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Complaint Investigation

Panorama Gardens Nursing And Rehabilitation Center

May 29, 2026 · Panorama City, CA · 9541 Van Nuys Blvd.
Citations 3
CMS Rating 3/5
Beds 151
Provider ID 056337
Healthcare Facility
Panorama Gardens Nursing And Rehabilitation Center
Panorama City, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

PANORAMA GARDENS NURSING AND REHABILITATION CENTER in PANORAMA CITY, CA — inspection on May 29, 2026.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0550
Resident Rights Deficiencies

During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 4 on 6/30/2021 with diagnoses including epileptic seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) related to external causes, need for assistance with personal care, and blindness (the complete or nearly complete loss of sight that cannot be corrected with glasses, contact lenses, medicine, or surgery).

During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired.

The MDS indicated Resident 4 required supervision or touching assistance from staff with eating, required substantial/maximal assistance from staff with oral hygiene and personal hygiene, and was dependent on staff for toileting.

During an observation on 5/29/2026 at 10:52 a.m., in Resident 4's room, observed HK enter Resident 4's room without knocking or introducing herself prior to entering Resident 4's room.

During an interview with HK on 5/29/2026 at 10:53 a.m., HK stated that she did not knock prior to entering Resident 4's room. HK stated that she should have knocked and should have informed the resident of her presence before entering. HK stated that she did not knock prior to entering Resident 4's room because the Resident (Resident 4) was sleeping and further stated that she was confused, which contributed to her failure to knock prior to entering the room.

During an interview on 5/29/2026 at 12:44 p.m., with the DSD, the DSD stated that all staff should knock on residents' door, introduce themselves, and wait for permission before entering a resident's room.

The DSD stated that knocking before entering a residents' room without first obtaining permission.

The DSD further stated that knocking before entering is important to maintain resident's dignity and demonstrate respect to residents.

During a review of the facility's policy and procedure (P&P) titled Resident Rights, reviewed on 3/9/2026, the P&P indicated it is a policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies.

The P&P further indicated to be treated with consideration, respect, and full recognition of his or her dignity and individuality.

056337 05/29/2026

Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd.

Panorama City, CA 91402

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired.

The MDS further indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility (movement).

The MDS indicated resident is at risk for developing pressure ulcers/injuries.

The MDS indicated the use of a pressure-reducing device for the bed as part of the resident's skin and ulcer (a small open sore or wound generally found in the stomach or on the skin)/injury treatment.

During a review of Resident 1's Order Summary Report dated 2/26/2026, the Order Summary Report indicated the resident (Resident 1) was to use a Low Air Loss Mattress.

During an observation on 5/28/2026 at 9:45 a.m., in Resident 1's room, observed Resident 1 lying in bed, on a LALM.

Observed Resident 1 wearing an adult brief and was positioned on multiple layers of linen.

During an observation and concurrent interview with Certified Nursing Assistant 1 (CNA 1) on 5/28/2026 at 10:36 a.m., in Resident 1's room, in the presence of the Infection Preventionist (IP) for translation, observed CNA 1 providing care to Resident 1 in Resident 1's room.

Observed Resident 1 laying on a LALM with multiple layers of linen between the resident and the mattress. CNA 1 stated that Resident 1 was lying on one fitted sheet, one folded draw sheet, and an adult brief.

When asked how many layers were between the resident (Resident 1) and the LALM, CNA 1 stated there were six layers.

During an observation and concurrent interview with the MDS Nurse (MDSN) on 5/29/2026 at 9:34 a.m., in Resident 1's room, observed Resident 1 lying on the LALM with multiple layers of linen.

The MDSN stated that Resident 1 was lying on one fitted sheet, one folded draw sheet, and an adult brief, creating a total of six layers between the resident and the LALM.

The MDSN further stated that residents on a LALM should have only one layer between the resident and the LALM to function properly and help prevent PU/PI.

During an interview with Treatment Nurse 1 (TN 1) on 5/29/2026 at 10:29 a.m., TN 1 stated that residents on LALM should have only one layer between the resident and the LALM.

During an interview on 5/29/2026 at 2:02 p.m., with the Director of Nursing (DON), the DON stated that the purpose of a LALM is to help prevent and/or promote healing of PU/PI by providing pressure redistribution through alternating air pressure on the LALM.

The DON further stated that a LALM is also used for residents who are unable to turn and reposition themselves.

The DON stated that residents on a LALM should have only two layers between the resident and the LALM surface, an adult brief and a sheet.

The DON stated that excessive layers between the resident and the mattress could interfere with the effectiveness of the LALM, increase the risk of PU/PI development, delay wound healing, and defeat the purpose of the LALM.

During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort.

056337 05/29/2026

Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd.

Panorama City, CA 91402

During a concurrent interview and record review on 5/29/2026, at 12:26 p.m. with the DSD, the DSD reviewed the facility's policy titled, Nursing Staffing Competency.

The DSD stated that she (DSD) was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation.

During a review of the facility's policy and procedure (P&P) titled Nursing Staff Competency, reviewed on 3/9/2026, the P&P indicated It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facilities resident population in accordance with the facility assessment.

The policy further indicated 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.

The P&P further indicated that successfully completed orientation and skills check are required prior to the employee's annual evaluation.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PANORAMA CITY, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PANORAMA GARDENS NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.