Veterans Home of California - Chula Vista

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was administered as prescribed for one of three sampled residents (Resident 1), when the physician orders for that medication was not transcribed (copying a doctor's medication order into a residents medication administration record or electronic health record), by the licensed nurse. This failure resulted in Resident 1 missing a cycle of her breast cancer medication for approximately 25 days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff did not leave medication unattended on the bedside for one of two sampled residents (Resident 1). This failure had the potential to compromise the health and safety of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and sanitary environment when: 1. One of the shower rooms, Room A729, was found with broken tiles and an exposed wall cavity. This failure had the potential to result in exposing residents to pests and contaminants, compromising the hygiene and safety of a medically vulnerable population of 107 residents.2. The shared bathroom for one of 24 sampled resident's (Resident 39) and one unsampled resident (Resident 34), had a large, unsealed hole located directly above the toilet. This failure resulted in Resident 39 and Resident 34 feeling stress and discomfort with the disrepair (poor condition of a building) and had the potential to result in injuries or infections from dust, insulation, or debris falling from an unsealed ceiling.

Inspectors wroteBased on interview and record review, the facility identified building damage that remained consistent during the public safety committee meeting reports from 4/23/2024 to 10/23/2025, and the facility's Quality Assurance and Performance Improvement failed to address a plan of repair to correct the issue. This failure had the potential to adversely affect the health of residents. Cross-reference F584Findings:During a review of the facility's Health and Safety Committee Meetings Records, from 4/23/2024 to 10/23/2025, the meeting records indicated that the walls have holes, scrapes, and paint damage, and this remains consistent. During an interview on 1/15/2025 at 4:16 p.m. with the Staff Services Manager (SS), SS stated he keeps track of all damage found during Environment of Care (EOC-area in building where residents are cared for) rounds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the garbage was disposed properly, when one of the garbage compactor's (a machine that reduces the volume of trash by compacting it) had no top cover and was not closed when not in use. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment for one of three sampled residents (Resident 1), when the facility accepted Resident 1 for readmission with an order of intravenous (IV, into a vein) antibiotic and the facility was unable to provide this treatment after admission. This failure resulted in delayed medication treatment and Resident 1 being transferred to a different facility that could provide the necessary treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure surgical masks (a loose-fitting mask worn over the nose and mouth to help reduce the spread of infection) were worn on Unit 300 where Covid-19 (a contagious respiratory disease) positive residents resided. This failure had the potential to spread respiratory disease to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: 1. One plastic bin containing white colored powder was observed underneath food preparation counter and was unlabeled and undated. 2. One bag of opened frozen peanut butter cookies was observed in the walk-in freezer and three sandwiches observed in the refrigerator were unlabeled and undated. 3. One bag of food labeled, meat substitute was observed expired in the walk-in freezer. 4. Five broken tiles were observed at the base of the wall in the kitchen next to the dish drying racks. These failures had the potential to place residents at risk for developing foodborne illnesses by exposing residents to contaminated food and unsanitary practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of a notice of transfer/discharge was sent to the Ombudsman (an advocate for residents of nursing homes) for three of 44 sampled residents (Residents 19, 47, and 99) when: 1. Resident 19 was transferred to the hospital on 1/22/2025. 2. Resident 47 was transferred to the hospital on 8/27/2024. 3. Resident 99 was transferred to the hospital on 1/8/2025. This failure had the potential for residents to be inappropriately transferred or discharged which could result in violating their rights.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold policy notification to one of 44 sampled residents (Resident 47) and/or his representative upon Resident 47's transfer to an acute care hospital on 8/27/2024. This failure had the potential for Resident 44 and/or his representative to not be informed of his rights to return to the facility following hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan for weight loss was updated for one of 44 sampled residents (Resident 20). This failure had the potential for Resident 20 not to receive nutrition interventions and treatments according to evaluation of his needs and contributing to continued weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive systematic approach for monitoring nutrition interventions was implemented for one of 44 sampled residents, (Resident 20), who experienced an unplanned unintentional weight loss of 7.79% in six months, according to facility policy. This failure had the potential for Resident 20 to experience additional unintentional weight loss, which could lead to further decline in the resident's health and nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services for a universe of 103 residents when: 1. During an inspection of one of two medication rooms, outdated Procrit (drug to treat low red blood cell count), Mantoux (diagnostic test to detect tuberculosis infection which is a lung infection) vial, and insulin (drug to manage blood sugar levels) pen were observed stored and available for resident use. This failure had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. 2. During an inspection of one of two medication carts, one expired nitroglycerin (drug to manage chest pain) vial was observed stored and available for resident use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% when three errors for Resident 9 and Resident 87 occurred out of 42 opportunities for a medication administration error rate of 7.14%. For Resident 9, the medication glipizide (drug to manage blood sugars) was not administered 30 minutes before meals. For Resident 87, one medication was omitted, and the medication fexofenadine (drug to manage allergies) was given to the resident at the same time as fruit juice. This failure had the potential to expose residents to preventable medication errors which could result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with accepted standards of practice and/or manufacturer's instructions when: 1. During an inspection of one of two medication rooms, one outdated insulin vial was stored and available for resident use. 2. During an inspection of one of two medication rooms, a bulk bottle of atovaquone (anti-infective drug) oral suspension (liquid) for Resident 39 was not stored in accordance with manufacturer's instructions and available for resident use. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dental appointment was scheduled for one of 44 sampled residents (Resident 72). This failure had the potential to result in Resident 72 experiencing infection, pain, or complications from ill-fitting dentures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at an acceptable temperature to be appetizing for residents according to the facility's resident council and the facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when: 1. Enhanced Barrier Precautions (EBP - infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 84 during perineal hygiene care (cleaning of genital area), medication administration, and tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach) administration. 2. Enhanced Barrier Precautions (EBP-infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 25 during medication administration via tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an accurate comprehensive person-centered care plan for one of three sampled residents (Resident 1), when Resident 1's exhibited behaviors were not monitored or documented. This failure had the potential to result in Resident 1 not receiving interventions necessary to maintain mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate/ necessary supervision to prevent elopement (when a resident leaves the premises or safe area without the facility's knowledge and supervision) with injury for one of three sampled residents (Resident 1), when the facility staff failed to assess level of supervision required for safety for Resident 1, who was cognitively impaired, for elopement risk when he attempted to leave the facility and fell at the facility's back gate on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the resident every two hours. Resident 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, assessment tool to guide care) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner by: 1. Failing to transmit the completed annual MDS assessment within 14 days after completion for one of four unsampled residents (Resident 65). 2. Failing to complete and transmit the MDS discharge assessment for one of four unsampled residents (Resident 112) in a timely manner. 3. Failing to transmit the completed MDS discharge assessment within 14 days after completion for one of four unsampled residents (Resident 43). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility to ensure the charge nurse key sets for Unit 300, 700, and 1100 were kept in a location not accessible by unlicensed staff. This failure had the potential for unauthorized staff to have access to the medication rooms and had the potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the regular menu was followed as printed. This failure had the potential to alter the nutritional value of the meal, which could decrease food intake and compromise the residents' nutritional status in a facility population of 113 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary conditions were maintained in the food and nutrition services department for food safety and storage according to standards of practice and facility policy when: 1. Three ice machines were dirty with light brown, grayish colored residue inside the ice chutes that flows into the ice bin. 2. Kitchen Cutting boards were found overworn, discolored, scratched, and scored. 3. Kitchen Storage bins for serving utensils were dirty and contained debris. 4. A mixing blade attachment was found soiled with dried brown debris in the kitchen. 5. The electrical outlet on the food preparation island in the kitchen was missing a cover and had a dark colored stain around the outlet. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential kitchen equipment were maintained in a safe, operating, and fully functioning manner when: 1. The water at the hand wash sink by the entrance to the kitchen took an extended period to reach 100 degrees Fahrenheit (F, a scale for measuring temperature), 2. The high temperature dish machine did not come to the required final rinse temperature for sanitation, and 3. There was condensation dripping from a ceiling pipe on cases of milk cartons in a walk-in refrigerator. These failures had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner.

Inspectors wrote2. During a concurrent observation and interview on 3/4/2024 at 10:20 a.m. with Resident 76, in Resident 76's room, there was an area above the corner desk where purple and white paint was peeling off from the ceiling and the wall. Resident 76 stated she had reported the peeling paint to the staff about a month ago. Resident 76 stated the peeling paint was getting bigger every day. Resident 76 stated the peeling paint bothered her because it looked like water damage, and she was concerned about the area having mold. During an interview on 3/4/2024 at 3:12 p.m. with Office Assistant (OA), OA stated she saw the peeling paint on Resident 76's room last week and put in a Sprocket Work Order (a document that includes details of maintenance tasks and outlines a process for completing those tasks). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS, assessment tool to guide care) was completed within 14 days of the Assessment Reference Date (ARD, end-point date for the observation periods of the assessment) for one of 25 sampled residents (Resident 16). This failure had the potential to result in Resident 16 not receiving timely and appropriate care based on changes in his health care status.

Inspectors wroteF919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd Based on observation, interview, and record review, the facility failed to develop a care plan (resident demographic) for mobility related to right ankle fracture for one of 25 sampled residents (Resident 108). This failure had the potential to result in a decline in physical mobility for Resident 108.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a severe weight loss of 14.75% (percent) in six months, was assessed for one of four unsampled residents (Resident 17). In addition Resident 17's weight loss was not addressed according to standards of practice for weight loss. This failure had the potential to result in functional decline, infections, decubitus ulcers (injury to skin, tissue from prolonged pressure), exacerbation of cognitive and mood disorders, and an increased risk of death for Resident 17.

Inspectors wroteBased on interview and record review, the facility failed to ensure hospice nursing and aide notes, reflective of assessments and care provided, were obtained from the hospice (end of life care) provider for two of three sampled residents (Residents 66 and 78) for hospice review. This failure had the potential for inconsistent or inadequate communication in the coordination of care for the residents.

Inspectors wroteF919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd F919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one out of 25 sampled residents (Resident 108). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses administered gabapentin (used to treat pain) medication at the correct time (9 PM), as ordered by the physician for 1 of 3 sampled residents (Resident 1). This failure had the potential for Resident 1 to have unresolved pain and disruption of sleep.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure for reporting suspected financial abuse, for one of three sampled residents (Resident 1), within 24 hours. This failure resulted in a year long delay of California Department of Public Health (CDPH) oversight and investigation of the suspected abuse, placing other residents at risk for potential financial abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal belongings were secured for one of three Residents (1) when another Resident (2) occupied Resident 1's room while he was at the hospital. This failure resulted in Resident 1's personal belongings being left unsecured in his room with the potential to be lost or stolen.

Inspectors wroteBased on observation interview and record review, the facility failed to implement its policy for Suicide Prevention, for one of three Residents (1), when sharp objects remained in Resident 1's room after staff conducted a safety sweep. This failure resulted in Resident 1 having access to sharp objects, with the potential to use them for self-harm.