Balboa Nursing: Resident Missing 3 Days - CA
Staff discovered Resident 1 missing around 12:18 p.m. when he was last seen using the elevator. Nobody saw him leave the building through any of the facility's three exits.
The Quality Assurance Nurse told inspectors the resident "was independent" and "roam around and used elevator" throughout the building daily. Staff knew he could "walk throughout building on a daily basis" and typically returned to his room without assistance.
When staff realized he was gone, they searched the entire building and surrounding neighborhood. The facility record noted: "Resident left facility without MDs order, not informing staffs or signing out. Resident has not back yet, unknow location at this time."
The Department of Public Health received the elopement report on August 18, two days after the resident disappeared.
State inspectors found the facility's three entrances created multiple escape routes. The front lobby stayed open from 8 a.m. to 8 p.m., with residents allowed to gather near the exit. A side entrance connected to the parking area. Only the back exit remained locked.
The receptionist told inspectors that licensed nurses would inform her "when residents would need supervision or could be by themselves." But in this case, no one monitored the independent resident's movements despite his daily wandering pattern.
This wasn't an isolated incident. The Administrator revealed three elopements occurred in the past six months, with two happening just last week.
"There were two elopements last week," the receptionist confirmed during her interview.
The Administrator blamed staffing levels, explaining that "Resident 1's elopement happened on the weekend when there were less staff." The facility promised to "increase surveillance" following the incident.
The Quality Assurance Nurse acknowledged the supervision failure: "Nobody saw Resident 1 leaving the building." She told inspectors her expectation was "to make sure elopement would not occur again for resident safety."
Federal inspectors found the facility violated safety regulations by failing to provide adequate supervision to prevent accidents. The citation noted the facility "failed to provide resident safety when a resident eloped form the facility without staff being aware."
The inspection occurred on August 19, the same day Resident 1 was finally located after three days missing. Inspectors interviewed staff throughout the afternoon, documenting how an independent resident could disappear from a building where he was known to wander daily.
The facility's record keeping revealed the scope of the oversight failure. Staff noted the resident's "established history of walking throughout the premises and able to go back to his room, ambulate around with no assistance." Yet no system existed to track his movements or ensure his return.
With five residents escaping in six months, Balboa Nursing & Rehabilitation Center's supervision protocols proved inadequate for residents who could move freely but lacked judgment about leaving the building safely.
The August 19 inspection found the missing resident after a 72-hour search that included the building, neighborhood, and likely involved local authorities, though the facility provided no details about how or where he was ultimately discovered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Balboa Nursing & Rehabilitation Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BALBOA NURSING & REHABILITATION CENTER in SAN DIEGO, CA was cited for violations during a health inspection on August 19, 2025.
Staff discovered Resident 1 missing around 12:18 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.