Veterans Home Of California - Barstow

Based on observation, interview, and record review, the facility failed to ensure that staff followed infection prevention and control practices when Custodian 1 did not use appropriate personal protective equipment (PPE) while performing environmental cleaning in a room under Enhanced Barrier Precautions (EBP).This failure had the potential to result in the spread of infection putting both residents and staff at risk.Findings:During a concurrent observation and interview on 4/19/26 at 12:02 PM with Certified Nursing Assistant (CNA) in Resident 6 and Resident 25's room, two EBP signs were observed posted by the room's entrance. CNA stated Resident 25 was on EBP for his wound on the left leg and Resident 6 was on EBP for his chronic suprapubic catheter.During an observation on 4/22/26 at 9:38 AM in Resident 6 and Resident 25's room, where two EBP signs were posted, Custodian 1 was observed not wearing gloves and gown while sweeping the floor, touching the beds, curtains, and dresser.During a concurrent observation and interview on 4/22/26 at 9:40 AM with the Hospital General Service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to document non-pharmacological interventions for five of five sampled residents (Residents 1, 21, 24, 25, and 31) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Alprazolam (generic for Xanax, a medication for anxiety) 0.5 milligrams (mg) OD (orally disintegrating, dissolves in the mouth), take one tablet by mouth and allow to dissolve daily for anxiety, manifested by mood changes, irritability, negative thoughts. Monitor for behavior and side effects every shift, dated 2/13/25; b. Bupropion (generic for Wellbutrin XL, extended release, a medication for depression) 150 mg, take one tablet by mouth daily for depression disorder m/b (manifested by) verbalization of hopelessness and sadness. Monitor for behaviors and side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. During a review of Resident 31's Physician Orders on 4/30/25 at 9:11 a.m., the physician's orders indicated Resident 31 had three active orders for blood pressure medications: a. Amlodipine (generic for Norvasc, a medication for high blood pressure) 5 milligram (mg, a unit of measure) tablet. Take one tablet by mouth daily, hold for SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110, dated 9/10/24. b. Chlorthalidone (generic for Thalitone, a medication for high blood pressure) 25 mg tablet. Take one tablet by mouth every morning for hypertension (blood pressure), hold if SBP less than 110 or if DBP (diastolic blood pressure, the bottom number in a blood pressure reading) less than 50, dated 9/10/24. c. Metoprolol succinate (generic for Toprol XL, a medication for high blood pressure) 50 mg ER (extended release). Take one tablet by mouth every evening. Hold if SBP less than 110, DBP less than 50 or HR (heart rate) less than 50, ordered 9/10/24. The holding parameters were updated to hold if SBP less than 105, HR less than 50 on 2/7/25. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the accurate provision of medication for one out of five sampled residents (Resident 1) when Resident 1 did not receive hypoglycemia (low blood sugar) medication as ordered by the prescriber. This failure had the potential for Resident 1 to experience symptoms of hypoglycemia, including confusion and dizziness. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and b. Glutose 15 gel (brand name for glucose (sugar) 15 grams, a medication to treat low blood sugar) by mouth as needed for blood sugar (BS) less than 80, dated 12/10/24. A review of Resident 1's January through April 2025 Medication Administration Records (MAR) indicated Resident 1's BS was less than 80 on the following dates and times: - 1/3/25 at 6:00 a.m. BS 70 - 3/11/25 at 6:00 a.m. BS 76 - 4/21/25 at 6:00 a.m. BS 78 The January through April 2025 MARs indicated Resident 1 did not receive Glutose 15 as ordered on any of the above dates.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when two boxes of eye drops were found in a bin labeled and full of ear drops in one of one sampled medication rooms. This failure had the potential for residents to receive the wrong medication, which could result in the residents experiencing negative health outcomes. Findings: During a concurrent observation and interview on 4/28/25 at 11:56 a.m., with the Director of Staff Development (DSD) 1, a tour of the Skilled Nursing Facility (SNF) unit medication room was conducted. Eight boxes of ear drops were observed in a black bin labeled, EAR DROPS. Two boxes of eye drops (one box of Refresh and one box of Visine, both used to treat dry eyes) were also stored in the same bin. DSD acknowledged two eye drops were in the ear drop bin. During a concurrent interview and record review on 5/1/25 at 2:27 p.m., with the Director of Nursing (DON) 1, the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed by the facility on 5/31/24 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy for Theft and Loss Reporting and Investigation for one of three sampled residents (Resident 1), when the Report of Suspected Dependent Adult-Elder Abuse (Form SOC 341) for Resident 1 was not completed and sent to the ombudsman. This failure had the potential to result in an inadequate investigation of the loss of Resident 1's property. Findings: On 1/6/25 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident loss of one hundred dollars and a fifty dollar gift card. Resident 1, an [AGE] year-old male admitted on [DATE], with diagnoses of Hypertension, and Emphysema. During an interview on 1/6/25 at 10:50 a.m. with the Health and Safety officer (HS 1), HS 1 stated the incident was reported on 12-29-24 by the CNA (CNA 1) for Resident 1. CNA 1 verified the resident had one hundred dollars and a fifty dollar gift card in his wallet and the money and gift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that food was stored in a safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe. 2. The kitchen freezer contained foods that were not dated and labeled. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During a concurrent observation and interview on 6/4/2024 at 9:02 a.m. with Food Manager (FM) in the kitchen, there was a spatula (kitchen utensil used to mix ingredients) with cracks on the right lower side and a yellow dried substance on the top edges. FM confirmed the spatula was not safe to be used due to the risk of food contamination and food-borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services-Sanitation (All Homes), dated 11/5/2023, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair (i.e. free…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a safe and comfortable working environment for staff when the water temperature of the kitchen's hand washing station was 156.1 degrees Fahrenheit (unit used to measure temperature). This failure had the potential for staff burning their hands and poor handwashing practices, leading to a potential spread of infection. Findings: During a concurrent observation and interview on 6/4/2024 at 11:06 a.m. with the Director of Dietetics (DOD) and the Food Manager (FM) in the kitchen, the Surveyor checked the water temperature at the hand washing station using a thermometer (a device that measures temperature), and the water temperature registered at 156.1 degrees Fahrenheit. DOD and FM confirmed the water temperature was too hot and had the potential for staff to burn their hands. DOD stated the hot water has always been out of range, and there was no work order to fix it. FM stated the hand washing water temperature should be 120 degrees Fahrenheit, but there was no work order. During a review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview , the facility failed to ensure a safe, clean, and comfortable environment, when the wheelchair of one of 15 sampled residents (Resident 29) was not found in good working condition with a torn, cracked, and frayed armrest. This failure had the potential to violate Resident 29's rights to a safe, clean, and comfortable environment. Findings: During a concurrent observation and interview on 6/5/2024 at 8:42 a.m. with Resident 29, Resident 29 was observed sitting in their wheelchair. The wheelchair had a large tear on the right armrest with the cushion exposed. In addition, the armrest had a large worn area consisting of multiple rough raised cracks and the edges were frayed with white lining showing through the black armrest cover. Resident 29 stated that the armrest was torn when they received the wheelchair from the facility. Resident 29 further stated that the worn armrest bothered them, was not comfortable, and did not look nice. During an interview on 6/5/2024 at 3:20 p.m. with Lead Registered Nurse (LRN), the LRN stated the armrest was torn,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to date an opened bottle of Polyethylene Glycol (medication to treat constipation) for unsampled Resident 30. This failure had the potential for Resident 30 to receive expired and less than optimal medications. Findings: During a review of Resident 30's Face Sheet (resident demographics), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language and problem-solving abilities that are severe enough to interfere with daily life) and chronic pain. During a review of Resident 30's Quarterly Minimum Data Sheet (MDS, standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 30 had a severe cognitive impairment. During a concurrent medication storage observation and interview on [DATE] at 10:11 a.m. with Licensed Vocational Nurse (LVN) 3, the medication cart for the 600 POD had an opened bottle of Polyethylene Glycol for Resident 30 which was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR, a record of all medications administered to a resident) was accurately documented on 6/2/2024 for two of 15 sampled residents (Residents 19 and 48) when: 1. For Resident 19, a licensed nurse did not document that medications were administered for the 8 a.m. dose on 6/2/2024. 2. For Resident 48, a licensed nurse did not document that medications were administered for 10 a.m. dose on 6/2/2024. These failures had the potential to result in inaccurate medication administration including underdosing or overdosing Residents 19 and Resident 48. Findings: 1. During a review of Resident 19's Face Sheet (resident demographics), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses of high blood pressure and urinary incontinence. During a review of Resident 19's MAR, dated June 2024, the MAR indicated, on 6/2/24, for the 8 a.m. administration time, there were no staff initials…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain the kitchen dishwasher in a safe operating condition. This failure had the potential to result in safety concerns. Findings: During a concurrent observation and interview on 6/4/2024 at 9:00 a.m. with Food Service Technician (FST) 2 in the kitchen, the dishwasher was spraying water resulting in a pool of water on the floor. FST 2 stated the spraying started when the machine was turned on. During an interview on 6/5/2024 at 8:40 a.m. with Chief Plant Operations (CPO), CPO stated the dishwasher machine was spraying water because it was missing the multi-flap curtains. During an interview on 6/5/2024 at 8:50 a.m. with the Food Manager (FM), FM stated the expectation was to prevent the water spraying out of the dishwasher machine, due to infection control and safety issues. During a review of the dishwasher's manual, [undated], the manual indicated, Multi-flap curtains are used throughout the dishwasher to keep moisture inside and reduce the potential of hot water injury. During a review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.