Health inspection·May 25, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with dignity and respect when Resident 1 was placed in the facility activity room wearing a gown (a short collarless garment that ties in the back), with her hair uncombed, and her face unclean and unwashed. This deficient practice had the potential to result in decreased self-esteem and self-worth. Findings: A review of Resident 1`s admission Record indicated that the facility admitted the resident on 04/29/2023 with diagnoses that included, obesity (abnormal or excessive fat accumulation that presents a risk to health), Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes sugar), and a need for assistance with personal care. A review of Resident 1's History and Physical (H&P) indicated that the resident did not have the capacity to understand and make decisions. During an interview with the Director of Nursing (DON) on 5/15/2023 at 3:45 p.m., DON stated that on 5/2/2023, Registered Nurse Supervisor 3 (RN3) responded to a family member`s complaint and went to the activity room where Resident 1 was observed wearing a gown and was not groomed. DON stated that residents in the facility should look presentable and properly groomed as part of the care that residents receive in the facility. DON stated it is undignified for a person to be unkempt and unclean. During an interview with RN 3 on 5/25/23 at 12:14 p.m., RN 3 stated that on 5/2/2023 at around 2:00 p.m., Resident 1 ' s responsible party (Responsible Party 1 [RP 1]) complained to RN 3 that Resident 1 was in the activity room not wearing her dentures, not being cleaned, and wearing a gown which was open and exposing the resident ' s back. RN3 stated that she observed Resident 1 in the activity room wearing a gown, but the gown was tied, and the back was not exposed. RN3 stated that she further observed Resident 3 with her hair uncombed, and her face unclean and unwashed. RN3 stated that she observed Resident 1 without her dentures. RN3 stated that she spoke with Certified Nurse Assistant 3 (CNA3) and reminded CNA 3 that residents have to be cleaned and groomed before they are brought to the activity room and should be wearing their own personal clothing. RN3 stated its not dignified for anyone to be unclean and dirty while attending or participating in any group activity. RN3 stated that it is embarrassing for a person to be left dirty in the presence of other residents in the facility. During an interview with CNA 3 on 5/25/2023 at 2:15 p.m., CNA 3 stated that on 5/2/2023 she was the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056180 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)