Panorama City Conv & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Panorama City Conv & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 27, 2026

  Based on observation, interview, and record review, the facility failed to monitor medical devices to prevent pressure related injuries for 2 of 4 residents (Residents 3 and 7) when reviewed for pressure injuries. Resident 3 experienced harm when they developed avoidable pressure ulcers to both heels and their left calf, related to lack of monitoring of a medical device (E-Z boot - plastic splint designed to stabilize the foot and ankle, preventing rotation and contracture with a soft, fleece-lined interior, non-skid base, and hook-and-loop velcro closure - also called a podus Boot). This failure placed residents at further risk for avoidable pressure injuries. Findings included. […]

• Actual harm, isolatedF689May 12, 2025

  Based on observation, interviews and record review, the facility failed to provide the two staff person assistance and use of a gait belt for transfers as required according to the plan of care for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell and sustained a head laceration when staff transferred them without a second staff person to assist and properly support resident with a gait belt. This failure placed residents at risk for falls with injury, pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and kidney disease. […]

• Actual harm, isolatedF689Jun 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow the resident's individualized care plan fpr safe transfers and the resident sustained a fracture requiring hospitalization . This failure placed residents at risk for injury and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's policy Mechanical Lift Usage, revised 05/08/2017, showed residents that require maximum to total assistance with transfers were not to be lifted without the aid of a mechanical lift. […]

• Actual harm, isolatedF689Jan 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards including fall with injury for 1 of 3 sampled residents (1) reviewed for accident hazards. This failure placed residents at risk for injury, pain and a diminished quality of life. This failure caused harm to Resident 1 when the resident was transferred without a gait belt, had a fall with injury and sustained a left hip fracture. Findings included . Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 12/12/2022, documented the resident was cognitively intact, required extensive assistance from two staff members for bed mobility and transfers, and extensive assistance from one staff for ambulation (walking). […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2026

  Based on interview and record review, the facility failed to ensure the dishwasher was cleaning dishes at required temperatures for 1 of 1 kitchen dishwashers reviewed under kitchen task. This failure created the potential to expose residents to unsanitary conditions and increased risk of foodborne illness. Findings included .On 01/26/2026 at 9:55 AM, during a kitchen observation, review of the Food Services Department Daily Dish Machine Temerature Log documented, Wash Cycle must reach a temperature of 150-160 degrees Fahrenheit. Rinse Cycle must reach a temperature of no less than 180 degrees. Please report temperature outside of the required range to your Supervisor immediately. […]