Balboa Nursing & Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on observation, interview and record review, the facility failed to provide resident safety when a resident (Resident 1) eloped form the facility without staff being aware. As a result, Resident 1 had successful elopement and was found on 8/19/25. Findings: On 8/18/25 the Department of Public Health received a report of elopement for Resident 1 at 8/16/25 and facility search done at 10 P.M. per the report.
During a review of Resident 1's facility record on 8/17/25 at 1:23 P.M. indicated .Resident left facility without MDs [doctor's] order, not informing staffs or signing out.received a report that Resident left the unit around lunch time. Resident does walk throughout building on a daily basis. Resident has not back yet, unknow location at this time. Staff has searched the building and surrounding neighborhood.Observed that established history of walking throughout the premises and able to go back to his room, ambulate around with no assistance. A building-wide search was promptly initiated.but the he could not be located. On 8/19/25 at 12 P.M., an observation of the facility was conducted. The facility building has three entrances/exit. The entrance/exit included the front lobby, the side entrance/exit by the parking area and at
the back. On 8/19/25 at 12:10 P.M. an interview with the Quality Assurance Nurse (QA). The QA stated Resident 1 was last seen on 8/16/25 around lunch time. QA stated Resident 1 was last seen around 12:18 P.M. using the elevator. On 8/19/2025 at 12:53 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 was independent. CNA 1 stated Resident 1 roam around and used elevator. On 8/19/25 at 2:03 P.M., an interview with Receptionist 1 was conducted. Receptionist 1 stated facility front entrance/exit opened from 8 A.M. to 8 P.M. Receptionist 1 stated some residents could be in the front lobby by the front entrance/exit. Receptionist 1 stated licensed nurse would inform me when residents would need supervision or could be by themselves. Receptionist 1 stated there were two elopements last week. On 8/19/25 at 4:10 P.M., an interview with the Administrator (ADM) and QA was conducted. The ADM stated there were three elopements in the last six (6) months and the two elopements occurred this month. ADM stated there three were entrances/exits in the building. QA stated the back entrance/exit was locked. ADM stated the facility would increase surveillance. ADM stated Resident 1's elopement happened on the weekend when there were less staff. QA stated nobody saw Resident 1 leaving the building. QA stated her expectation was to make sure elopement would not occur again for resident safety.
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
Event ID:
BALBOA NURSING & REHABILITATION CENTER in SAN DIEGO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIEGO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BALBOA NURSING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.