not identify triggering events and his care plan was not specific enough to guide staff response.
A resident with unspecified dementia and severe cognitive impairment was observed in bed with quarter bedside rails raised on both sides, and the rails had gaps between the bars. The DON confirmed there was no physician order and no bedside rails entrapment risk assessment for the resident, and the facility policy required alternatives first, IDT assessment of risks and benefits, and informed consent before bed rail use.
Late Administration of Zenpep With Meals: A resident with adrenocortical insufficiency and liver cirrhosis was ordered Zenpep with meals, scheduled for breakfast, lunch, and dinner. An LVN administered the medication more than 2 hours after the breakfast dose was due, and the DON confirmed it was late and not given with the meal. The facility policy stated medications are to be given as prescribed and within 60 minutes of the scheduled time.
Inaccurate documentation of RNA sit-to-stand services was identified for a resident with DM, hemiparesis, gait and mobility impairment, and severely impaired cognition. PT and the MDS showed the resident needed substantial/maximal assistance for transfers, and PT recommended an RNA program for sit-to-stand mobility using side rails. Although the record showed the service was provided, RNA later stated it was not given on one documented day and the DON confirmed the record was inaccurate.
Resident rooms with three beds each did not meet the required 80 sq ft per resident. During an observation and interview with the Admin and Maintenance Resource, rooms 10, 12, and 24 were measured and each fell below the minimum per-resident space. The Admin stated awareness of the regulation, and the facility policy required at least 80 sq ft per resident in multiple resident bedrooms.
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 Respect Resident Communication, Privacy, and Dignity
Penalty
Summary
The facility failed to provide care in a manner that promoted and maintained residents’ rights for two sampled residents. For one resident, the record showed diagnoses including encephalopathy, morbid obesity, and reduced mobility, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for multiple ADLs. The care plan directed staff to converse with the resident while providing care, but during an observation a CNA lowered the head of the resident’s bed without first informing or explaining the action and provided bedside care without conversing with the resident. During interview, the IP confirmed that the CNA did not explain that the head of bed would be lowered and did not communicate with the resident while at the bedside. The ADM stated that staff should explain procedures and communicate with residents prior to performing care interventions to uphold residents’ rights. The CNA stated she did not inform the resident because she did not know how to explain the procedure in English and said she does not speak much English; she also stated that when residents speak to her in English, she tells them, “No English.” The DSD stated that staff should explain procedures before providing care, obtain permission to perform a procedure such as lowering the head of bed, and engage residents in conversation to demonstrate respect. For another resident, the record showed diagnoses including epileptic seizures related to external causes, need for assistance with personal care, and blindness, and the MDS indicated severely impaired cognitive skills for daily decision making with substantial assistance or dependence for several ADLs. During observation, housekeeping staff entered the resident’s room without knocking or introducing herself first. The housekeeping staff member stated she should have knocked and informed the resident of her presence before entering, but did not do so because the resident was sleeping and she was confused. The DSD stated that all staff should knock on residents’ doors, introduce themselves, and wait for permission before entering a room, and the facility’s Resident Rights policy stated that residents are to be treated with consideration, respect, and full recognition of dignity and individuality.
Improper Use of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for one resident who was admitted with encephalopathy, morbid obesity due to excess calories, and reduced mobility. The resident's MDS indicated severely impaired cognitive skills for daily decision making, dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and mobility, and risk for developing pressure ulcers/injuries. The resident also had an order to use a low air loss mattress as part of skin and ulcer/injury treatment. During observations, the resident was found lying on the low air loss mattress with multiple layers of linen between the resident and the mattress. CNA 1 stated the resident was on one fitted sheet, one folded draw sheet, and an adult brief, and said there were six layers between the resident and the mattress. The MDS Nurse also stated there were six layers between the resident and the mattress and that residents on a low air loss mattress should have only one layer between the resident and the mattress for it to function properly and help prevent pressure ulcers/injuries. The DON stated residents on a low air loss mattress should have only two layers between the resident and the mattress surface, an adult brief and a sheet, and that excessive layers could interfere with the effectiveness of the mattress. The facility policy stated it is the policy of the facility to prevent and treat pressure ulcers, alternate pressure under bony prominences, and provide resident comfort.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
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 Offload Heel Pressure and Protect Contracted Hand
Penalty
Summary
Resident 69, who had diagnoses including type 2 diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and dysphagia, was identified as being at moderate risk for pressure injury development and dependent on staff for multiple activities of daily living and mobility. On 8/22/2025, the resident was found to have a fluid-filled blister on the left heel measuring 3.2 cm by 3.4 cm. The physician ordered daily cleansing, Betadine, and a dry dressing, and the care plan included floating the heels. The facility also documented that the resident was at risk for pressure ulcer development and further skin breakdown related to diabetes, incontinence, and decreased mobility. Despite the heel blister and the care plan intervention to float the heels, staff observed the resident lying on a regular mattress with both heels in direct contact with the mattress surface and no pillow or offloading device in place. A CNA stated she forgot to float the heels. During later observations, a pillow placed behind the lower legs and heels was resting against the wheelchair footrests, and staff stated the pillow had slipped down and was then readjusted. Treatment staff stated the heel should remain floating at all times, and the DON stated the heel pressure injury was avoidable and that the resident’s heels should never have been resting flat on the bed. When wound care was performed, the left heel was noted to have worsened from an intact blister to a partial-thickness open area with a pink wound bed and the resident reported significant pain. Treatment staff stated the blister had most likely developed from pressure from the bed and that an alternating pressure pad mattress had not been obtained even though the resident had prior non-blanchable redness and was at high risk for pressure injury. The facility’s policy stated pressure ulcers should be prevented by repositioning and using pressure mattresses, wedges, and pillows. The deficiency also included Resident 13, whose severe left-hand ROM limitation and closed-fist position were documented, but no device was in place to protect the palm from the fingernails or to prevent skin injury. Staff and family described the hand as curled, stiff, and unable to open, and the hospice MD stated he was unaware of the severe ROM loss and would have appreciated notification.
Failure to Provide Ordered ROM and Restorative Mobility Services
Penalty
Summary
The facility failed to provide range of motion (ROM) and mobility services for a resident admitted on hospice care who had diagnoses including atherosclerotic heart disease, major depressive disorder, age-related cognitive decline, and anxiety disorder. On the initial joint mobility evaluation, the resident had ROM limitations in multiple joints of both arms and legs, but the record showed no ROM exercises were provided after those limitations were identified. Hospice aide visit notes repeatedly left the exercise section blank, and nursing progress notes did not document reported changes in ROM during this period. The resident’s quarterly joint mobility evaluation later showed a severe ROM limitation in the left-hand fingers, along with additional ROM limitations in the right hip, left shoulder, left hip, and both knees. The resident’s hospice updated assessments also documented loss of ROM and later contractures. Despite these findings, the facility did not document interventions to address the worsening left-hand ROM, and the resident’s care plan called for observing and reporting changes, including decreased functional abilities and decreased ROM. Facility staff and therapy staff stated the resident did not receive ROM exercises for months after the initial evaluation, and the occupational therapist stated no licensed nurse was notified of the substantial decline in the left hand after the quarterly evaluation. The resident’s left hand progressed to a closed-fist position, with the fingers unable to fully extend. During observations, the left-hand fingers remained bent, and no device was in place between the fingernails and the palm. The resident developed skin cuts on the left ring finger near the nail bed, and staff noted the nails had been trimmed to prevent them from digging into the palm. The hospice RN stated the contracture had developed over weeks to months and that the main concern was preventing skin issues from the closed position. The resident’s physician stated the loss of ROM could have been slowed with daily ROM exercises and that a one-time OT evaluation could have provided conservative measures such as braces or towel rolls. A separate resident also did not receive the ordered restorative nursing aide program for sit-to-stand transfers as scheduled, and the restorative nurse later stated the program had been forgotten.
Failure to Report Changes in Condition and Resident Decline
Penalty
Summary
The facility failed to notify the physician and/or resident representative of changes in condition for three sampled residents. One resident with type 2 diabetes had physician orders for blood glucose checks twice daily with instructions to call the medical doctor if blood sugar was less than 60 mg/dL or greater than 200 mg/dL, but multiple elevated results in July and August 2025 were not reported to the physician. Interviews with nursing staff and the DON confirmed that the high blood sugar results should have been communicated and that no progress notes showed physician notification for those elevated readings. A second resident with diabetes and a history of stroke had fasting blood sugar checks ordered three times weekly and a care plan addressing hyperglycemia. The record showed repeated elevated fasting blood sugars across July and August 2025, including values in the 200s, 300s, 400s, and one reading of 484 mg/dL. Although staff sent faxes and made calls regarding the resident’s high blood sugars and medication requests, the DON stated the physician should have been notified when the resident’s blood sugars remained in the 200s during July. Staff interviews also showed that some elevated readings were not reported to the RN supervisor or physician, and documentation of notification was incomplete or absent. A third resident on hospice had documented decline in range of motion, including severe limitation of the left-hand fingers on the quarterly JME, later contractures, and a subsequent order for restorative nursing passive range of motion. The record showed the resident’s left hand was later observed in a closed fist position with the fingers not fully straightening. The facility did not notify the primary physician of the decline in left-hand ROM after the significant loss of motion was identified on the JME. The report also states the resident’s family was not notified of a cut on the left ring finger until later documentation showed the physician and family were notified of the injury and treatment.
Incomplete care planning for ROM decline, therapy documentation, UTI, and vaccine refusal
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple residents with identified needs. For one resident admitted with atherosclerotic heart disease, major depressive disorder, age-related cognitive decline, and anxiety disorder, the record showed functional ROM limitations on admission and later worsening ROM loss in the left hand to severe limitation with the hand in a closed fist position. Although the resident’s assessments documented ROM decline over time and later contractures, the care plan did not include interventions to prevent further ROM limitation, did not address the severe left-hand decline when it was identified, and did not include the RNA program until later physician orders. The interdisciplinary care plan reviews also did not document notification to the family member regarding the resident’s ROM limitations. For another resident admitted with cervical spinal stenosis, type 2 DM, muscle weakness, monoplegia affecting the right dominant side, and difficulty walking, PT and OT evaluations and plans of care were completed and therapy encounter notes showed multiple treatment sessions. The resident’s care plans included PT and OT services, and the IDT care plan review noted that therapists would implement a Sign-in Sheet during therapy sessions because the resident stated therapy was not being provided as expected. However, the care plans did not include the Sign-in Sheet intervention, and the Sign-in Sheets were not completed for each PT and OT treatment session documented in the encounter notes. The DON stated the Sign-in Sheet was an intervention that should have been included in the comprehensive care plan. The facility also failed to develop care plans for a resident who developed a UTI after a change in condition with blood in the urine and a physician order for Levaquin, and for two residents who refused influenza, pneumococcal, and COVID vaccines. One resident was admitted with muscle weakness and ESRD, and the DON stated a care plan should have been developed for the new UTI diagnosis. The infection preventionist stated there were no care plans for the vaccine refusals for the older resident with severe cognitive impairment or for the cognitively intact resident on dialysis who refused influenza and pneumococcal vaccines. The facility policy stated the IDT shall develop a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs.
Failure to Include Pain Interventions in Care Plan for Heel Blister
Penalty
Summary
The facility failed to update the care plan for a resident to include pain interventions after the resident developed a Stage 2 fluid-filled blister on the left heel. The resident was admitted on 1/15/2025 and re-admitted on 6/26/2025 with diagnoses including type 2 DM, hemiplegia and hemiparesis following cerebral infarction affecting the right side, and dysphagia. The H&P dated 6/27/2025 indicated the resident had capacity to understand and make decisions, and the MDS dated 6/30/2025 showed the resident was usually understood by others, usually understood others, was dependent on staff for toileting, bathing, and lower body dressing, and required maximal assistance with mobility. The MDS also indicated the resident did not have pain in the five days before the assessment and did not have a PU at that time but was at risk for developing one. On 8/22/2025, the COC evaluation documented a fluid-filled blister on the left heel measuring 3.2 cm by 3.4 cm with depth unable to be determined, and the pain assessment was marked not clinically applicable. The physician order for treatment of the blister did not include an order to address possible pain, and the care plan initiated the same day did not include any pain interventions. During wound care on 8/28/2025, the resident was observed crying while the heel was repositioned, and when asked about pain, the resident stated, "Yes, it hurts a lot." The TN stated the care plan did not have interventions to address pain and should have been updated when the blister was identified. The DON stated the licensed nurses should have obtained a physician's order for pain medication and updated the care plan, especially given the resident's history of a pressure ulcer, mobility limitations, and pain related to osteoarthritis.
Missed Required Physician Visit Intervals
Penalty
Summary
The facility failed to ensure Resident 63 was seen face-to-face by the physician at the required intervals. Record review showed Resident 63 was admitted with diagnoses including DM and stroke, and the MDS dated 8/21/2025 indicated the resident was cognitively intact and dependent on staff for personal hygiene. The clinical summary showed an in-person visit with MD 1 on 11/15/2024, followed by telephone visits on 1/30/2025, 2/26/2025, and 3/05/2025, with an in-person encounter on 3/01/2025 and another telephone visit on 3/25/2025. Surveyor review and interviews with the DMR, ADM, and DON confirmed these visits, and the DON stated the resident should have been seen every 30 days for 90 days and then every 60 days after that, but the facility did not ensure the required physician visit intervals were met between 11/15/2024 and 3/01/2025. The facility also failed to ensure Resident 63 was seen within the first 30 days after readmission from the hospital on 4/24/2025 and then at 30-day intervals up to 90 days after readmission. The record showed the resident returned from the hospital on 4/24/2025, but the next documented in-person office visit was not until 6/25/2025 with MD 2, followed by in-person visits on 7/03/2025 and 8/26/2025. During interview, the ADM and DON reviewed the Physician Visits policy and stated it should be more specific about the 60-day requirement after the first 90 days, and the DON stated licensed nurses should have ensured the resident was seen as required. The report stated this had the potential for the physician to miss addressing the beginning of Resident 63's elevated blood sugars.
Failure to Follow Clear Diabetes Monitoring and Physician Notification Guidance
Penalty
Summary
The facility failed to establish and implement policies with clear guidance for managing elevated blood sugar levels for one resident with diabetes mellitus and a history of stroke. The resident was cognitively intact and dependent on staff for personal hygiene. Physician orders included fasting blood sugar checks on a schedule and pioglitazone for diabetes, and later an order was added for blood sugar checks before breakfast and before dinner with instructions to call the physician if blood sugar was less than 80 mg/dL or greater than 250 mg/dL twice a day. During review of the resident’s MAR, the DON verified multiple elevated blood sugar readings in August, including 454 mg/dL, 459 mg/dL, 425 mg/dL, 484 mg/dL, and 310 mg/dL. The DON stated the physician should have been notified when the first blood glucose was 454 mg/dL. The DON also reviewed the facility’s Change in Condition policy and stated licensed nurses should follow the parameters of the usual sliding scale insulin order, such as notifying the physician if blood sugar was less than 70 mg/dL or greater than 400 mg/dL. The DON later stated the diabetes policy did not specify that blood sugar orders required a parameter for physician notification, and the resident’s blood sugar order did not have such a parameter even though one should have been present. The MDir stated there should be a parameter and that if none exists, the licensed nurse should call the physician to obtain one. The facility’s Diabetic Protocol policy stated to call the physician if blood sugar was below 70 or above 400, and also for two or more blood glucose values above 250 with a new or markedly different clinical situation, but the DON and ADM were unable to explain the language clearly. The ADM and DON also stated the Physician Visits policy should be more specific about physician visits after the first 90 days, and the DON stated licensed nurses should have ensured the resident was seen by the physician as required.
Failure to Follow Care Plan and Blood Sugar Orders
Penalty
Summary
The facility failed to carry out a care plan intervention for a resident with CHF and major depressive disorder that required the head of the bed to be elevated. The resident was observed sleeping in bed with the head of the bed flat during two separate observations. During one observation, a CNA stated the resident usually slept in that position and was unsure about the resident’s heart issues, while an LVN later confirmed the resident was sleeping flat on her back. The resident’s care plan included elevating the head of the bed, and the DON stated the resident had a history of CHF and needed the head of the bed elevated to make breathing easier. The facility also did not follow a physician order for a resident with type 2 DM that required the physician to be notified if accuchecks were greater than 200 mg/dL. The resident’s MAR showed multiple blood sugar results above that threshold in July and August, but there was no documentation in the nursing progress notes that the physician had been notified. An LVN stated the high accuchecks should have been reported to the physician and documented, and the DON confirmed there was no documentation that the high sugar levels had been reported as ordered. The DON stated the order was not followed by the nurses. The facility further failed to control another resident’s blood sugar, which remained elevated for approximately seven weeks. The resident had DM and stroke, was severely cognitively impaired, and was dependent on staff for personal hygiene. The MAR showed repeated blood sugar readings in the 200s, 300s, and 400s, including values as high as 484 mg/dL. Nursing notes showed the resident had a UTI and was receiving cefdinir, and staff sent faxes to the physician stating the resident’s blood sugars were still high and requesting Januvia be restarted. Staff interviews showed nurses recognized the elevated readings, but documentation did not show timely physician notification or clarification of the blood sugar parameters, and the DON stated the physician should have been notified when the blood sugars remained elevated.
Lack of Documentation Supporting Buspirone Initiation
Penalty
Summary
The facility failed to ensure there was evidence to support the initiation of buspirone for one resident with diagnoses including psychosis and PTSD. The resident’s MDS dated 7/25/2025 indicated cognitive skills for daily living were intact. Physician orders showed an active order for buspirone 5 mg twice daily for anxiety manifested by constant worrying causing panic, with the DON stating the physician ordered the medication on 7/31/2025 with a start date of 8/21/2025. During record review and interviews, the DON stated the physician last saw the resident on 6/30/2025. A physician progress note dated 7/23/2025 did not document an assessment for anxiety or the clinical rationale for buspirone. Psychiatric progress notes dated 7/15/2025 documented no psychiatric medications at that time. The resident’s Behavior/Psychoactive IDT Review dated 7/11/2025 did not document discussion of anxiety or specific non-pharmacological interventions for the resident’s worries, and the DON confirmed there was no documented evidence that individualized non-pharmacological interventions were developed before buspirone was started.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that Resident 11, who required assistance with nail trimming, received care and services to maintain good personal hygiene. Resident 11 was admitted and later readmitted with diagnoses including hypertension and type 2 diabetes mellitus. The MDS dated 7/1/2025 indicated impaired cognitive skills for daily decision making and that the resident required partial to moderate assistance from staff for showering, dressing, footwear, and personal hygiene. The care plan revised on 7/1/2025 identified an ADL self-care performance deficit related to medical comorbidities, including muscle weakness, and stated that the resident required moderate assistance with personal hygiene care. During a concurrent observation and interview with the DON, Resident 11's fingernails on both hands were observed to be long and to have black substances under the nails. The DON stated that the resident's nails needed cleaning and trimming and that a dirty appearance can affect a person's self-esteem. Review of the CNA ADL personal hygiene documentation showed that Resident 11 had not refused care at any time from 8/1/2025 to 8/26/2025. The facility policy titled Resident Rights-Dignity and Respect stated that residents will be appropriately dressed in clean clothes and be well groomed.
Bedside Rail Use and Padding Not Maintained as Required
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents by not managing bedside rails as ordered and by not maintaining required rail padding. One resident with unspecified dementia and gastroesophageal reflux disease was observed in bed eating with quarter bedside rails up on both sides of the bed, and the rails had gaps between the bars. The DON stated there was no care plan for bedside rail use and that the resident had no identified need or benefit for the rails, while also stating that bedside rails pose a risk of limb entrapment and injury. For the second resident, who had diagnoses including HTN and seizures and was documented as having severely impaired cognition and dependence on staff for most ADLs, the physician ordered two half upper rails up and padded for seizure precautions. The care plan also addressed side rails used as a seizure precaution and included the intervention for padded upper rails. During multiple observations, the resident was in bed with both upper side rails up, but the padding had slipped down and exposed the hard side rails to the resident. During a concurrent observation and interview, the ADON stated the padding slips down easily and should be readjusted after care, and noted the resident had fragile thin skin and could be bruised from hitting the hard side rails if the padding was not there. The DON stated that if the padding for seizure precautions is not fully covering the bed rail, then it cannot protect the resident during a seizure. The facility policy stated that the resident environment should remain free of accident hazards and that side rails should be padded for seizure management.
Failure to Assess PTSD Triggers and Individualize Care Plan
Penalty
Summary
The facility failed to provide trauma-informed care for one resident with diagnoses including PTSD, anxiety disorder, dementia, psychosis, and COPD. The resident was admitted and later readmitted to the facility, and a history and physical indicated he did not have the capacity to make decisions. A later MDS indicated he was able to make himself understood, understand others, and was cognitively intact, with partial assistance or supervision needed for most ADLs. An order was also entered to transfer him to the hospital emergency room via paramedics due to chest discomfort and uncontrolled anxiety behaviors, and he was observed shouting that he could not breathe and wailing before staff gave a breathing treatment and called 911. During interviews and record review, the resident stated he had PTSD but had not discussed with staff what his reactions were or what caused his episodes. He stated that having many people come into or pass through his room made him feel angry and worked up, and that seeing the paramedics during his transfer also caused those feelings. His bed was observed to be the first bed next to the door, requiring people to walk past him to reach his roommates. The Special Care Unit Director stated the resident’s social services assessments identified PTSD, veteran status, and the recent loss of his mother, but did not identify triggering events that might cause retraumatization. The resident’s care plan titled At Risk for Re-traumatization related to history of trauma and PTSD, created later in the stay, did not identify any PTSD triggers. The Special Care Unit Director stated the resident did not want to discuss the trauma or triggers, but also stated that if a resident does not want to talk about trauma on first assessment, another assessment should be attempted later or in a different way, and that there was no progress note showing another attempt to identify triggers. She also stated the resident had recently said hearing people speak in different languages upset him and made him paranoid, and that this should have been care-planned. The DON stated that without knowing the resident’s triggers or having interventions specific to him in the plan of care for PTSD, the facility could not provide the needed care. The facility policy stated trauma survivors should receive culturally competent, trauma-informed care and that residents with PTSD should have an individualized person-centered plan of care addressing their needs.
Bed Rails Used Without Required Assessment, Consent, or Physician Order
Penalty
Summary
Facility staff failed to assess Resident 9 for the risk of entrapment, obtain informed consent, and obtain a physician order for the use of bedside rails. Resident 9 was admitted and later readmitted with diagnoses including unspecified dementia and gastroesophageal reflux disease. The MDS dated 7/23/2025 indicated the resident’s cognitive skills for daily living were severely impaired, and the resident was totally dependent on staff for eating, oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 8/26/2025 at 8:05 a.m., Resident 9 was seen in bed eating with quarter bedside rails up on both sides of the bed, and the rails had gaps between the bars. During interview and record review on 8/27/2025, the DON stated there was no physician order and no bedside rails assessment for Resident 9, and that the facility normally obtains a physician order, consent from the resident or responsible party, and conducts a bedside rails risk of entrapment assessment before installation or use. A CNA stated she was assigned to Resident 9, took her to the activity room, and then returned her to bed and put the bedside rails up. The facility policy stated alternatives to bed rails should be attempted first, the IDT should assess entrapment risk, and informed consent must be obtained prior to installation or use.
Late Administration of Zenpep With Meals
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when Resident 52 did not receive Zenpep at the prescribed time with meals. Resident 52 was re-admitted with diagnoses including adrenocortical insufficiency and liver cirrhosis. The physician's order dated 10/25/2023 directed 2 capsules of Zenpep with meals for liver cirrhosis/pancreatic insufficiency, with scheduled administration at 7:30 AM, 12 noon, and 5 PM. During interview, LVN 1 stated Resident 52 had breakfast at around 7:30 AM but Zenpep was administered at about 9:50 AM, more than 2 hours after the scheduled time. The DON confirmed breakfast is served between 7:30 AM and 8 AM, reviewed the order, and stated Zenpep was to be given with meals during breakfast, lunch, and dinner. The facility policy stated medications are administered as prescribed and within 60 minutes of the scheduled time.
Inaccurate Documentation of RNA Sit-to-Stand Services
Penalty
Summary
The facility failed to accurately document the provision of Restorative Nursing Aide (RNA) services for one resident in the medical record. Resident 69 was admitted with diagnoses including type 2 diabetes mellitus, unspecified fall, gait and mobility abnormalities, and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s PT evaluation showed both legs had range of motion within functional limits, but the resident required substantial/maximal assistance for rolling, moving from lying to sitting, chair/bed-to-chair transfers, and sit-to-stand transfers. The resident’s MDS indicated clear speech, difficulty expressing ideas and wants, understood verbal content, severely impaired cognition, no functional ROM limitations in the arms or legs, and substantial/maximal assistance needed for transfers from lying to sitting, chair/bed-to-chair transfers, and sit-to-stand transfers. The PT discharge summary also documented substantial/maximal assistance for sit-to-stand and chair/bed-to-chair transfers and recommended the RNA program for passive ROM to both legs and sit-to-stand mobility using side rails five times per week as tolerated. A physician order dated 8/22/2025 directed the RNA program for sit-to-stand mobility using side rails five times per week as tolerated. The Documentation Survey Report for 8/2025 showed the resident received RNA for sit-to-stand transfers on 8/25/2025 and 8/26/2025. However, during observation and interview, RNA 1 stated the resident required two-person assistance for sit-to-stand transfers and could not remember the last time the resident received the RNA program. RNA 1 later stated the resident did not receive the RNA sit-to-stand program on 8/26/2025 and that RNA 1 forgot to provide it. The DON reviewed the record and stated the Documentation Survey Report was not accurate for 8/26/2025 because RNA 1 documented providing the service when it was not actually provided. The facility policy required the clinical record to be accurate, complete, dated, and signed by the appropriate individuals.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that three resident rooms with three beds each met the required square footage of at least 80 square feet per resident in multiple resident bedrooms. During an observation and interview on 8/28/2025 at 5:30 p.m. with the Administrator and Maintenance Resource, the Maintenance Resource measured rooms 10, 12, and 24 and found that each room fell below the required space per resident: room 10 measured 237.89 square feet total, or 79.3 square feet per resident; room 12 measured 234.08 square feet total, or 78.0 square feet per resident; and room 24 measured 236.00 square feet total, or 78.66 square feet per resident. The Administrator stated awareness of the regulation requiring at least 80 square feet per resident in multiple resident bedrooms, and a review of the facility policy titled Physical Environment confirmed that resident rooms must provide at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in a single resident room.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,091 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 25 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Panorama Gardens Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.