Panorama Gardens Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Panorama Gardens Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 12, 2024

  Based on interview and record review, the facility failed to ensure that one of six sampled residents (Resident 1) was kept free from significant medication error (the administration of medication, or omission of a medication that endangers the health and safety of a resident), when on 5/30/2024, Student Nurse 1 (STU 1) administered medications to Resident 1 that were intended for a different resident (Resident 2). This deficient practice resulted in Resident 1 receiving three (3) medications that were intended for Resident 2 and placed Resident 1 at increased risk of severe health complications including hallucinations (false perception; the experience of seeing, hearing, feeling, or smelling something that does not exist), mood changes (such as agitation [feeling of irritability or… […]

• Actual harm, isolatedF686Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 69 and Resident 13), who were investigated under the pressure ulcer (PU - damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows) care area, received care consistent with professional standards of practice by failing to: 1. Prevent the worsening of a Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on Resident 69's left heel,… […]

• Actual harm, isolatedF688Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to provide services to maintain range of motion (ROM- full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 13 and Resident 69) reviewed under the Position/Mobility care area by failing to: 1. Provide Resident 13 with ROM exercises to both arms and legs following the identification of ROM limitations on the initial Joint Mobility Evaluation (JME- brief assessment of a resident's ROM in each joint of both arms and legs), dated 3/18/2025. 2. […]

• Actual harm, isolatedF600May 6, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 2) when on 4/23/2025 Resident 1 used his (Resident 1) right hand to graze (a skin injury to the outer layers of the skin) Resident 2's left cheek. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. […]

• No harm, potential for more than minimal, patternF684Jun 12, 2026

  Based on observation, interview, and record review, the facility failed to provide the needed resident-centered (an approach that puts the individual's needs, preferences and well-being at the heart of their care plan) care and services for three of four sampled residents (Resident 1, 3, and 4) by failing to: 1. Implement the facility's significant change in condition policy by not having documented evidence that a change in resident's condition was completed when a skin discoloration was identified on 5/23/2026 for Resident 1. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. 2. […]