Health inspection·December 5, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Physical Therapist 1 (PT 1) wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while providing physical therapy (PT) services in bed for one of one sampled resident (Resident 1) who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes).This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 11/19/2025 with diagnoses including right femur (thigh bone) fracture (broken bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and extended spectrum beta-lactamase (ESBL - enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotics). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/22/2025, the MDS indicated that Resident 2 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and Resident 2 was dependent on staff with toileting hygiene, shower/bathe, upper/lower body dressing, bed mobility (movement), and transfer.During a record review of Resident 2's Order Summary Report, the Order Summary Report indicated the following:- EBP: PPE required for high resident contact care activities. Indication - Indwelling catheter (a thin flexible tube inserted into the urethra to drain the bladder)/MDRO urine, ordered 11/20/2025.- Indwelling catheter care every shift for obstructive uropathy (OU - a condition in which the flow of urine is blocked), ordered 11/19/2025.- Skilled PT orders: PT evaluation and treatment daily five times per week for four weeks to address difficulty walking. Resident may receive therapeutic exercises and therapeutic activities, ordered 11/20/2025.During a concurrent observation and interview on 12/5/2025 at 2 p.m., with PT 1, observed EBP signage on the wall next to Resident 2's room door. Observed Resident 2 lying in bed, and PT 1 stated that he (PT 1) was going to provide range of motion (ROM - the full movement potential of a joint, or a series of joints, in any direction) exercise to Resident 2. PT 1 started to provide ROM exercise to Resident 2, but PT 1 wore gloves and a surgical face mask only and did not wear an isolation gown.During a concurrent observation and interview on 12/5/2025 at 2:07 p.m., with the Infection Preventionist (IP), observed the EBP signage for Resident 2 and observed PT 1 inside Resident 2's room and providing PT services to Resident 2. The IP stated that PT 1 should wear an isolation gown while providing PT services for Resident 2.During an interview on 12/5/2025 at 2:10 p.m., with PT 1, PT 1 stated that he (PT 1) provided ROM exercises to Resident 2 and then repositioned Resident 2's body. When PT 1 was asked Residents Affected - Few (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 12/05/2025 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)