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Balboa Nursing & Rehabilitation Center

3520 Fourth Avenue, San Diego, CA 92103 · San Diego County · (619) 291-5270

194 certified beds, about 182 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1969

Certified for Medicaid Certified for Medicare
Overall
4 of 5
Health inspections
3 of 5
Staffing
2 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 056105 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 15, 2025, inspectors cited 6 health deficiencies (the California average is 15.6, the national average 9.2).

Of 44 health citations since January 2019, 1 was rated as actual harm or immediate jeopardy to residents.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.79 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.60 of those hours.

37.2% of nursing staff left within the year CMS measured (California average 36.7%).

CMS links it to PACS Group, an affiliated group of 275 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 44 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
36D
6E
1F
Potential for minimal harm
0A
0B
0C
April 23, 2026Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2026
    Inspectors wroteBased on interview and record reviews, the facility staff failed to report an allegation of abuse for one of three sampled resident (Resident 1). This failure had the potential for further abuse to Resident 1.
March 5, 2026Complaint inspection · 2 citations
  1. E
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 3, 2026
    Inspectors wroteBased on interview, and record review the facility failed to ensure the use of unnecessary drugs by administering antibiotics without adequate indication, monitoring or appropriate duration, for two of three sampled residents (Resident 1, Resident 2, and Resident 3) reviewed from 12 residents identified on the Infection Preventionist (IP) list of health-care associated infection (HAI-infections acquired at the facility) for urinary tract infections (UTI- an infection in the bladder/urinary tract) when:1. Resident 1 received an order for an antibiotic on 1/9/26 for Macrobid (a commonly prescribed antibiotic used specifically to treat bacterial urinary tract infections) without supporting documentation for monitoring UTI symptoms and/or side effect monitoring. [...]
  2. E
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 3, 2026
    Inspectors wroteBased on interview, and record review the facility failed to implement an effective infection control prevention and antibiotic (medication for infection) stewardship (responsible use) process for three of three sampled residents (Resident 1, Resident 2, and Resident 3) reviewed from 12 residents identified on the Infection Preventionist (IP) list of health-care associated infection (HAI-infections acquired at the facility) for urinary tract infections (UTI- an infection in the bladder/urinary tract) when:1. Resident 1 received an order for an antibiotic on 1/9/26 for Macrobid (a commonly prescribed antibiotic used specifically to treat bacterial urinary tract infections) without supporting documentation for monitoring UTI symptoms and/or side effect monitoring. [...]
January 27, 2026Complaint inspection · 2 citations
  1. F
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to protect and keep private residents' Protected Health Information (PHI- refers to any individual identifiable health information that is created, received, stored or transmitted by a healthcare provider which includes demographic data, medical history, test results, and payment information and this information is protected under HIPPA-the Health Insurance Portability and Accountability Act of 1996) for 59 of 194 residents when it posted lists of residents' Enhanced Barrier Precautions (EBP) in the 2nd, 3rd, and 4th floor shower rooms. This failure did not protect the residents' medical privacy and had the potential to allow residents' PHI to be seen by anyone going into the shower room.
  2. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2026
    Inspectors wroteBased on observations, interviews and record review the facility failed to maintain a homelike environment for four of nine residents (3,4,5,16) when it did not fix leaking ceilings and windows in resident rooms 417,421, and 425. This failure created hazardous non-homelike environment for the affected residents when it rained.
December 12, 2025Complaint inspection · 1 citation
  1. D
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 9, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to identify a resident's behavior of hitting and yelling at staff and residents for one of two residents reviewed for behavioral disturbances. (Resident 1) This failure had the potential for Resident 1 to have further altercations with other residents of the facility and a potential safety risk for Resident 1.
September 9, 2025Complaint inspection · 1 citation
  1. D
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 3, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to administer pain medication for one of two residents (Resident 1) in a timely manner. This failure placed Resident 1 at risk of unnecessary pain.
August 19, 2025Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident safety when a resident (Resident 1) eloped form the facility without staff being aware. As a result, Resident 1 had successful elopement and was found on 8/19/25.
July 23, 2025Complaint inspection · 3 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were obtained, signed, and transcribed to maintain continuity of care one of three residents (Resident 1) reviewed with a wound vacuum assisted closure (vac- medical device used to help wounds heal by creating a vacuum over the wound, drawing out excess fluid and infectious materials, and promoting the formation new tissue) device. As a result, Resident 1 was sent to the hospital without a wound vac as ordered post-operatively (OP) and placed Resident 1 at risk for delayed wound healing infection and worsening of their condition due to improper or interrupted treatment. [...]
  2. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 5, 2025
    Inspectors wroteBased on interview, and record review, the facility failed to supervise residents who smoke according to resident's smoking assessment for one of three sampled residents (Resident 2). As a result, Resident 2 was not supervised as required, which could have led to potential safety risks for smoke related injuries and for other residents who smoke. A review of Resident 2's admission Record indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg and trunk on the same side of the body) affecting the left side of the body. [...]
  3. D
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services. This deficient practice placed all 188 residents at risk for uncoordinated care, delays in addressing clinical concerns, and inconsistent implementation of nursing policies and procedures. On 7/23/25 10:30 A.M., a complaint investigation was initiated with the Administrator (ADM). The ADM stated the facility did not have a Director of Nursing (DON) and would be assisted by the Quality Assurance (QA) nurse for any assistance during the complaint investigation. On 7/23/25 at 1:22 P.M., an interview was conducted with LN 2. LN 2 stated we don't have a full-time DON yet. LN 2 stated the QA nurse was the former DON. On 7/24/25 at 4:02 P.M., an interview was conducted with the Director of Staff Development (DSD). [...]
June 6, 2025Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one resident, Resident 1, who eloped (a patient leaving a healthcare facility without proper authorization or staff awareness)from the facility late at night, was unlocatable by the facility for nearly 14 hours, and sustained a fall while away from the facility. This failure had the potential for Resident 1 to suffer serious injury.
May 15, 2025Standard inspection · 6 citations
  1. E
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on observation, interview, facility document and policy review, the facility failed to follow the prepared menu for residents who received diets with mechanical soft or ground meat for 30 of 183 residents who resided in the facility and failed to follow the prepared menu for residents who received diets with pureed meat for 21 of 183 residents who resided in the facility.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a dignified dining experience for 1 (Resident #92) of 6 sampled residents reviewed for nutrition.
  3. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (Resident #77 and Resident #185) of 38 residents whose MDSs were reviewed.
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was followed for 1 (Resident #30) of 7 residents reviewed for nutrition.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed a physician's order for supervision during meals for 1 (Resident #30) of 7 residents reviewed for nutrition.
  6. D
    Provide appropriate foot care.
    F687 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 15, 2025
    Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide timely podiatry services for 1 (Resident #388) of 3 sampled residents reviewed for activities of daily living.
March 20, 2025Complaint inspection · 2 citations
  1. G
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 4, 2025
    Inspectors wroteBased on interviews and record review, the facility failed to protect a resident (Resident 1) with suicidal ideation (SI, when you think about, consider or feel preoccupied with the idea of death and suicide) tendency from harm, when staff did not: 1. Supervise Resident 1 with known SI tendencies to harm herself with overdosing on medications and cut herself with a butter knife, 2. Follow through on a provider ' s recommendations (five opportunities) for SI safe monitoring of Resident 1, 3. Developed of interdisciplinary and core staff communication for the planning, monitoring and evaluating Resident 1 ' s plan of care related to overdosing self, to ensure Resident 1 did not have access to medications for her safety and well-being, and, 4. Fully account for Resident 1 ' s belongings including medications from home. [...]
  2. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 4, 2025
    Inspectors wroteBased on interviews and record review, the facility failed to communicate and develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to a resident ' s (Resident 1) suicidal ideation (SI, when you think about, consider or feel preoccupied with the idea of death and suicide) tendency for one of one sampled resident. As a result, the lack of communication among facility staff related to Resident 1 ' s SI and a resident centered care plan with specific interventions to monitor Resident 1 from harming herself with overdosing of medications and cutting herself with a butter knife on 1/20/25.
August 5, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 30, 2024
    Inspectors wroteBased on observation, interview and document review, the facility failed to prevent Resident 1 from physically assaulting Resident 2. This failure resulted in Resident 2 sustaining a physical injury and feeling fearful.
June 27, 2024Complaint inspection · 3 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 26, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP) was notified timely of resident's skin issues and resident's change of condition (COC) for one of seven residents (Resident 1), reviewed for quality of care. This failure resulted in Resident 1's responsible party unaware of Resident 1's current health status.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 26, 2024
    Inspectors wroteBased on interview and record review, the facility failed to consistently provide skin care and administer intravenous (IV) antibiotics (anti-infective) medication, as ordered by the physician, for one of seven residents (Resident 1) reviewed for quality of care. These failures had the potential to affect Resident 1's health and well-being.
  3. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 26, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure a Licensed Nurse (LN) 1 signed a resident's initial skin evaluation timely for one of one sampled resident (Resident 1) reviewed for skin conditions. As a result, Resident 1's medical record did not reflect timely completion of assessment.
June 4, 2024Complaint inspection · 1 citation
  1. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurate for one of two sampled residents (Resident 1) when Resident 1's medical record indicated a licensed vocational nurse (LVN 1) administered an intravenous (IV) antibiotics (anti-infective) medication. As a result, documenting that an IV medication was administered to Resident 1 by a LVN, was not acceptable per standards of practice and could cause confusion among the healthcare providers.
August 25, 2022Standard inspection · 13 citations
  1. E
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent RNA (CNAs with specialized certification to provide rehabilitation services) to five of 12 residents (Resident 44, 55, 82, 112, 162) reviewed for limited range of motion (ROM). This failure had the potential for residents to experience a decrease in mobility and worsening contractures (permanent tightening of the muscles and tendons causing the joints to stiffen).
  2. D
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    F576 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide communication tools for two of four (Residents 48 and 114), reviewed for communication. This failure had the potential for staff to be unaware of the needs of Residents 48 and 114.
  3. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview, and record review, the facility failed to protect confidential information for one of one resident reviewed for privacy (5). This failure had the potential for residents' private medical information to be visible to unauthorized persons.
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physician's order for: 1. Oral hygiene for one of three residents reviewed for dental concerns (107) and, 2. Application of a medicated shampoo for one of one residents reviewed for skin conditions (107). This failure had the potential to place Resident 107 at risk for further dental complications and worsening skin condition.
  5. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medicated shampoo was applied as stipulated by facility policy, for one of one residents reviewed for skin conditions (107). This failure had the potential to place Resident 107 at risk for further skin complications.
  6. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided for one of two residents (69) reviewed for ADLs. This failure had the potential to result in an increased risk for infection.
  7. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff provided assistance with eating for two of two residents reviewed for ADLs (40, 32). As a result, Residents 40 and 32 were unable to eat their meals.
  8. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. Discontinued medications were left in the medication cart for resident use; 2. Metoprolol (medication to treat high blood pressure) was not administered as ordered by the physician for Resident 29. This had the potential to increase the risk for dizziness, confusion, and fainting; and 3. Midodrine (medication to treat low blood pressure) was not administered as ordered by the physician for Resident 112. This had the potential to increase the risk for heart disease and stroke.
  9. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist, in their monthly medication regimen review, identified and reported irregularities in the medication therapy of the residents when: 1. Resident 96 had two physician orders for ropinirole (medication to treat restless leg syndrome, uncontrollable urge to move the legs due to uncomfortable sensation) that could potentially exceed the maximum dose for ropinirole specified by the manufacturer; 2. Resident 112 had a physician's order for Norco (narcotic pain medication) despite the resident's documented allergy to morphine (narcotic pain medication similar in structure to Norco); and 3. [...]
  10. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications when: 1. Resident 121 was receiving apixaban (blood thinner that prevents blood clotting) and was not monitored for signs and symptoms of bleeding; and 2. Resident 112 was receiving levetiracetam (medication to prevent seizures or convulsions) without monitoring for seizure activity or episodes to assess the effectiveness of the medication.
  11. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from excessive, unnecessary psychotropic medications when: 1. Resident 29 had physician orders for two antidepressant medications for depression (sad mood and lack of interest) in the same therapeutic class without documented rationale for use; and 2. Resident 112 had physician's orders for two antipsychotic medications without documented rationale for use. These failures could result in medication related adverse events from duplicate medication therapy.
  12. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass observation did not exceed 5 percent. There were 29 opportunities. Two medication errors were identified. The error rate was 6.9 percent.
  13. D
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2022
    Inspectors wroteBased on interview and record review, the facility failed to conduct an antibiotic stewardship (an ongoing program to monitor and review antibiotic use) for one of three residents (Resident 41), reviewed for infections. This failure had the potential for Resident 41 to become resistant to antibiotic therapy from the prolonged use.
January 18, 2019Standard inspection · 6 citations
  1. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on interview and record review, the facility failed to ensure clinicians followed accepted Resident Assessment Instrument (resident care planning) guidelines to accurately assess anticoagulant (blood thinner) use on the Minimum Data Set (MDS-screening tool) for 11 of 36 sampled residents (8, 45, 48, 91, 95, 113, 121, 128, 130, 135, and 138). This failure provided inaccurate resident information to the federal database, and had the potential to affect the residents' care.
  2. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on observation, interview and record review. The facility did not provide accommodations for a wheel chair bound resident when 1 of 36 residents, Resident 50, could not reach the shirts hanging in his closet and the paper towels in his bathroom. This deficient practice prevented Resident 50 from achieving independent functioning, dignity, and well-being in accordance with his needs and preferences.
  3. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on observation, interview, and record review the facility failed to correctly administer an antibiotic medications to 1 of 36 sampled residents (364 ). This failure had the potential to negatively affect Resident 364's treatment for an infection.
  4. D
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    F808 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare therapeutic diets (diets prescribed by a physician for treatment of a medical condition) for 1 of 36 sampled residents (176). This failure had the potential for Resident 176 to experience difficulty swallowing when eating and drinking.
  5. D
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a hospice agency's contact information, documentation of services, and prospective visit calendar was present in the clinical record for one of two hospice residents (60). As a result, there was the potential to put Resident 60 at risk for delayed or uncoordinated care between the facility healthcare team and the hospice agency.
  6. D
    Have policies on smoking.
    F926 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 17, 2019
    Inspectors wroteBased on interview and record review, the facility failed to implement their smoking policy when 1 of 36 sampled residents was not informed, assessed, or referred to the DON when smoking. (364) As a result, Resident 364 was not provided a safe smoking environment.

Fire safety inspections

28 fire safety citations on file: 11 on May 15, 2025, 9 on August 25, 2022, 8 on January 18, 2019.

Every fire safety citation28 citations
  1. F
    Conduct risk assessment and an All-Hazards approach.
    E 6 · May 15, 2025 · Corrected (the home has a date of correction)
  2. F
    Conduct testing and exercise requirements.
    E 39 · May 15, 2025 · Corrected (the home has a date of correction)
  3. F
    Implement emergency and standby power systems.
    E 41 · May 15, 2025 · Corrected (the home has a date of correction)
  4. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · May 15, 2025 · Corrected (the home has a date of correction)
  5. F
    Have restrictions on the use of highly flammable decorations.
    K 753 · May 15, 2025 · Corrected (the home has a date of correction)
  6. E
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · May 15, 2025 · Corrected (the home has a date of correction)
  7. E
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · May 15, 2025 · Corrected (the home has a date of correction)
  8. E
    Install corridor and hallway doors that block smoke.
    K 363 · May 15, 2025 · Corrected (the home has a date of correction)
  9. E
    Ensure proper usage of power strips and extension cords.
    K 920 · May 15, 2025 · Corrected (the home has a date of correction)
  10. D
    Provide properly protected cooking facilities.
    K 324 · May 15, 2025 · Corrected (the home has a date of correction)
  11. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 15, 2025 · Corrected (the home has a date of correction)
  12. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 25, 2022 · Corrected (the home has a date of correction)
  13. E
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · August 25, 2022 · Corrected (the home has a date of correction)
  14. E
    Ensure proper usage of power strips and extension cords.
    K 920 · August 25, 2022 · Corrected (the home has a date of correction)
  15. E
    Have proper medical gas storage and administration areas.
    K 923 · August 25, 2022 · Corrected (the home has a date of correction)
  16. D
    Conduct risk assessment and an All-Hazards approach.
    E 6 · August 25, 2022 · Corrected (the home has a date of correction)
  17. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · August 25, 2022 · Corrected (the home has a date of correction)
  18. D
    Properly provide smoke detection systems in areas open to corridors.
    K 347 · August 25, 2022 · Corrected (the home has a date of correction)
  19. D
    Install properly constructed and protected linen or trash chutes.
    K 541 · August 25, 2022 · Corrected (the home has a date of correction)
  20. D
    Meet requirements for the use of electrical equipment.
    K 919 · August 25, 2022 · Corrected (the home has a date of correction)
  21. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · January 18, 2019 · Corrected (the home has a date of correction)
  22. D
    Provide primary/alternate means for communication.
    E 32 · January 18, 2019 · Corrected (the home has a date of correction)
  23. D
    Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
    K 227 · January 18, 2019 · Corrected (the home has a date of correction)
  24. D
    Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
    K 343 · January 18, 2019 · Corrected (the home has a date of correction)
  25. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · January 18, 2019 · Corrected (the home has a date of correction)
  26. D
    Ensure gas cylinders are properly stored.
    K 906 · January 18, 2019 · Corrected (the home has a date of correction)
  27. D
    Meet requirements for the use of electrical equipment.
    K 919 · January 18, 2019 · Corrected (the home has a date of correction)
  28. D
    Ensure proper usage of power strips and extension cords.
    K 920 · January 18, 2019 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeCaliforniaUnited States
All nursing staff (RN, LPN and aides)3.794.523.86
Registered nurses0.600.670.69
All nursing staff on weekends3.464.093.42
Nurse aides2.18
Licensed practical nurses1.01
Nursing staff turnover (share who left in a year)37.2%36.7%45.8%
Registered nurse turnover43.5%38.1%42.9%
Administrators who left1

CMS expects 4.48 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.93 on weekdays and 3.46 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.27 in April to June 2025 to 3.79 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.790.603.933.46 0.0%0 of 90182
Oct to Dec 20254.170.514.353.72 0.0%0 of 92182
Jul to Sep 20254.400.564.633.82 0.0%0 of 92183
Apr to Jun 20254.270.554.463.79 0.0%0 of 91187
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
California, Jan to Mar 20264.360.594.523.972.3%0.5% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for California

JobMedianMiddle halfEmployed
California, all employers
CNAs (nursing assistants)$22.90$22.04 to $26.35110,060
LPNs and LVNs$38.34$35.98 to $45.0682,850
Registered nurses$67.44$58.87 to $83.25338,940
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Balboa Nursing & Rehabilitation Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeCaliforniaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
4.810.313.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.30.80.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.41.21.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.01.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.51.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
5.89.814.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.94.34.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
5.412.015.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
18.322.923.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
10.211.212.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.42.31.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.11.61.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Balboa Nursing & Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (56.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

56.5% this home

Better than the national rate

US median of homes 51.5% · California: 301 better, 190 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 368 eligible stays.

Potentially preventable readmissions

10.7% this home

No different from the national rate

US median of homes 10.7% · California: 10 better, 22 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 422 eligible stays.

Infections that led to a hospital stay

7.3% this home

No different from the national rate

US median of homes 7.1% · California: 8 better, 48 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 269 eligible stays.

Self-care and mobility at discharge

74.0% this home

Median of homes: California59.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 223 residents counted.

Falls with major injury

0.6% this home

Median of homes: California0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 467 residents counted.

New or worsened pressure ulcers

1.0% this home

Median of homes: California0.6% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 467 residents counted.

Medication list given at discharge

89.6% this home

Median of homes: California96.2% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 96 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: BALBOA HEALTHCARE, INC.. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Rajper, SaleemContracted managing employeeIndividual04/01/2019
Christensen, SpencerW-2 managing employeeIndividual09/01/2021
Apt, FrederickCorporate officerIndividual01/01/2024
Hancock, MarkCorporate officerIndividual01/01/2024
Jergensen, JoshuaCorporate officerIndividual01/01/2024
Mitchell, JohnCorporate officerIndividual01/01/2024
Christensen, SpencerOperational/managerial controlIndividual09/01/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on December 12, 2025: "Ensure each resident must receive and the facility must provide necessary behavioral health care and services."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on May 15, 2025: "Ensure each resident receives an accurate assessment."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on March 5, 2026: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
  4. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on January 27, 2026: "Keep residents' personal and medical records private and confidential."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.46 hours per resident per day, below the California average of 4.09.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

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Assisted living in California

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Common questions

What is Balboa Nursing & Rehabilitation Center's Medicare star rating?
CMS rates Balboa Nursing & Rehabilitation Center 4 out of 5 stars overall, with 3 for health inspections, 2 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Balboa Nursing & Rehabilitation Center get at its last inspection?
6 health deficiencies at the standard inspection on May 15, 2025. The California average is 15.6.
Has Balboa Nursing & Rehabilitation Center been fined?
CMS lists no fines in the last three years.
Does Balboa Nursing & Rehabilitation Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Balboa Nursing & Rehabilitation Center?
CMS lists 7 owners and managers, and links the home to PACS Group. Legal business name: BALBOA HEALTHCARE, INC..

Sources

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