Lake Balboa Care Center

Inspectors wroteBased on interview and record review, the facility failed to complete the facility's admission packets including admission agreements and the facility orientation packets upon admission per its policy and procedure (P&P) for three of four sampled residents (Resident 1, Resident 3, and Resident 4). This failure had the potential to result in the residents and residents' responsible parties (RP - an individual who signs a facility's admission agreement to manage a resident's care, administrative tasks, and billing arrangements) not being able to exercise their rights including a resident's continued stay in the facility with Medi-Cal (Medicaid - a public health insurance program funded by the government that provides free or low-cost medical care to people with low incomes and limited resources, and Medi-Cal is the specific name used in California) benefits.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party (RP - an individual who signs a facility's admission agreement to manage a resident's care, administrative tasks, and billing arrangements) for one of four sampled residents (Resident 1) that the facility had the Medi-Cal (Medicaid - a public health insurance program funded by the government that provides free or low-cost medical care to people with low incomes and limited resources, and Medi-Cal is the specific name used in California) certificate and was eligible to provide the care and services for the Medi-Cal beneficiaries when the Medicare (an official government health insurance program mainly for people age [AGE] and older, as well as some younger people with disabilities) skilled benefits end. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) by: 1. Failing to ensure a care plan was developed for three of five sampled residents (Resident 7, 15 and 35) investigated during review of the Infection Control task when Residents 7, 15, and 35 refused Coronavirus Disease 2019 (COVID-19,respiratory illness that spreads easily through respiratory droplets from coughs, sneezes, or talking) pneumonia (an infection/inflammation in the lungs), influenza (an infection of the nose, throat and lungs) and respiratory syncytial virus (RSV-a common respiratory virus. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses practiced professional standards of practice while administering insulin (hormone that regulates the amount of glucose [sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin injections sites for one of one sampled resident (Resident 2) investigated under the care area insulin. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 2. Cross reference to F760.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin (hormone that regulates the amount of glucose [sugar] in the blood) injections sites for one of one sampled resident (Residents 2) investigated under the care area insulin. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 2 and for Resident 2 to not get the appropriate amount of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control guidelines by failing to: 1. Ensure one of one sampled ice machines did not have black substances inside the ice compartment bin. This deficient practice had the potential to result in contamination of the ice which could lead to waterborne diseases (illnesses caused by pathogenic microorganisms, bacteria, viruses, and parasites transmitted through contaminated water) for 48 of 50 residents in the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance and palatability for lunch when roast beef was served dry and too tough to chew for two of three residents (Resident 2, 37) during a lunch dining observation. This failure had the potential to place Resident 2 and 37 at risk of unplanned weight loss, a consequence of poor food intake, from receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quaternary Ammonium Solution (QUAT- a class of disinfectant ingredients commonly used in household, healthcare, and commercial cleaning products) had a holding concentration of 200 parts per million (ppm-unit of measure). This deficient practice had the potential to result in ineffective sanitization of work surfaces against bacteria and viruses in the kitchen which could lead to resident consuming food that are contaminated and result to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and waste properly when: 1. One of one black dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed due to overfilling of bagged trash and empty cartons. 2. There were eight transparent trash bags containing soiled diapers, gloves, empty glove boxes, and other unidentifiable trash piled on the concrete near the dumpster. These failures had the potential to attract insects, pests, and rodents and potentially spread infection to 50 of 50 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of eight sampled residents (Resident 15) failing to ensure the Infection Preventionist Nurse (IPN) documented when the physician initially ordered to discontinue Resident 15's Vancomycin (a strong antibiotic [medication used to treat infections] used primarily to treat severe infections) on 3/24/2026, after the physician was made aware that vancomycin use did not meet the criteria for Resident 15's antibiotic use. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Residents 15

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure at least 80 square (sq.) feet (ft.) per resident was provided for ten (10) of 23 resident rooms (room [ROOM NUMBER], 103, 105, 107, 110, 112, 115, 117, 119, and 121). This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Registered Dietitians (RD) conducted a nutrition-focused physical assessment (a physical exam that RDs perform to assess nutritional status or evaluate malnutrition [lack of sufficient nutrients in the body]) by not speaking to residents or residents' family members/representatives and by not physically assessing residents during the Nutrition Evaluation and Registered Dietician Nutritionist (RDN) Review for two of three sampled residents (Resident 1 and Resident 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on intake and output (I &O- the tracking of all fluids that enter (intake) and leave (output) a resident's body over a set period, usually 24 hours) by failing to monitor and ensure residents on fluid restrictions (a medically prescribed diet limiting total daily liquid consumption) did not exceed their fluid restriction volume for two of three sampled residents (Resident 2 and resident 3). This deficient practice had the potential to cause fluid overload (condition where you have too much fluid volume in your body) for Resident 2 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling and storage practices by failing to ensure: 1. A clear plastic bag containing a cup of food brought by family member for a resident was labeled with a date for when it was brought into the facility. 2. A clear plastic container of strawberries did not have visible black/green discoloration consistent with mold-like (type of fungus) substance present on several strawberries stored inside one of three sampled refrigerators (Refrigerator 2). 3. An opened package of hamburger buns was labeled with an open date stored inside one of three sampled refrigerators (Refrigerator 3). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 2) with meals that accommodated their food preferences. This deficient practice resulted in Resident 2's food preferences not being honored and had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) confidential personal information was protected when a copy of Resident 1's Discharge Summary and Post-Discharge Plan of Care was given to Resident 2. This deficient practice violated Resident 1's rights and resulted in the unauthorized exposure of Resident 1's confidential information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Physical Therapist 1 (PT 1) wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while providing physical therapy (PT) services in bed for one of one sampled resident (Resident 1) who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individualities for one of one sampled resident (Resident 26) when Certified Nursing Assistant 2 (CNA 2) was standing over the resident while assisting him during a meal. This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of three sampled residents (Resident 94), when Licensed Vocational Nurse 1 (LVN 1) left Resident 94's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the resident's right to privacy and confidentiality of medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) to one of three sampled residents (Resident 15) prior to administering as needed (prn) opioid ([narcotic-treats moderate to severe pain) pain medication. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from use of opioids.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's indwelling catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) tubing was not touching the floor for one of one sampled resident (Resident 195) reviewed under indwelling catheter. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident for ten (10) of 26 resident rooms (room [ROOM NUMBER], 103, 105, 107, 110, 112, 115, 117, 119, and 121). The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility failed to provide the needed care and services that were resident centered for two of five sampled residents (Resident 2 and Resident 5) by failing to implement the facility's policy on pacemaker (small device that's implanted [placed] in the chest to help control the heartbeat) by not documenting the residents' type of pacemaker, date of insertion, rate, pacemaker check lab (a facility that monitors and maintains pacemakers) and phone number per the facility's policy. This deficient practice had the potential to result in confusion in the care and services provided to Resident 2 and Resident 5, which could place the residents at risk of not receiving appropriate care due to incomplete resident medical care information.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's infection control policy by failing to: 1. Ensure two of two visitors were offered Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) testing upon entering the facility. 2. Ensure a resident was placed on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) per physician's order for one of four sampled residents (Resident 4). These deficient practices had the potential to place residents, staff members, and visitors at risk of spreading infections.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses held (did not give) a resident's blood pressure (the force of blood pushing against the walls of the arteries) medications when the resident's blood pressure was outside of the physician's prescribed parameters (a set of defined limits) for one of one sampled resident (Resident 39) investigated under pharmacy services. This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure the 9:00 p.m. dose of cefepime (antibiotic- it can treat bacterial infections) was administered on 2/16/2024 per physician's orders for one of one sampled resident (Resident 20) investigated under Antibiotic Use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) knocked and asked permission prior to entering two of two sampled residents' rooms (Resident 98 and 28). This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's call light (a remote control that allows patients to request assistance from nurses or other staff) was within reach for one of one sampled resident (Resident 150) investigated under the care area of accommodation of needs. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of five sampled residents (Resident 7) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident's wishes regarding his/her health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure a bag of raw beef located in one of two facility refrigerators (Refrigerator 1) was labeled and dated when taken out of the freezer and placed in the refrigerator to be thawed. This deficient practice had the potential to place 46 out of 48 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for 10 of 23 multiple resident rooms (room [ROOM NUMBER], 103, 105, 107, 110, 112, 115, 117, 119, and 121). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.