Veterans Home Of California - West Los Angeles

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to timely follow up on the dental treatment recommended for one of two residents (Resident 1). On 9/17/2024, the dentist had recommended oral surgery for Resident 1. This failure had resulted in fluctuates of Resident 1's mood and potentially affecting his overall quality of life. The referral for the oral surgery was only sent again by the facility on 6/25/2025, which was a delay of 281 days, equivalent to 9 months and 8 days. During an observation and concurrent interview on 8/19/25 at 12:30 p.m. with Resident 1, a [AGE] year-old male with a history of dementia (progressive or persistent loss of intellectual functioning and memory), atrial fibrillation (abnormal heart rhythm), and poor dentition, was observed with upper front teeth (numbers 7-10) visibly missing or decayed, eating mashed potatoes. Resident 1 stated, he lost his front teeth years ago and stopped using his partial lower dentures due to pain. Resident 1 stated, the dentist…

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 develop and implement a resident centered comprehensive care plan with interventions for resident preferences including to be left alone in the shower room and aiding with showering, to meet the needs of one of three sampled residents, Resident 1. This failure resulted in Resident 1's unsupervised fall, fractured breastbone, breastbone bruise, fractures of thoracic spine (the mid-back section of the spine), scalp bruise and 2-day hospital stay. Findings: Resident 1 was a [AGE] year-old female admitted to the skilled nursing facility on [DATE], with a history of legal blindness and severe osteoarthritis (degeneration of joint cartilage and the underlying bone, causes pain and stiffness, especially in the hip, knee, and thumb joints. During an observation and interview on 4/22/25 at 2:40 p.m. Resident 1 was observed in bed laying face up, and stated she recalled the fall event on 4/15/25. Resident 1 stated she was legally blind but could see…

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 multiple allegations of sexual abuse involving residents diagnosed with dementia were reported to the required authorities when: 1. The facility did not notify local law enforcement, the Ombudsman (independent advocate who protects the rights and ensures the well-being of patients in long-term care facilities), the state survey agency (CDPH, California Department of Public Health), and the facility's Administrator (ADMIN) immediately, but not later than 2 hours after the allegation was made, when one of five sampled residents (Resident 1) reported an allegation of rape. 2. The facility did not notify the state survey agency (CDPH, California Department of Public Health) immediately, but not later than 2 hours after the allegation was made, when one of five sampled residents (Resident 1) was sexually abused by Resident 2 in the common area, witnessed by staff. These findings resulted in the delay of the investigation process by local law…

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 food safety and sanitation guidelines were followed when: 1. Two kitchen staffs did not wear hair restraints while in the kitchen. 2. Two of three ice machines were dirty. 3. Three of three water filters for the ice machine were expired. 4. Two of three dishwashers did not reach minimum temperature for wash cycle. 5. One bottle of expired rice wine vinegar in dry storage. 6. One kitchen staff did not wash hands between handling dirty to clean dishes These failures posed the risk for food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile resident population of 144 facility residents who received food prepared in the kitchen. Findings: 1a. During an observation on 12/2/24 at 11:26 a.m. in the Main Kitchen, Food Service Technician (FST) 6 entered kitchen without hair net and took prepared meal trays from the [brand name] food warmer labeled SNF (skilled nursing facility) C2. During an interview on 12/2/24 at 11:46 a.m. with the Food…

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's Quality Assurance Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) committee failed to identify, prioritize, and address the staffing need for a Director of Dietetics to provide qualified oversight of all kitchen services. These failures resulted in compromising food safety and the potential to cause severe food borne illnesses and injuries in a medically fragile population of 144 residents. (Refer to F802, F805, F812) Findings: During a concurrent interview and record review on 12/6/24 at 10:00 a.m. with QAPI representatives including the Director of Nursing (DON) and the Standards and Compliance Manager (SCM), the QAPI Meeting Minutes, dated January to November 2024 were reviewed. The minutes indicated no focus on meeting the staffing need for a Director of Dietetics that would provide qualified oversight over dietary staff to deliver safe and sanitary food service and ensure kitchen staff was competent in performing their job duties safely and effectively. The DON and SCM…

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 kitchen staff were routinely trained and evaluated for competency skills when kitchen staff were unable to effectively operate the dishwasher in the satellite kitchens, B207-Food Prep and B307-Food Prep. This failure had the potential for residents to be served food on unclean dishes and result in food borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 118 residents. Findings: During an observation on 12/2/24 at 11:39 a.m. in the B307-Food Prep satellite kitchen, the highest temperature the [brand name] dishwasher, a high temperature dishwasher (dishwasher that used high temperatures to clean and sanitize), reached during wash cycle was 148 degrees Fahrenheit (unit of measurement). During an interview on 12/2/24 at 11:41 a.m. with Food Service Technician (FST) 1, FST 1 stated he did not know if the dishwasher needed to maintain a minimum temperature of 150 degrees Fahrenheit during the wash cycle. During an…

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 ensure the therapeutic diet was served in accordance with the diet order for three residents (Resident 61, 102, and 139). This failure had the potential for choking in medically fragile residents which can lead to aspiration (when secretions, food material or gastric secretions descend into the lungs) and death. Findings: 1a. During a review of Resident 102's Face Sheet (demographics), the Face Sheet indicated Resident 102 was admitted on [DATE] with a diagnosis of cerebral infarct (type of stroke that can cause brain injury). During a review of Resident 102's Diet Order dated 9/10/24, the Diet Order indicated, Resident 102 had an active order for mechanical soft, finely chopped diet (textured/modified diet that consists of moist and soft foods that were easier to chew and swallow). During an observation on 12/3/24 at 11:30 a.m. on Unit C3, a meal tray delivery cart, with a hot and cold side was parked by the nurse's station. Staff were…

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 an accurate Minimum Data Set (MDS, federally mandated assessment tool used to evaluate the health of nursing home residents) was completed for one of 29 sampled residents (Resident 119). This failure had the potential to result in negative outcomes for Resident 119 due to missed specialized services. Findings: During a review of Resident 119's Face Sheet (demographic), the Face Sheet indicated Resident 119 was admitted on [DATE] with diagnoses including schizotypal disorder (severe mental health condition), obsessive-compulsive personality disorder (mental disorder that can cause harmful thoughts and behaviors) and anxiety disorder. During a review of Resident 119's Preadmission Screening and Resident Review II (PASRR II, federally mandated review process that screens individuals seeking admission to Medicaid-certified nursing facilities for mental illness or intellectual and developmental disability), dated 2/24/23, the PASRR II indicated…

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 implement the Safe Smoking Care Plans for two of 29 sampled residents (Resident 89 and Resident 142) when: 1. a.Resident 89 was smoking in a non-smoking area without supervision. 1. b.Resident 89 was escorted by staff to smoke in a non-smoking area. 2. Resident 142 was not offered a smoking apron (protective apron to prevent burns and injuries from cigarettes and ash). These failures had the potential to cause severe injuries from fires and burns to Resident 89, Resident 142, other residents, staff, and visitors. Findings: 1. a. During a review of Resident 89's Face Sheet (demographics), the Face Sheet indicated Resident 89 was admitted on [DATE] with diagnoses including nicotine dependence and mild cognitive impairment (condition that causes memory or thinking difficulties). During a review of the facility provided document titled, SNF (skilled nursing facility) Resident Smokers- 2024, current as of 12/2/24, the document indicated…

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 ensure measures to prevent smoking accidents were implemented for two of 29 sampled residents (Resident 89 and Resident 142) when: 1.a. Resident 89 was smoking in a non-smoking area without supervision. 1.b. Resident 89 was escorted by staff to smoke in a non-smoking area. 2. Resident 142 was not offered a smoking apron (protective apron to prevent burns and injuries from cigarettes and ash). These failures had the potential to cause fires and burns, endangering the health and safety of Resident 89, Resident 142, other residents, staff, and visitors. Findings: 1.a. During a review of Resident 89's Face Sheet (demographics), the Face Sheet indicated Resident 89 was admitted on [DATE] with diagnoses including nicotine dependence and mild cognitive impairment (condition that causes memory or thinking difficulties). During a concurrent observation and interview on 12/2/24 at 1:17 p.m. by the Main Entrance with Resident 89, Resident 89 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.

Based on observation, interview, and record review, the facility failed to follow safe food handling protocol for resident personal food when: 1. Food was not labeled or dated. 2. Expired food was not disposed of and left in the refrigerator. This failure had the potential to result in residents consuming food that did not follow their dietary restrictions or allergies, and had gone past safe consumption window, leading to the increased risk of food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) . Findings: 1a. During a concurrent observation and interview on 12/2/24 at 4:01 p.m. with Registered Nurse (RN) 4 on Unit C2, there was an opened jar of pickles undated in the Residents' communal refrigerator. RN 4 stated, It should have an expiration date. RN 4 further stated if a food was found in the Residents' communal refrigerator without a name or date, then the food item should have been thrown away. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Service- Outside Food for Residents, dated…

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 two of four outside dumpsters' lids were closed. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 144 residents. Findings: During a concurrent observation and interview on 12/3/24 at 10:21 a.m. with the Chief Engineer (CE) in the loading dock area, two of four large dumpsters did not have a lid to cover the garbage. The CE confirmed there were no lids for the dumpsters. During an interview on 12/4/24 at 3:22 p.m. with the Chief of Plant Operations (CPO), the CPO stated, I have never heard I need a lid for the dumpsters. During a review of the U.S [United States] Food and Drug Administration's (FDA) Food Code, dated 2022, the FDA Food Code indicated in Section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD…

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 follow their policy and procedure for unusable drugs when morphine sulfate (a prescription narcotic pain medication) with no active Physician's Order was not removed from the medication cart. This failure resulted in the unauthorized administration of morphine sulfate without a physician's order to Resident 1. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted on [DATE] with diagnoses including osteoarthritis (chronic joint disease that can cause pain) of hip. During a review of Resident 1's Morphine Sulfate Inventory Log, current as of [DATE], the log indicated Licensed Vocational Nurse (LVN) signed out dose #13 on [DATE] at 00:00 a.m. During a review of Resident 1's Physician's Orders, dated [DATE], the orders indicated, Morphine sulfate 15 milligram tablet to be taken by mouth twice a day as needed for moderate to severe pain. The order indicated an end date of [DATE]. Facility…

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 Resident 1 was free of any significant medication error when Resident 1 was administered morphine sulfate (a prescription pain medication) without a physician's order. This failure resulted in the unauthorized administration of morphine sulfate. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted on [DATE] with diagnoses including osteoarthritis (chronic joint disease that can cause pain) of hip. During a review of Resident 1's Morphine Sulfate Inventory Log, current as of 10/31/24, the log indicated Licensed Vocational Nurse (LVN) 1signed out dose #13 on 10/18/24 at 00:00 a.m. During a review of Resident 1's Physician's Orders, dated 7/15/24, the orders indicated, Morphine sulfate 15 milligram tablet to be taken by mouth twice a day as needed for moderate to severe pain. The order indicated an end date of 10/12/24. The facility was unable to provide documentation of an active physicians order…

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 maintain an effective infection control training program when the facility did not develop a written policy and procedure, sufficiently train, and track competency regarding Enhance Barrier Precautions (EBP, use of gown and gloves during high contact resident care activities, designed to reduce spread of infections) for all staff. This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases and resulted in staff being unable to demonstrate infection control competency and safety in caring for a medically-compromised resident population of 143. Findings: During a review of Centers for Medicare and Medicaid Services (CMS)'s memorandum titled, QSO-24-08-NH: Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, the memorandum indicated, 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO- germ resistant to many antibiotics) that…

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 infection control and prevention measures were implemented when: 1. Multiple staff failed to implement Enhanced Barrier Precautions (EBP, an intervention to reduce the transmission from germs from one resident to the next) for 4 of 13 sampled residents. 2. Laundry staff in Yellow Zone (designated area with restrictions to limit spread of COVID-19, a highly contagious virus) was not wearing N95 mask (air-filter mask used to decrease spread of respiratory diseases) and eye protector. These failures had the potential to result in the spread of infection diseases among residents, staff, and visitors. Findings: 1. During an interview on 7/30/23 at 2:30 pm with the Infection Preventionist (IP), IP stated the facility implemented the guidance from the Centers of Medicare and Medicaid Services (CMS) related to Enhanced Barrier Precautions in April of 2024. IP stated residents who had wounds, indwelling devices, and residents colonized (having a high concentration of a specific micro-organism without causing…

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 implement physician's orders for neurological assessments (frequent assessments to evaluate brain and nervous system functioning and changes) for two of three sampled residents (Resident 1 and Resident 2) after the residents sustained falls. These failures had the potential to delay identifying changes in the residents' neurological status which could result in the delay of necessary treatments. Findings: 1. a. On 7/30/24 at 1:52 p.m., a review of Resident 1's medical record was conducted. The medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, and abnormalities of gait and mobility. During a review of Resident 1's IDT [interdisciplinary team] Meeting Notes, dated 7/16/24, the IDT Meeting Notes indicated, Resident 1 had a fall on 7/1/24. During a review of Resident 1's Physician Order, dated 7/1/24, the Physician Order indicated, .monitor neuro…

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 report abuse allegation to the State Survey Agency, for one of four sampled residents (Resident 1) when Resident 2 displayed unwanted sexual actions in front of Resident 1. This failure resulted in undue emotional distress for Resident 1 and the potential for other residents to endure sexual abuse in a clinically vulnerable population. Findings: On 2/22/2024, an unanounced visit was made to the facility to investigate a complaint. The complaint involved Resident 2 masterbating in front of Resident 1 on 2/19/2024, at 7:40 A.M., while both residents were in the dining hall. This incident was witnessed by two facilty dining hall staff. During a review of Resident 1's History & Physical (H&P), dated 1/31/2024, the H&P indicated, Resident 1 was a [AGE] year old female, admitted on [DATE] with a history of major depressive disorder, dementia (memory loss), Chronic Obstructive Pulmonary Disease (COPD, a condition caused by damage to the airways,…

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: Follow medication manufacturer's specifications when the pharmacy labels indicated no dosage amount and when no dosing cards were present for the Diclofenac gel tubes (a medication for pain) ordered for Residents 24, 65, 98, 107, 114, 7, 12, 31, 37, 52, 60, 83, 86, 99, 101, and 136. These failures resulted in the potential for 16 residents to be inadequately treated for pain. Findings: During a review of Physician's Orders for Residents 24, 65, 98, 107, 114, 7, 12, 31, 37, 52, 60, 83, 86, 99, 101, and 136 showed no dosage or amount was specified for Diclofenac gel. During a review of Lexicomp (a nationally recognized drug reference), the manufacturer for Diclofenac indicated, . Apply up to 4 g ([gram] a unit of measurement) to each affected area up to 4 times daily; maximum dose per area: 16g/day; maximum total body dose (all areas combined): 32 g/day .Use dosing card to measure dose. During a concurrent observation and interview on 1/22/24 at 11:45 AM with Registered Nurse (RN) 2, at the treatment cart for…

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 ensure two residents, Residents 85 and 40, were free from unnecessary psychotropic medications (medications that affect the mind, emotions, and behavior) when: 1. Resident 85 was administered Seroquel (medication used to treat mental health conditions) and Doxepin (medication used to treat depression). a. There was no documented evidence that a gradual dose reduction (GDR) was attempted for Seroquel or Doxepin, b. There was inadequate side effect monitoring for Doxepin, c. The facility did not use a formalized rating scale for extrapyramidal symptoms (EPS - involuntary movement that can not be controlled) for Seroquel according to manufacturer specifications. 2. Resident 40 was administered risperidone (a medication used to treat mental health conditions) the facility did not use a formalized rating scale for extrapyramidal symptoms for risperidone use according to manufacturer specifications. These failures resulted in the potential for…

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 ensure dental services were provided to three out of 30 sampled residents (Resident 56, Resident 101, and Resident 40) when: 1. Resident 56 needed treatment for dentures that no longer fit. 2. Resident 101 did not have a referral for an oral surgeon. 3. Resident 40 had no dental examination since 2022. These failures had the potential for infection, pain or other oral complications. Findings: 1. During a concurrent observation and interview on 1/25/24 at 8:29 AM with Resident 56 and family member (FM) 2, in Resident 56's room, Resident 56 had missing upper and lower teeth. A partial upper denture and full lower denture were observed in a container inside the bedside table drawer. FM 2 stated Resident 56 did not wear his dentures, because they no longer fit properly. FM 2 stated, We ended up having to grind his food to eat. FM 2 stated, she arranged outside dental care for Resident 56, because the facility dentist had left a year and a…

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 ensure the resident was educated regarding his inhaler including the expiration and beyond use date for one of 30 sampled residents (Resident 70). These failures had the potential to result in Resident 70 experiencing adverse effects by overdosing or underdosing the medication, acquiring an oral fungal infection, not having appropriate symptom relief, and using expired medication. Findings: During a review of Resident 70's Face Sheet, (demographics record) dated [DATE] indicated, Resident 70 was admitted to the facility on [DATE], with diagnoses which included other diseases of the respiratory system. During a concurrent observation and interview on [DATE] at 4:05 PM with Resident 70, in his bedroom a Symbicort inhaler (a metered dose inhaler which dispenses the drug that is inhaled to treat lung condition) was observed on Resident 70's bedside table. There was no expiration date labeled on the inhaler. Resident 70 stated, I take two…

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 provide a clean, and sanitary environment when: 1. Resident 141's windowsill and carpet were observed with an accumulation of grayish white colored substance and the carpet with unknown debris. 2. The base of two of six bedside tables were observed in the day room with dried brown colored residue. These failures had the potential to develop health problems that could potentially affect the wellbeing of the residents. Findings: 1. During a concurrent observation and interview on 1/23/24 at 9:49 AM, with Resident 141, the windowsill and the carpet were observed with an accumulation of grayish white colored substance in Resident 141's room. Resident 141 stated he already informed the staff, but it was not addressed. During an interview on 1/23/24 at 9:55 AM with the Supervising Registered Nurse (SRN) 4, SRN 4 stated Resident 141's room needed to be cleaned. During an interview on 1/23/24 at 9:57 AM with Custodian Supervisor (CS), CS stated, resident's rooms should be cleaned daily. 2. During a concurrent…

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 ensure, a comprehensive individualized plan of care for dentition (missing teeth) was developed for Resident 56. This failure had the potential to affect Resident 56's health status by not receiving the necessary care and services for his changing needs. Findings: During a concurrent observation and interview on 1/25/24 at 8:29 AM with Resident 56's family member (FM) 2, in Resident 56's room, Resident 56 had missing upper and lower teeth. FM 2 stated Resident 56 did not wear his dentures because they no longer fit properly. FM 2 stated, We ended up having to grind his food to eat. A partial upper denture and full lower denture were observed in a container inside the bedside table drawer. During a review of Resident 56's clinical record, the clinical record indicated he was admitted to the facility on [DATE], with diagnoses that included disorders of the teeth and supporting structures. During a review of a Physician's order dated…

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 update the nursing care plan (an individualized plan that provides direction for a resident's medical care) for one of 30 sampled residents (Resident 101). This failure had the potential to affect the provision of care for the resident. Findings: During a review of Resident 101's clinical record, the record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including: adult hypertrophic pyloric stenosis (narrowing of the pylorus, the opening from the stomach, into the small intestine), morbid (severe) obesity, esophagitis (inflammation that damages the tube running from the throat to the stomach), and type two diabetes mellitus (a chronic condition that affects the way the body processes sugar). During an interview on 1/24/24 at 9:59 AM with Registered Nurse (RN) 1, RN 1 stated that Resident 101 does not have or wear dentures. During an interview on 1/25/24 at 8:35 AM with Resident 101, Resident 101 stated that he had partial…

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 ensure a Physician's order to avoid straws was followed for one of 30 sampled residents (Resident 38). This failure had the potential to put Resident 38 at risk for aspiration (sucking liquid into the airway and lungs). Findings: During breakfast observation on 1/23/24 at 8:08 AM, in Resident 38's room, Resident 38 was feeding himself scrambled eggs and drinking a carton of milk with a straw. Resident 38 stated, I'm finished, thank you, but did not respond to questions. The meal ticket on Resident 38's breakfast tray indicated, No Straws. In addition, a straw was observed in the water pitcher on his bedside table. A sign on the wall indicated, STOP PLEASE REMEMBER TO . OPEN MILK AND PUT IN STRAW . During an interview on 1/23/24 at 8:29 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, the straw did not come on the meal tray. CNA 2 stated Resident 38, Demanded a straw so we have to go get it. During a review of Resident 38's face…

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 provide adequate supervision for one of 30 sampled residents (Resident 34) when Resident 34, who was at risk for elopement, exited the facility undetected by staff and was found in the employee parking lot. This failure had the potential to result in Resident at risk for injury. Findings: During an interview on 1/22/24 at 7:26 PM with family member (FM) 1, FM 1 stated, on 11/3/23, she was notified by the facility that Resident 34 was found outside in the employee parking lot. FM 1 stated she was surprised by this information since Resident 34 wore a wander guard bracelet and had a wander guard tag on his walker (wander guard is a system which tracks the location of residents who are at risk for elopement and triggers an alarm when the resident is in close proximity to exit doors). FM 1 further stated Resident 34 walked slowly and would have traveled past the Unit C 3 nursing station, out the Unit C 3 exit doors, down the elevator to the first floor, past the security desk, out the main lobby doors, and down…

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 ensure their medication error rate did not exceed five percent or greater. There were 31 opportunities with two observed errors resulting in a medication error rate of 6.45%. These failures resulted in: 1. Placing Resident 9 at risk for anemia (low iron) when Registered Nurse (RN) 8 administered less than the ordered amount of ferrous sulfate (iron). 2. Placing Resident 9 at risk for adverse drug interactions (An action of a drug on the effectiveness or toxicity of another drug) and potentially causing a blockage in Resident 9's gastrostomy tube (a tube placed into the stomach to deliver nutrition directly to the stomach), when RN 8 failed to flush water in between each administration of medications into Resident 9's gastrostomy tube. Findings: 1. During a review of Resident 9's Face Sheet (demographics record) dated 1/24/24, indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included anemia. During an…

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 ensure all drugs and biologicals used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. Medications were found in treatment carts with missing or unreadable pharmacy labels, 2. Discontinued medications found inside both medication and treatment carts, 3. An expired open tuberculin vial was found in the medication storage room refrigerator. These failures had the potential for medications to be administered incorrectly causing an underdosing or overdosing of medications, or to be administered to the wrong residents causing harm to the resident, and inaccurate tuberculosis test results. Findings 1. During a concurrent observation and interview on [DATE] at 11:45 AM in Unit C3 Medication Storage Room, with Registered Nurse (RN) 2, an unlabeled Mupirocin ointment (medication that treats bacterial skin infections) was observed inside the treatment cart. RN 2 stated, the medication did…

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 facility document and P&P review, the facility failed to ensure adaptive equipment was available for one of 123 unsampled resident's (Resident 30). This failure posed the risk for Resident 30 to not reach his maximum level of independence. Findings: Review of the facility P&P titled Adaptive Equipment and Devices reviewed 3/7/23 showed in part, the facility shall provide special feeding devices/utensils for residents who need them to maintain or improve their ability to eat independently. Issuing adaptive equipment and devices: E. Adaptive feeding devices will be issues to a specific resident, labeled, and provided on their meal trays by the Food and Nutrition Services Department. Review of Resident 30's medical record showed he was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and vascular dementia (a form of dementia caused by an impaired supply of blood to 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, interview and facility Policy and Procedure and document review, the facility failed to ensure two of four ice machines were clean. This failure had the potential for ice contamination which could lead to mold and harmful bacteria in a facility population of 153 residents who received ice from the facility. Findings: Review of the facility P&P titled Ice Machine Cleaning, Sanitation and Maintenance Policy reviewed 9/14/23 showed, The Veterans Home is responsible for cleaning, sanitizing, and maintaining all ice machines in the licensed area and in the kitchen every three months, and as needed. Review of the ice machine manufacturer's guidelines located on the inside panel of the ice machine located in the main kitchen showed, Cleaning/Sanitizing Procedure Step Six: Remove parts for cleaning. Step Seven: Mix a solution of cleaner and warm water, depending upon the degree of mineral build up, a larger quantity of solution may be required. Mix enough solution to thoroughly clean all parts. On 1/23/24 at 8:29 AM an observation of the ice machine located in the main…

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 facility P&P review, the facility failed to ensure the policy on outside food for residents was followed. This failure posed the risk for food borne illness in residents who received food from outside sources. Findings: Review of the facility P&P titled Food and Nutrition Services- Outside Food for Residents reviewed 11/5/23 showed in part, The Veterans Homes of California allow visitors and family members to bring in food for residents. It is essential that any food brought in and served to residents is safe to consume i.e., home, restaurant or carryout and does not increase the risk of foodborne illness, conflict with critical dietary restrictions, allergies, sensitivities or increase the risk of choking or aspiration. Veteran's Home staff will follow safe food handling protocol when handling resident personal food. Residents, family and staff will be educated on standard food safety procedures, as needed. See attachment for educational handout for all to use .II. General food Safety Guidelines: e. The policy's handout attached, Food Safety Guidelines for…

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 follow infection control prevention measures when: 1. A paper ruler (disposable paper measuring ruler) and used gloves were found next to the trash can in Resident 111's room. 2. Property Consultant (PC) was observed with a surgical mask worn under the chin while talking to Resident 98. These failures had the potential to spread and transmit communicable diseases and infections. Findings: 1. During a concurrent observation and interview on 1/23/24 at 9:49 AM, used gloves and a paper ruler were observed next to the trash can in Resident 111's room. The Supervising Registered Nurse (SRN) 4 stated, the gloves and the paper ruler should have been discarded in the trash can and not on the floor. During an interview on 1/23/24 at 11:04 AM, with the Certified Nursing Assistant (CNA) 3, CNA 3 stated the paper ruler was used to measure the wound during wound care. During an interview on 1/24/24 at 2:05 PM, with the Infection Preventionist (IP), the IP stated the used gloves and paper ruler should have been disposed of…

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 administer Physician' Ordered Prevnar (vaccine to protect against pneumococcal disease) for Resident 133. This failure had the potential to result in Resident 133 to contract pneumococcal disease (pneumonia/ lung infection). Findings: During an observation on 1/23/24 at 2:15 PM in Unit C 2 medication storage room, an unopened vial of Prevnar labeled for Resident 133 was found in the refrigerator. The pharmacy label indicated an administer on date of 7/6/23. During an interview on 1/22/24 at 4:32 PM with Registered Nurse (RN) 5, RN 5 stated Prevnar was ordered on 7/6/23 to be administered for Resident 133. RN 5 further stated Prevnar was not administered to Resident 133 as ordered because there was no consent and no documentation of refusal. During a review of the facility's Policy and Procedure (P&P) titled, Medication, Administration Standards 1565v.2, undated, indicated, Notify MD & Document Missed Medication . The licensed nurse will notify the physician/ designee whenever medication is refused or held or…

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 treat one of three sampled residents, (Resident 1), with respect and dignity when Certified Nursing Assistant 1 (CNA 1) did not respect Resident 1's privacy and property, when she was seen on video rummaging through Resident 1's personal belongings. This failure resulted in Resident 1 feeling upset and angry. Findings: On 10/11/23, a facility visit was conducted to investigate an allegation from the facility and the California Highway Patrol (CHP) of CNA 1 seen on video looking through Resident 1's belongings and eating his food. During a review of Resident 1's medical record on 10/11/23, it indicated he was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, dysphagia (difficulty swallowing), and kidney disease. On 10/11/23, at 11:08 a.m. during a review of Resident 1's Minimum Data Set [MDS], (MDS-a resident assessment tool used to develop a plan of care) dated 8/24/23, it indicated his Brief…

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 follow their policy & procedure when Resident 1 had an over the counter (OTC) medication stored at his bedside. This failure had the potential for an adverse drug reaction and for other residents on Unit C-3 to have access to the drug. Findings: During an observation on 10/11/23 at 10:48 a.m., Resident 1 had a box of OTC Emergen-C 1000 mg [milligrams] Vitamin C tablets in an unlocked drawer near his bed. During a review of Resident 1's medical record on 10/11/23, it indicated he was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, dysphagia (difficulty swallowing), and anemia (low red blood cell count). During a review of Resident 1's August 2023 Physician's Order Sheet, on 12/20/23, it indicated he was prescribed .Vitamin C 250 mg [milligram] tablet by mouth twice a day for clot prevention . There was no order from the Physician that this medication could be left in Resident 1's possession. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify physician on duty after Resident 1's fall incident. This failure had the potential not to provide Resident 1's appropriate care, and services needed after the fall. Findings: An announced visit was conducted on 10/31/23 to investigate an incident regarding a fall. During a review of Resident 1's medical record, Resident 1 was admitted to the facility on [DATE] with diagnoses including cognitive impairment, blindness, and heart failure. A review of the Nursing note dated 10/27/23, at 12:18 a.m. indicated Resident 1 was found lying on the floor in his room. During a concurrent interview and record review on 12/20/23 at 4:36 p.m. with Supervising Registered Nurse (SRN) 1, SRN 1 stated the charge nurse on duty reported Resident 1 had an unwitnessed fall and there was no injury. The nursing note indicated on 10/27/23, multiple attempts to inform primary provider and also on-call provider; unable to reach via telephone as it keeps going…

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.