Balboa Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Balboa Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF740Mar 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF583Jan 27, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Mar 10, 2021

  Based on observations, interviews and record review, the facility failed to properly prevent and contain COVID-19. Specifically, the facility failed to 1) ensure staff properly wore Personal Protective Equipment (PPE) during Droplet Precautions, 2) properly dispose of used isolation gowns, 3) ensure staff washed hands after patient care, 4) offer to wash a resident's hands before a meal, 5) develop a system to effectively utilize the Utility room with a clear designation of a clean and a dirty area, and 6) properly isolate residents on Droplet Precautions when doors were left open. […]

• No harm, potential for more than minimal, patternF757Mar 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF881Mar 5, 2026

  Based 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. […]