Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Balboa Care Center during CMS and state inspections, most recent first.
Missing Care Plans for Vaccine Refusal and Psychotropic Medication Use: The facility did not develop individualized care plans for several residents who refused influenza, pneumococcal, COVID-19, and/or RSV vaccines, despite records showing varying cognitive status and consent refusals by residents or family members. The facility also lacked a care plan for a resident receiving Seroquel for bipolar disorder and clonazepam for anxiety, and RN confirmed the omission during record review.
A resident with type 2 DM and Parkinson’s disease received Novolog insulin injections without proper rotation of injection sites. MAR review showed repeated use of the same abdomen and arm areas, and the DON acknowledged multiple instances where the sites were not rotated. The facility policy required meds to be given per orders, and the Novolog label directed staff to rotate injection sites to avoid using the same spot for each injection.
A resident with type 2 DM and Parkinson's disease received Novolog insulin injections without proper site rotation. The MAR showed repeated injections in the same abdomen and arm areas, and the DON acknowledged multiple instances where sites were not rotated. The facility policy required medications to be given per orders, and the Novolog label instructed rotation of injection sites to reduce the risk of lipodystrophy.
Infection Control Lapses With Ice Machine, PPE Use, EBP Placement, and Soiled Bathroom Equipment: A kitchen ice machine had black substances inside the ice compartment bin, and the DS stated the buildup should have been cleaned and could contaminate ice. A resident on EBP for MDRO urine was turned and repositioned by a CNA without an isolation gown, and another resident with a PICC line was not placed on EBP despite staff noting infection risk. A soiled toilet seat cover was also left on a toilet riser in a resident bathroom, and staff stated it should have been removed after use.
Dry, Tough Roast Beef Served at Lunch: Two residents were observed struggling with roast beef that was dry, tough, and difficult to chew during lunch. One resident with DM and malnutrition ate the other items but not the meat, while another resident with dysphagia and malnutrition said the meat was like shoe leather and could not be eaten. The DS confirmed the au jus was missing and the meat was dry and tough, and RN 2 also stated it should not have been served.
Improper Quat Sanitizer Concentration in Kitchen: The Dietary Supervisor observed a red bucket of quat used to sanitize kitchen work and food prep surfaces, but test strips showed the solution was only 100 ppm instead of the required 200 ppm. The solution was retested with fresh quat and again read 100 ppm. Facility policy stated the sanitizer concentration must be tested for effectiveness and replaced when readings are below 200 ppm.
Improper disposal of garbage and refuse was observed when one black dumpster was overfilled and not completely closed, and eight transparent trash bags containing soiled diapers, gloves, empty glove boxes, and other trash were piled on the concrete in the dumpster enclosure. The DSD and DON stated the dumpster should be closed and other waste placed in lidded bins, and the facility policy required outside trash areas to be kept clean, sanitary, safe, and compliant while avoiding overfilling bags or bins.
Incomplete Documentation of Physician Order Change: An IPN failed to document the full physician conversation regarding a resident’s vancomycin order. The resident had DM, HTN, elevated WBC, and VRE, and was receiving vancomycin for C-diff prophylaxis. The Antibiotic Time Out showed no active infection, and the IPN stated the physician initially discontinued the medication before it was continued after FM request, but that initial discontinuation was not documented in the medical record.
Insufficient square footage was identified in multiple resident rooms after surveyors found that 10 of 23 rooms did not meet the required 80 sq. ft. per resident. The facility’s waiver request and room measurements showed several double- and quadruple-occupancy rooms providing only 77.5 to 78.5 sq. ft. per resident, although residents were observed moving freely and staff had adequate space to provide care.
Surveyors found that the facility’s RDs did not perform in-person, nutrition-focused physical assessments or direct interviews for two residents receiving hemodialysis, despite significant conditions such as ESRD, DM, and moderate protein-calorie malnutrition. The Dietary Supervisor obtained food preferences, and the RDs completed Nutrition Evaluation and RDN Reviews remotely or based solely on chart review and DS input, without speaking to the residents or their representatives or physically assessing chewing, eating ability, or skin integrity. One RD worked entirely remotely and stated she did not need face-to-face assessments, while the on-site RD acknowledged a high-risk dialysis resident should have been seen but was never assessed due to the resident’s dialysis schedule. These practices conflicted with facility policies, RD job descriptions, and the Academy of Nutrition and Dietetics’ Nutrition Care Process, which call for assessment data from interview, observation, and collaboration with the client.
The facility failed to follow its I&O policy and physician-ordered fluid restrictions for two dialysis residents with ESRD and other comorbidities. One resident with a 1,500 mL/day fluid restriction repeatedly received between 1,650 mL and 3,300 mL per day based on combined CNA and nurse documentation, despite clear orders and care plan breakdowns by shift. Another resident with a 1,000 mL/day restriction had multiple days where CNA documentation showed intake between 1,050 mL and 1,220 mL. The ADON acknowledged that CNAs provided fluids without proper coordination with licensed staff, that nurses did not adequately monitor or total 24-hour intake, and that the facility’s written I&O procedures for documenting and totaling fluids each shift were not effectively implemented.
Surveyors found multiple failures in food handling and storage, including an undated bag containing a cup of food brought in by a family member for a resident stored in a kitchen refrigerator, a container of strawberries with visible mold-like discoloration that had not been checked for spoilage, and an opened package of hamburger buns stored without an open date. The Dietary Supervisor acknowledged that family-prepared foods should be discarded after 24 hours, that staff had not checked the strawberries for spoilage, and that all opened food items should be labeled with an open date, as required by facility policies on foods brought by visitors, storing produce, and labeling and dating foods.
A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis had a documented CCHO/renal diet and a care plan intervention to honor personal dietary choices, with the RDN noting a preference for soup at lunch and the meal card specifying soup as an added lunch item. During a lunch observation, the DON noted that the resident's tray did not include soup despite the meal ticket indicating it should, and the Dietary Supervisor later confirmed that kitchen staff are required to follow meal tickets and that the resident's preference was not honored, contrary to the facility's food preference policy.
A resident with severe cognitive impairment and multiple medical conditions had their detailed discharge summary and post-discharge plan, including full identifying and clinical information, mistakenly included in another resident’s discharge packet. An RN acting as supervisor relied on discharge paperwork pre-printed and placed in the chart, verified only the initial pages for the correct name and medication list, and failed to review all pages, resulting in the other resident receiving confidential PHI. The DON and RN acknowledged this as a HIPAA violation, contrary to facility policy requiring protection of all resident health information.
A physical therapist did not wear an isolation gown while providing range of motion exercises and repositioning a resident on enhanced barrier precautions for an MDRO infection and indwelling catheter. Despite clear signage and facility policy requiring gown and gloves for high-contact care, only gloves and a mask were used during the therapy session.
A resident with Parkinson's disease and dysphagia was assisted by a CNA who stood over him during feeding, contrary to the facility's policy requiring staff to sit at eye level to maintain dignity. The CNA stated it was easier for her to stand, despite the Director of Nursing's directive to assist residents in a sitting position.
A resident's privacy was compromised when an LVN left their electronic health record open and unattended during a medication pass. The resident, who was dependent on staff for care, had their medication list and photo visible on a computer screen. The LVN admitted this was a HIPAA violation, as the facility's policy requires that medication carts be locked and screens closed when not in use.
A facility failed to provide non-pharmacological interventions before administering opioid pain medication to a resident with atrial fibrillation and pneumonia. Despite physician orders to attempt non-pharmacological methods like repositioning and relaxation, the resident received Percocet on multiple occasions without these interventions, increasing the risk of adverse effects.
A resident with an indwelling catheter was observed with the catheter tubing touching the floor, contrary to the facility's infection control policy. The resident, who required substantial assistance due to mildly impaired cognition, was at risk of infection due to this oversight. Both an LVN and the DON acknowledged the risk of bacterial transmission from the tubing touching the floor.
The facility was found to have ten rooms that did not meet the required minimum square footage per resident during a recertification survey. Despite the deficiency, observations and interviews indicated that residents and staff did not experience issues with space for mobility or care. The facility had applied for a Room Variance Waiver, asserting that the space was adequate for residents' needs.
The facility failed to document essential pacemaker information for two residents with atrial fibrillation and cardiac pacemakers. The care plans lacked details such as the pacemaker type, insertion date, rate, and contact information, contrary to the facility's policy. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the responsibility to obtain this information upon admission.
The facility failed to offer COVID-19 testing to visitors upon entry, contrary to its policy, and did not place a resident with E. coli bacteremia on contact isolation as ordered by a physician. The DON decided against isolation despite available private rooms and a physician's order, believing the infection was not severe enough. These actions led to deficiencies in infection control practices.
Missing Care Plans for Vaccine Refusal and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for several residents after they refused recommended vaccinations. For Resident 7, the record showed admission with acute pyelonephritis, UTI, and unspecified dementia. The resident’s consent forms documented refusal of influenza, pneumococcal, COVID-19, and RSV vaccines by Family Member 2. The H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decisions. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines, and also stated the facility does not develop a care plan for residents’ refusal of vaccination. For Resident 15, the record showed admission with unspecified elevated WBC count, DM, and HTN. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines by Family Member 3, and the vaccination consent documented refusal of RSV vaccine. The MDS indicated the resident’s cognitive skills for daily decisions were intact. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines. For Resident 35, the record showed admission with unspecified MS, UTI, and essential HTN. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines, and the vaccination consent documented refusal of RSV vaccine. The H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated cognitive skills for daily decisions were intact. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines. For Resident 33, the record showed admission with unspecified asthma, fall, and weakness. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines by Family Member 4, and the vaccination consent documented refusal of RSV vaccine. The H&P indicated the resident had capacity to understand and make decisions, while the MDS indicated moderately impaired cognitive skills for daily decisions. The IPN stated the resident had refused pneumococcal and RSV vaccines and stated the facility does not develop a care plan for vaccination refusal unless there was a change in condition. The DON stated care plans are developed to address residents’ problems and needs and that vaccination is a medical need, but the facility did not develop individualized care plans with goals and interventions for these residents’ vaccine refusals. The facility also failed to develop a care plan for Resident 8’s use of Seroquel and clonazepam. The resident’s record showed admission with dementia, bipolar disorder, and anxiety. The MDS indicated moderately impaired cognition for daily decision-making and that the resident was mostly dependent for ADLs. The order summary showed Seroquel 25 mg, three tablets at bedtime for bipolar disorder, and clonazepam 1 mg at bedtime for anxiety. During review of the care plans, RN 2 confirmed there was no care plan addressing the resident’s Seroquel use or anxiety-related behavior requiring clonazepam, and stated individualized care plans are important so the facility can provide proper care to meet the resident’s needs.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nurses failed to follow professional standards of practice when administering Novolog insulin to a resident with type 2 DM and Parkinson’s disease. The resident was admitted on 6/1/2023 and readmitted on 2/24/2026, and the MDS dated 3/2/2026 indicated the resident could make himself understood and understand others, but needed substantial assistance from staff for dressing and bathing. The resident had an active order for Novolog FlexPen 100 units/ml to be given subcutaneously before meals and at bedtime according to sliding scale. Review of the MAR from 3/8/2026 through 3/23/2026 showed repeated insulin administrations in the same injection areas, including the left upper quadrant of the abdomen on 3/8 and 3/9, the left arm on 3/16 and 3/17, and the left lower quadrant of the abdomen on 3/22 and 3/23. The DM care plan directed staff to administer medication as ordered. During interview and record review, the DON stated nurses were expected to rotate injection sites and acknowledged multiple instances where the resident’s insulin injection sites were not rotated. The facility policy required medications to be administered in accordance with prescriber’s orders, and the FDA label for Novolog stated to rotate injection sites from one injection to the next and not use the same spot for each injection.
Insulin Injection Sites Not Rotated
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not rotating insulin injection sites for one sampled resident with type 2 DM and Parkinson's disease. The resident was admitted on 6/1/2023 and readmitted on 2/24/2026, and the MDS dated 3/2/2026 indicated the resident could make himself understood and understand others, but needed substantial assistance from staff for dressing and bathing. The resident had an active order for Novolog FlexPen 100 units/mL to be given subcutaneously before meals and at bedtime. Review of the MAR from 3/8/2026 through 3/23/2026 showed repeated insulin administrations in the same areas, including the abdomen left upper quadrant on 3/8 and 3/9, the left arm on 3/16 and 3/17, and the abdomen left lower quadrant on 3/22 and 3/23. During interview and record review, the DON stated there were multiple instances where the insulin injection sites were not rotated in 3/2026 and that sites should be rotated to prevent damage to the skin tissues of the resident and medication errors. The facility policy required medications to be administered in accordance with prescriber orders, and the FDA label for Novolog stated to rotate injection sites from one injection to the next to reduce the risk of lipodystrophy and not use the same spot for each injection.
Infection Control Lapses With Ice Machine, PPE Use, EBP Placement, and Soiled Bathroom Equipment
Penalty
Summary
The facility failed to maintain infection control in the kitchen when a concurrent observation with the Dietary Supervisor found black substances inside the ice compartment bin of one sampled ice machine. When the inside of the ice compartment where the door latched was wiped with a paper towel, the towel collected black substances that adhered to it. The Dietary Supervisor stated the black substances should have been wiped away and cleaned during regular cleaning, and stated that if the substances got into the ice and were ingested, it could cause foodborne illnesses. The DON stated the ice machine should be regularly cleaned and maintained so the ice is not contaminated by pathogens, and the facility policy required the ice machine to be cleaned and sanitized monthly. The facility also failed to ensure PPE use during enhanced barrier precautions for a resident with MDRO urine. Resident 7 was admitted with toxic encephalopathy, sepsis, and UTI, had severely impaired cognition, and required substantial to dependent assistance with ADLs. The resident had a physician order for EBP due to MDRO urine. During observation, a CNA turned and repositioned the resident without wearing an isolation gown, even though the CNA stated the resident was on EBP and that a gown should have been worn when touching the resident. The IPN stated staff must wear gowns and gloves for residents on EBP during high close-contact care such as touching, repositioning, and cleaning. The facility further failed to place a resident with a PICC line on EBP. Resident 62 was admitted with reduced mobility, dysphagia, and need for assistance with personal care, and had a physician order for a right upper arm PICC line site check. During observation, the resident was repositioned and changed, and staff stated the resident was not on EBP. The IPN stated the PICC line did not place the resident on EBP, while an RN stated the PICC line placed the resident at high risk for infection and that the resident needed to be on EBP. In addition, a soiled toilet seat cover remained on the toilet riser in a resident bathroom during observation. The resident stated the dirty cover should have been thrown away, and a CNA stated it should have been removed right after use to prevent the spread of infections.
Dry, Tough Roast Beef Served at Lunch
Penalty
Summary
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature was not met when roast beef served at lunch was observed to be dry and too tough to chew for two residents. Resident 2 had diagnoses including type 2 DM and moderate protein calorie malnutrition, and his MDS indicated he could make himself understood and understand others, needed substantial assistance with dressing and bathing, and setup assistance with feeding. His order included a CCHO, NAS, regular diet with level 7 texture. During lunch dining observation, his family member repeatedly tried to cut the roast beef into tiny pieces while Resident 2 ate the other food items but did not eat the meat. During the same meal, Resident 37, who had diagnoses including dehydration, dysphagia, and protein calorie malnutrition, and whose MDS indicated moderately impaired cognition, supervision with eating, dependence for other ADLs, and some difficulty or pain while swallowing, was observed having a hard time cutting the meat into pieces. Resident 37 stated he was unable to eat because the meat was too tough like shoe leather. His order included a CCHO diet. The Dietary Supervisor reviewed the menu and confirmed roast beef au jus was served for lunch, then tested and chewed the meat for about a minute before swallowing. The Dietary Supervisor stated the au jus was missing, the meat was dry and tough, and it should not have been served to the residents. RN 2 also observed the meat and stated it looked very dry and tough and should have been noticed sooner to offer a substitute. Facility policy required staff who observe chewing problems to refer the issue to the DON and to offer a food substitute if poor intake is noticed, and the in-room dining policy stated meals would be presented attractively.
Improper Quat Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to ensure that the Quaternary Ammonium Solution used to sanitize kitchen work and food preparation surfaces maintained a holding concentration of 200 ppm. During a concurrent kitchen observation and interview, the Dietary Supervisor showed a red bucket containing a clear quat solution and stated that it was used to sanitize work and food preparation surfaces. The Dietary Supervisor also stated that the facility kept a testing log to verify the quat concentration at 200 ppm according to the manufacturer’s guidelines, and that the bucket had already been tested for breakfast because the Sanitizer Dispenser Log had been filled for that testing period. The Dietary Supervisor tested the solution in the red bucket with a test strip, which turned orange and was identified as 100 ppm instead of the required 200 ppm. After the bucket was replaced with fresh quat solution, the solution was tested again and the strip again turned orange. The Dietary Supervisor then discarded the red bucket and stated that the quat solution would not be able to effectively disinfect work surfaces. The facility policy titled Quaternary Ammonium Log Policy stated that the quaternary sanitizer concentration would be tested for effectiveness and that the solution would be replaced when the reading was below 200 ppm.
Improper Disposal of Trash in Dumpster Area
Penalty
Summary
Improper disposal of garbage and refuse was observed at the back of the main facility building near the parking lot. During a concurrent observation and interview with the DSD, one black dumpster was seen overfilled with bagged trash and empty cartons and was not completely closed. In the same dumpster enclosure, eight transparent trash bags were observed piled on the concrete floor. The bags contained soiled diapers, gloves, empty glove boxes, and other unidentifiable trash. The DSD stated the dumpster should be completely closed and that other trash should be placed in bins. The DSD also stated the condition could attract pests, insects, and rats and was not sanitary. During a later interview and record review with the DON, the photo of the dumpster area was reviewed, and the DON stated the dumpster should be covered and other waste must be placed in bins with lids. The facility policy reviewed stated that outside trash and waste disposal areas are to be maintained in a clean, sanitary, safe, and compliant manner and to avoid overfilling bags or bins.
Incomplete Documentation of Physician Order Change
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of eight sampled residents when the Infection Preventionist Nurse did not document that the physician initially discontinued the resident’s vancomycin on 3/24/2026. Resident 15 was admitted with diagnoses including elevated WBC, DM, and HTN, and had a physician order dated 3/21/2026 for vancomycin hydrochloride oral suspension 125 mg/5 ml by mouth daily for C-diff prophylaxis for 14 days. The resident’s MDS dated 3/23/2026 indicated cognitive skills for daily decisions were intact. The Antibiotic Time Out dated 3/24/2026 indicated the resident did not have an active infection and had a culture positive for VRE. It also documented that the IPN notified Family Member 3, who wanted the vancomycin continued until completed. The MAR showed the resident received vancomycin from 3/22/2026 through 3/31/2026. During interview, the IPN stated she called the physician on 3/24/2026, the physician initially discontinued the vancomycin, and after speaking with FM 3, the physician agreed to continue it, but the IPN did not document the initial discontinuation or the complete physician conversation. The DON stated the IPN should have documented the entire conversation and that the resident’s medical record should be complete and accurate.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that at least 80 square feet per resident was provided in ten of 23 resident rooms, including rooms 101, 103, 105, 107, 110, 112, 115, 117, 119, and 121. During the recertification survey from 4/11/2026 to 4/12/2026, surveyors observed that residents in these rooms had sufficient space to move freely inside the rooms, and there was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff during the observations. A review of the facility’s Request for Room Variance Waiver letter dated 4/11/2026 showed that the listed rooms did not meet the federal 80 square foot requirement per resident. The facility’s Client Accommodations Analysis documented that rooms 101, 103, 105, and 107 each measured 155 square feet for two beds, rooms 110 and 112 each measured 310 square feet for four beds, and rooms 115, 117, 119, and 121 each measured 157 square feet for two beds, resulting in 77.5 to 78.5 square feet per resident. During the resident council meeting, no concerns were raised about room size, and the facility’s policy stated that multiple resident bedrooms must measure at least 80 square feet per resident and single resident rooms at least 100 square feet.
Failure to Perform Nutrition-Focused Physical Assessments for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Registered Dietitians (RDs) conducted nutrition-focused physical assessments, including direct interaction with residents or their representatives, for residents receiving hemodialysis. Resident 1 was admitted with ESRD, type 2 DM, moderate protein-calorie malnutrition, and dependence on hemodialysis. The care plan for Resident 1 identified risk for nutritional problems related to chronic kidney disease, ESRD, DM, and malnutrition, and included an intervention for the RD to evaluate and make diet change recommendations as needed. The facility’s process, as described by the Dietary Supervisor (DS), was that within the first three days of admission the DS interviews the resident for food preferences, and then the RD completes the second part of the evaluation and writes recommendations based on the DS’s information. Surveyors found that RD 1, who worked remotely, completed Nutrition Evaluation and RDN Reviews without conducting face-to-face assessments or speaking with residents or their families/representatives. RD 1 stated that she relied on the DS’s information and her own education and did not need to perform in-person assessments. For Resident 1, the Nutrition Evaluation and RDN Review were completed based on record review and DS input, without RD 1 physically assessing the resident or directly interviewing the resident or representative. The DON confirmed that RD 1 worked remotely and that RD 2 was expected to check and assess newly admitted residents, but also stated that, in the DON’s view, it was acceptable for RD 1 to assess residents remotely through thorough record review. For Resident 2, who was also on dialysis and considered high risk, RD 2 acknowledged that the resident should have been seen and evaluated in person but had not been assessed because the resident was off-site for dialysis on the day RD 2 was in the facility. RD 2 stated that RD 1 had assessed Resident 2 and documented the Nutrition Evaluation and RDN Review, again without an in-person assessment. RD 2 did not answer when asked about standards of practice for RDs or what a nutrition-focused physical assessment entails. The facility’s policies and job descriptions, as well as the Academy of Nutrition and Dietetics’ Nutrition Care Process documents reviewed by surveyors, emphasized assessing nutritional status through interview, observation, and physical assessment, and collaborating with the client in developing goals and monitoring outcomes, which contrasted with the facility’s practice of remote, record-based RD assessments for these residents on hemodialysis.
Failure to Monitor and Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its intake and output (I&O) policy and physician-ordered fluid restrictions for residents on dialysis. For one resident with end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis, the physician’s order and care plan specified a 1,500 mL daily fluid restriction divided among nursing and dietary shifts. The Assistant Director of Nursing (ADON) explained that licensed nurses were to document fluids they provided on an I&O record, CNAs were to document fluids they provided in the electronic health record, and that the combined total for each 24-hour period should not exceed the ordered restriction. However, review of CNA fluid intake documentation and the licensed nurses’ I&O records from multiple dates showed that the resident’s total daily fluid intake consistently exceeded the 1,500 mL restriction, ranging from 1,650 mL to 3,300 mL per day. The ADON stated that only fluids provided by licensed nurses and from the kitchen should be offered to residents on fluid restrictions, and that CNAs should inform licensed nurses before offering fluids to such residents for proper monitoring. The ADON acknowledged that the facility failed to monitor this resident’s intake according to the physician’s order and that licensed nurses should have communicated with each other, including during huddles, to remind CNAs which residents were on fluid restrictions. This failure resulted in repeated instances where the resident received more fluid than prescribed over an 11-day period. A second resident, also with end stage renal disease, dependence on renal dialysis, and hypertension, had a physician’s order, care plan, and dietary evaluation specifying a 1,000 mL fluid restriction divided among breakfast, lunch, and dinner, with PO intake to be monitored. Review of CNA task documentation over a one-month period showed that this resident’s daily fluid intake exceeded the 1,000 mL restriction on multiple dates, with recorded intakes between 1,050 mL and 1,220 mL. During interview and record review, the ADON confirmed that the resident received more fluids than ordered on those dates and stated that licensed nurses should have monitored the resident’s fluid intake to ensure it did not exceed 1,000 mL. The facility’s written I&O policy required nursing assistants to document all fluids consumed on a daily I&O sheet, licensed staff to document fluids given with medications, and the 3–11 shift to total 24-hour intake each day, but the documented intakes show that these monitoring and documentation processes did not prevent the residents from exceeding their ordered fluid restrictions.
Failure to Properly Label, Date, and Discard Resident and Kitchen Food Items
Penalty
Summary
Surveyors identified deficiencies in food handling and storage practices in the facility kitchen during an observation with the Dietary Supervisor (DS). In one refrigerator, an undated clear plastic bag containing a cup of food brought in by a family member was stored on the bottom shelf and labeled only with a resident’s room number, without a date indicating when it was brought into the facility. The DS stated that food prepared and cooked by family members for residents was stored in this refrigerator and should be discarded after 24 hours for resident safety. Review of the facility’s policy titled “Foods brought by family or visitor” indicated that perishable prepared foods must be checked by designated dietary staff, discarded after 24 hours of storage, stored in the facility kitchen, and labeled with the resident’s name, location, and date. In the same kitchen, surveyors observed a clear plastic container of strawberries dated 2/27/2026 in Refrigerator 2 with visible black/green discoloration consistent with a mold-like substance on several strawberries. The DS acknowledged that the strawberries had not been checked for spoilage or mold and stated that staff should ensure food items are fresh and safe to use and discard them if not. In another refrigerator (Refrigerator 3), an opened package of hamburger buns was stored without an open date label. The DS confirmed the buns did not have an open date and stated that food items should have an open date label to follow guidelines on when to use the food item by. Review of facility policies on “Storing Produce” and “Labeling and dating of foods” showed requirements to check produce for spoiled items and discard them upon delivery, and to mark commercially processed, ready-to-eat cold foods stored more than 24 hours with a use-by date, which were not followed in these instances.
Failure to Honor Resident Food Preference for Soup at Lunch
Penalty
Summary
The facility failed to provide meals that accommodated a resident's documented food preferences. A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis was admitted on 2/27/2026 and had a care plan for nutrition related to diabetes and chronic kidney disease with hemodialysis, which included an intervention to honor the resident's rights to make personal dietary choices. The resident's orders specified a CCHO/renal diet with regular/thin liquids. A Nutrition Evaluation and RDN Review completed on 2/28/2026 documented that the resident liked soup for lunch, and the resident's meal card indicated added food for lunch: soup. On 3/11/2026, during observation of the resident's lunch tray with the DON, it was noted that the resident did not receive soup, despite the meal card indicating that soup should be served. The DON confirmed that the resident should have had soup based on the meal card. In a subsequent interview, the Dietary Supervisor stated that kitchen staff are supposed to follow what is on residents' meal tickets at all times to honor residents' preferences and choices, and acknowledged that the facility failed to honor this resident's food preference by not serving soup at lunch. The facility's Food Preferences policy, last reviewed 2/17/2026, stated that residents' food preferences will be adhered to within reason and obtained through an initial resident screen within seven days of admission by the FNS Director.
Unauthorized Disclosure of Resident PHI in Discharge Paperwork
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s confidential personal and medical information when discharge documents for one resident were mistakenly given to another resident. The affected resident had been admitted and later readmitted with diagnoses including sepsis, Non-Hodgkin lymphoma, and hypotension. An admitting evaluation documented fluctuating capacity to understand and make decisions, and an MDS assessment showed severely impaired cognition. The resident’s Discharge Summary and Post-Discharge Plan of Care contained extensive protected health information, including full name, date of birth, admission and discharge dates, diagnoses, cognitive and physical status, nutritional status, height, weight, home address and phone number, physician and home health agency contact information, and medical equipment orders. The incident came to light when the husband of another resident who was being discharged contacted the facility’s Patient Concierge to report that the first resident’s discharge papers had been included with his spouse’s discharge paperwork. The Patient Concierge reported this to the medical records department. Review of a facility letter to the affected resident confirmed that the information disclosed included the resident’s full name, date of birth, admission date, address, discharge date, diagnosis, phone number, reason for admission, physician order for home health, height, weight, and reason for discharge. This disclosure occurred despite a facility policy stating that all resident health information is confidential, protected by HIPAA, and must not be disclosed in any form without legal authorization. Interviews with staff clarified how the error occurred. The Medical Records Assistant stated that nurses, not medical records, print discharge paperwork. The Infection Prevention Nurse, who was acting as the RN supervisor on the day in question, reported that night shift typically prepares and prints discharge paperwork and places it in residents’ physical charts. While discharging the second resident, the Infection Prevention Nurse pulled the discharge papers from that resident’s chart, checked only the first few pages to verify that the face sheet and medication list matched the correct name, and did not review all pages. As a result, the first resident’s Discharge Summary and Post-Discharge Plan of Care were inadvertently included in the second resident’s discharge packet. The Infection Prevention Nurse and the DON both acknowledged that all documents should have been checked to ensure they belonged to the correct resident and that providing these documents to another resident constituted a HIPAA violation and a breach of confidentiality.
Failure to Use Required PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a physical therapist (PT) failed to follow infection control practices by not wearing an isolation gown while providing in-bed physical therapy services to a resident who was on enhanced barrier precautions (EBP) due to an indwelling catheter and a multidrug-resistant organism (MDRO) infection. The resident had a history of right femur fracture, urinary tract infection, and extended spectrum beta-lactamase (ESBL) producing bacteria, and was dependent on staff for multiple activities of daily living. Facility records and signage indicated that gown and gloves were required for high-contact care activities under EBP. During direct observation, the PT was seen wearing only gloves and a surgical mask while performing range of motion exercises and repositioning the resident, despite EBP signage posted at the room entrance. The infection preventionist and the director of nursing both confirmed that an isolation gown should have been worn for such high-contact activities. The facility's infection control policy also specified the use of gown and gloves for high-contact care under EBP to prevent the spread of MDROs.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect, as observed during a meal assistance session with a resident diagnosed with Parkinson's disease, dysphagia, and depression. The resident, who required verbal cues to feed himself, was assisted by a Certified Nursing Assistant (CNA 2) who stood over him while feeding. This practice was contrary to the facility's policy, which requires staff to sit at eye level with residents during feeding to promote dignity and allow for better observation of any swallowing difficulties. During the observation, the CNA admitted to standing over residents because it was easier for her, despite the facility's policy and the Director of Nursing's statement that staff should assist residents in a sitting position to maintain their dignity. The facility's policies on feeding dependent residents and maintaining dignity and respect were reviewed, both emphasizing the importance of sitting at eye level with residents to ensure respectful and dignified care.
Violation of Resident Privacy Due to Unattended EHR
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN 1) left the electronic health record (EHR) of a resident open and unattended. This incident involved Resident 94, who was admitted to the facility with acute pulmonary edema and heart failure. The resident's Minimum Data Set (MDS) indicated that they had limited ability to understand others and were totally dependent on staff for personal care tasks. During a medication pass, LVN 1 left the computer screen displaying the resident's medication list and photo open while stepping away from the medication cart to enter the resident's room. LVN 1 acknowledged that leaving the electronic chart accessible was a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of residents' health information. The facility's policy requires that medication carts be kept closed and locked when not in sight and that resident information be kept private by closing the computer screen when not in use. This incident highlights a breach in the facility's adherence to HIPAA regulations and its own policies regarding the safeguarding of electronic protected health information (ePHI).
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions to a resident before administering as-needed opioid pain medication. The resident, who was admitted with diagnoses including atrial fibrillation and pneumonia, had intact cognition and required substantial assistance with daily activities. The physician's orders included administering Percocet for severe pain and providing non-pharmacological interventions such as repositioning and relaxation every shift. However, the Medication Administration Record showed that on three occasions, Percocet was administered without prior non-pharmacological interventions. During an interview, the Director of Nursing confirmed that non-pharmacological interventions should be attempted first to address potential external factors causing pain. The failure to do so increased the risk of adverse side effects from opioid use, such as dizziness and respiratory depression. The resident's care plan aimed to prevent interruptions in normal activities due to pain, and the facility's policy emphasized the inclusion of both pharmacological and non-pharmacological interventions in the care plan.
Infection Control Deficiency: Catheter Tubing Touching Floor
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for a resident with an indwelling catheter. The deficiency was observed when the catheter tubing of a resident, who was admitted with multiple diagnoses including a fracture of the neck of the femur, hypertension, and acute kidney failure, was found touching the floor. This observation was made during a review of the resident's care, which indicated that the catheter tubing should be positioned below the bladder level and away from the entrance room door. The resident's Minimum Data Set (MDS) indicated mildly impaired cognition and a need for substantial assistance with personal hygiene. During an interview, a Licensed Vocational Nurse (LVN) confirmed that the catheter tubing was indeed touching the floor, acknowledging the risk of infection. The Director of Nursing (DON) also stated that the tubing should not touch the floor due to the potential for bacterial transmission, which could lead to infection. The facility's policy on indwelling urinary catheter care, last reviewed in February 2025, mandates daily catheter care to promote hygiene and reduce infection risk. Despite these guidelines, the failure to maintain the catheter tubing off the floor was identified as a deficiency in the facility's infection control practices.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in ten of its 26 rooms, as observed during a recertification survey. Specifically, the rooms in question did not meet the regulatory requirement of at least 80 square feet per resident in multiple-resident rooms and 100 square feet in single-resident rooms. The rooms identified were 101, 102, 105, 107, 110, 112, 115, 117, 119, and 121, with square footage per resident ranging from 76 to 79.5 square feet, which is below the mandated minimum. Despite this deficiency, observations and interviews with residents and staff indicated that the space was sufficient for residents to move freely and for staff to provide care without restrictions. The facility had submitted an application for a Room Variance Waiver, which was dated 3/28/2025, to address the space deficiency. The waiver request indicated that the rooms, although smaller than required, did not interfere with the free movement of wheelchairs or other mobility devices and did not adversely affect the residents' health, safety, or well-being. Interviews with residents and staff confirmed that the rooms provided adequate space for care and privacy, and no concerns were raised regarding the lack of space. The facility's policy, last reviewed in February 2025, reiterated the requirement for room sizes, highlighting the discrepancy between policy and practice.
Failure to Document Pacemaker Information for Residents
Penalty
Summary
The facility failed to provide resident-centered care by not implementing its policy on pacemaker documentation for two residents. Resident 2 was admitted with diagnoses including atrial fibrillation and a cardiac pacemaker. The care plan for Resident 2, initiated shortly after admission, lacked essential pacemaker information such as the type, date of insertion, rate, pacemaker check lab, and contact number. Interviews with the MDS Nurse and Assistant Director of Nursing (ADON) confirmed the absence of this critical information, which should have been obtained upon admission. Similarly, Resident 5 was admitted with atrial fibrillation and a cardiac pacemaker. The physician's order for Resident 5 indicated missing details like the pacemaker's model and serial number. The care plan for Resident 5 also lacked information on the pacemaker's rate, check lab, and contact number. The MDS Nurse and ADON acknowledged the missing documentation and the ADON's unsuccessful attempt to obtain the information from the resident's cardiologist. The Director of Nursing (DON) stated that it is the facility's responsibility to gather pacemaker information upon admission. The facility's policy, reviewed shortly before the incidents, required periodic checks of residents with pacemakers and documentation of specific details in the care plan. The failure to adhere to this policy resulted in incomplete medical care information for the residents, potentially affecting their care and safety.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement its infection control policy by not offering COVID-19 testing to visitors upon entry, as required by their own policy. Interviews with family members, staff, and the Infection Preventionist (IP) revealed that visitors were not offered COVID-19 tests unless they exhibited symptoms, contrary to the facility's policy. The Director of Nursing (DON) stated that testing was not offered because the facility was not experiencing a COVID-19 outbreak and lacked resources to test every visitor. However, the facility's policy indicated that all visitors should be offered self-testing with a COVID-19 antigen test upon entry, regardless of symptoms or outbreak status. Additionally, the facility failed to place a resident on contact isolation as ordered by a physician. Resident 4, who was readmitted with a diagnosis of E. coli bacteremia, was not placed in a private isolation room despite having a physician's order for contact isolation. The IP and DON acknowledged that a private room was available, but the resident was instead placed in a shared room. The DON decided against isolation, believing the infection was not severe enough to warrant it, despite the physician's order. The facility's policy on infection prevention and control requires implementing contact precautions for known infections spread by direct or indirect contact. The failure to adhere to these policies and physician orders resulted in deficiencies in the facility's infection control practices, potentially putting residents, staff, and visitors at risk of spreading infections.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 3,109 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Van Nuys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Healthcare And Rehabilitation Center | 1.7 mi | — | 41 | 0 |
| Berkley Post-acute | 1.7 mi | — | 5 | 0 |
| Terrace Post Acute | 1.9 mi | — | 24 | 0 |
| Park View Nursing And Subacute | 2.3 mi | — | 7 | 0 |
| Eisenberg Village | 2.3 mi | — | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.