Inspection·December 13, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/12/2024 at 11:26 a.m., with the Director of Nursing (DON), the DON stated that the facility does not offer COVID-19 testing to visitors upon entry to the facility because the facility does not have to. The DON stated that the facility does not have to offer COVID-19 testing because the facility does not have a COVID-19 outbreak (more cases of disease in time or place than expected). The DON further stated that the facility does not have the resources to offer a COVID-19 test to every visitor that comes through the facility door. During a follow-up interview on 12/13/2024 at 2:00 p.m., with the DON, the DON stated that when visitors will ask for a COVID-19 test, the facility will then offer the COVID-19 test. The DON stated if visitors don't ask, the facility will not offer COVID-19 testing. The DON stated the facility does not offer COVID-19 testing because it is not necessary. The DON stated the facility should offer COVID-19 testing when the facility is in an outbreak, however, the facility is not in an outbreak. During a review of the facility's policy and procedure titled, Masking Policy, reviewed 11/19/2024, the policy indicated although masking regardless of vaccination status may continue to be required by the facility or, if warranted based on local respiratory virus transmission. The following requirement is still in place: Before entry, all visitors must be offered self-testing with a COVID-19 antigen test and a well-fitting, high-quality mask with good filtration to wear during their visits. This is regardless of vaccination status. If a visitor tests positive for COVID-19, whether symptomatic (showing symptoms) or not, they should not be allowed to visit until after they recover. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024 with diagnoses that included abnormalities of gait (manner of walking or moving on foot) and mobility, need for assistance with personal care, and thrombocytopenia (low number of platelets [small cell fragments in our blood that form clots and stop or prevent bleeding] in the blood). During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 12/9/2024 with diagnoses that included sepsis (a life-threatening complication of an infection) and bacteremia (the presence of bacteria in the blood). During a review of Resident 4's physician's order dated 12/9/2024 at 6:32 p.m., the physician order indicated transmission-based precautions (steps taken to prevent spread of infection to others): contact isolation: Escherichia coli (E-coli - a type of bacteria commonly found in the intestines of humans and animals, but some types can make people sick)/bacteremia blood until 12/12/2024. During a concurrent interview and record review on 12/13/2024 at 9:15 a.m., with the IP, reviewed Resident 4's admission Record and Resident 4's physician orders. The IP stated Resident 4 was readmitted to the facility on [DATE]. The IP stated that she received an order for Resident 4 to be placed on contact isolation for E. coli/bacteremia on 12/9/2024. The IP continued to state that Resident 4 was not placed in a private/isolation room upon Resident 4's readmission. The IP stated that during the time of Resident 4's readmission, the facility was expecting a new admission (Resident 2) to be assigned to the private/isolation room. When asked if the new admission (Resident 2) required to be in a private/isolation room, the IP stated that the new admission (Resident 2) did not require isolation. During an interview on 12/13/2024 at 11:46 a.m., with the admission Coordinator (AC), the AC stated that the facility was aware that Resident 4 would be readmitted back to the facility on [DATE], however was not aware that Resident 4 required a private/isolation room upon readmission. The AC stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 2 of 3 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 12/13/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the facility was expecting a new admission, Resident 2, that was assigned and family expected to be in the private/isolation room. However, the new admission, Resident 2, did not arrive on 12/9/2024 as planned. Resident 2 was admitted to the facility on [DATE]. During a concurrent interview and record review on 12/13/2024 at 12:30 p.m., with the IP, reviewed the facility's census (daily list indicating resident names with corresponding room numbers) dated 12/8/2024 (census for 12/9/2024), 12/9/2024 (census for 12/10/2024), and 12/10/2024 (census for 12/11/2024). The IP stated that there was a private/isolation room available on 12/9/2024, 12/10/2024, and 12/11/2024. The IP reviewed Resident 2's admission Record and stated that Resident 2 was admitted to the facility on [DATE] and was assigned to the private/isolation room. The IP reviewed Resident 4's admission Record and stated that Resident 4 was admitted on [DATE] and placed in a room with roommates with curtains to be drawn. The IP stated that Resident 4 should have been placed in a private/isolation room because the facility had an available room. When asked why Resident 4 was not placed in an isolation room, the IP did not answer. During a concurrent interview and record review on 12/13/2024 at 1:06 p.m., with the DON, reviewed Resident 4's physician orders. The DON stated that Resident 4 had an order for contact isolation dated 12/9/2024. The DON stated that there was a private/isolation room available upon Resident 4's readmission on [DATE]. The DON stated that Resident 4 required a private/isolation room because the facility received an order from the physician for contact isolation. The DON continued to state that the DON decided not to place Resident 4 in a private/isolation room because the infection was not in Resident 4's urine, or sputum (mucus and other matter brought up from the lungs by coughing), but the infection was in the blood and Resident 4 had no active bleeding. The DON stated Resident 4 did not have a true infection and did not require isolation precautions, despite the physician's order. The DON further stated that the IP had a proactive approach and the IP discussed and received an order for contact isolation. The DON stated Resident 4 should have just been placed on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). During a review of the facility's policy and procedure titled, Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, reviewed 11/19/2024, the policy indicated it is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions .Contact Precautions are used with a known infection that is spread by direct or indirect and the resident or the resident's environment .Room Placement: iii. When private rooms are not available, some residents may be cohorted (a group of people with a shared characteristic) or per an alternative risk-based approach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 3 of 3