Balmoral Home

In the surveyor’s words

From the most serious findings on record at Balmoral Home, in the surveyor’s own words.

• Actual harm, isolatedF684May 22, 2026

  Based on observation, interview and record review, the facility failed to follow standards of practice by not performing a proper nursing assessment of a resident's wound/skin condition, after a certified nursing assistant (C.N.A) notified the nurse of the existence of the wound/skin condition for 1 resident (R5) out of 3 residents reviewed for a skin assessments. This failure resulted in the delay of R5's wound treatment, for a wound that was septic, necrotic, infected with Fournier's gangrene, and required wound debridement.Findings Include:R5's face sheet documents that R5's diagnosis is not limited to peripheral vascular disease, type 2 diabetes mellitus, malignant neoplasm of overlapping sites of bladder, hypertensive heart disease without heart attack, hyperlipemia.R5's MDS (minimum… […]

• Actual harm, isolatedF689Feb 18, 2024

  Based on interviews and record reviews the facility failed to follow their fall policy to study fall causations, provide corrective actions to prevent reoccurrences, failed to provide adequate supervision and failed to develop specific fall interventions for 1 [R1] of 3 residents reviewed for falls. This failure resulted in R1 sustaining traumatic subarachnoid hemorrhage. Findings Include: R1's clinical record documents in part; R1 is a [AGE] year-old with the medical diagnosis of traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, dementia, unspecified severity, with other behavioral disturbance, malignant neoplasm of prostate, secondary malignant neoplasm of bone, muscle weakness (generalized), unsteadiness on feet, abnormalities… […]

• No harm, potential for more than minimal, widespreadF880Feb 5, 2023

  Based on observation, interview and record review, the facility failed to follow their policy on infection control by staff (a) failing to remove gloves while walking in various places in the facility, and (b) failing to wear proper PPE (Personal Protective Equipment) while entering contact/droplet isolation COVID-19 positive room. These failures have the potential of affecting all 147 residents residing in the facility. Findings include: On 2/4/2023 at 9:52am, V8 (Licensed practical Nurse/LPN) was observed entering R2 and R3's room, which was marked as an isolation room with droplet and contact/isolation precautions and red zone sign posted on the door. V8 was observed to go into the room and did not wear a gown or gloves while inside R2 and R3's room. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2022

  Based on observation, interview and record review the facility failed to follow proper sanitation and food handling practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) food temperatures are not monitored on steam table during meal service. These deficient practices have the potential to affect all 156 residents receiving food prepared in the facility kitchen. Findings include: On [DATE] at 9:30 AM during initial kitchen tour with V17 (Food Service Director) the following items were found in walk-in refrigerator: 1.) 3 jelly sandwiches not labeled/dated, 2.) 10 cases of [MEDICATION(S)] (8 oz.) containers not marked with the delivery date, 3.) 5 lb 2% Cottage Cheese container expired [DATE] per manufacturers stamp and facility label dated by staff… […]

• No harm, potential for more than minimal, widespreadF880Jun 3, 2022

  Based on observations, interviews and record reviews, the facility staff failed to wear their masks correctly over their nose and secure dirty linen in bags. These failures have the potential to affect all 156 residents. Findings include: On 05/31/2022 at 10:55 AM, surveyor was in R100's room. V5 (Nurse) entered R100's room with face mask below the nose. V5's nose/nares were exposed. V5 leaned over R100's bed and spoke to R100 with V5's face mask below V5's nose. On 06/01/2022 at 9:40 AM, surveyor toured facility's laundry area with V9 (Laundry Attendant). When V9 showed surveyor the laundry chute, surveyor observed the bin underneath the laundry chute with loose sheets, towels, a pillow, pillowcase and hanger in the bin. Linens were not secured in bags. […]