Veterans Home of California - Fresno

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), physician's orders for wound care was followed. This failure placed Resident 1's wound at a potential risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), wound was kept clean and covered. This failure resulted in Resident 1's wound found with maggots.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents when the facility did not employ or obtain the services of a licensed pharmacist. This failure resulted in no pharmacist oversight for required pharmacy services and had the potential risk to affect all residents receiving medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist conducted monthly drug regimen reviews (DRR) when four sampled residents (Residents 3, 7, 21, and 50) did not have evidence of drug regimen reviews since October 2025. This failure resulted in the potential for unidentified medication-related irregularities due to the absence of required drug regimen reviews.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store medications when two containers of discarded medications, designated for disposal, was found in Building 1A's soiled utility room and one container of discarded medications, designated for disposal, was found in Building 5A's soiled utility room and were accessible to unlicensed personnel. These failures had the potential for unauthorized access to medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an effective infection control and prevention program for three of 24 residents (Residents 10, 14, and 21), when nursing staff did not follow the use of PPE (personal protective equipment -specialized gear such as masks, gloves, gowns, and eye protection designed to protect healthcare workers from infectious materials and pathogens) for enhanced barrier precautions (EBP - an infection control strategy for nursing homes, requiring staff to wear gowns and gloves during high-contact resident care to reduce the spread of germs) when providing care to the residents.1. CNA 1 and LVN 1 did not wear a gown while providing care for Resident 102. CNA 2, RN 1, and SRN 1 did not wear a gown while providing care for Resident 143. CNA 3 did not wear a gown while providing care for Resident 21. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper discharge notification and documentation were made for one of two closed record sampled residents when:The facility did not notify the State Long Term Care Ombudsman of Resident 113's discharge. The facility did not perform and document a discharge medication reconciliation (process of comparing pre-discharge medications and post-discharge medications) for Resident 113 upon discharge from the facility. These failures had the potential to adversely affect the continuity of care for Resident 113.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one of 24 residents, when Resident 4's indwelling urinary catheter bag (a bag connected to a tube that drains urine from the resident's bladder) was observed on the floor. This failure had the potential to result in catheter-associated urinary tract infection (CAUTI) [an infection that can occur when germs enter the bladder through the tube].

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement Plan (QAPI) program when the facility did not utilize the QAPI process to address the known absence of a licensed pharmacist since October 2025. This failure resulted in the potential for continued noncompliance with pharmacy service requirements due to the facility's failure to utilize its QAPI program to identify and correct the issue.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 with the Sara lift (resident mobility lift), alone. This failure had the potential to negatively impact the resident's safety and increased risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (R3) when the interdisciplinary team (IDT) did not develop a new intervention after R3 fell on 3/14/25. This failure has the potential risk for R3 to sustain another fall and possible injuries.

Inspectors wroteBased on observations, interview, and record review, the facility failed to store and serve food in accordance with professional standards for food service safety when the fryer had a build-up of grease on the wheels and on the compartment underneath. The tile floor in front of the cooking line was missing grout between the tiles and it had a black build-up of food and grease. The floor under the center island of the cooking line had a build-up of black grime and old food. This failure resulted in the potential for food to be contaminated and cause food borne illness in 98 of 98 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality for three of 26 sampled residents (Residents 77, 51 and 47) when: 1. Resident 77, Diltiazem, Lisinopril and Metoprolol (Treatment for Heart/Blood pressure) medications were administered to the resident without checking the blood pressure/ heart rate as per physician's orders. 2. Resident 51, Alfuzosin (prostate medication) was administered without food as per physician's orders. 3. Resident 47, Novolog insulin (Treatment for blood sugar) was administered via ASPART insulin flexpen without priming the medication as per the manufacturer's instructions . These deficient practices had the potential to adversely affect the residents' medical health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (5%) or greater during the medication pass observation for three of 26 sampled residents (Residents 77, 51 and 47) when: 1. Resident 77, Diltiazem, Lisinopril and Metoprolol (Treatment for Heart/Blood pressure) medications were administered to the resident without checking the blood pressure/ heart rate. 2. Resident 51, Alfuzosin (Prostate medication) was administered without food. 3. Resident 47, Novolog insulin (Treatment for blood sugar) was administered via ASPART insulin flexpen without priming the medication. The facility had a cumulative medication error rate of 15.15% consisting of five errors out of 33 opportunities. These deficient practices had the potential to adversely affect the residents' medical health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enhance one of 26 sampled residents (Resident 68) quality of life, when Resident 68 qualification assessment for power wheelchair request was not provided. This failure resulted in a violation of Resident 68's Rights and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services for one of 26 sampled residents (Resident 68) to maintain highest practicable physical and psychosocial well-being, when Resident 68 request for qualification assessment for power wheelchair was not fulfilled. This failure had the potential to result in a decline of Resident's 68 physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and systematically organized medical records for two of 26 sampled residents (Resident 68 and Resident 550) when: 1. Resident 68's Restorative Nurses Aid-Weekly Notes documentation had incorrect dates. 2. Resident 550's medical chart contained Physician Progress Notes belonging to another resident. These failures had the potential to result in inaccurate clinical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policy for one of seven sampled residents (Resident 65) when staff did not wear gowns prior to high care activity to Resident 65 who had indwelling foley catheter (a thin tube inserted into the bladder to drain urine) and was in Enhanced Barrier Precaution (EBP - an infection control strategy where staff wears gowns and gloves in high care activity). This failure had the potential for Resident 65 to contract further infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a safe environment, free from accidents and hazards, for one of the three sampled residents (Resident 1). Resident 1, who was fully dependent and required assistance for all Activities of Daily Living (ADLs), sustained an injury while being repositioned by a Certified Nursing Assistant (CNA). This failure resulted in Resident 1 sustaining a head injury when his head hit the headboard of the bed, resulting in an abrasion on the posterior head, accompanied by a bump and bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. The ice machine in the satellite kitchen in building five and the ice machine in the satellite kitchen in building one had a build-up of a yellow substance and discoloration on their water tubes. This failure had the potential to contaminate the water and the ice after it was formed. 2. Buildup of dirt and debris were found under kitchen appliances and countertops, and crumbs were found behind an ice machine and on the bottom shelf of a reach-in freezer. This failure had the potential for microorganism growth and to attract pests. 3. The bulk sugar was contaminated with a black substance. This failure had the potential to contaminate the residents' food. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents disposable care equipment (DCE-basin, urinal and bedpan) were stored in a clean and sanitary manner and the facility's policy and procedure (P&P) was not followed in building five in multiple bathrooms. These failures had the potential for residents to live in an unsafe and unclean, non-homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for lunch on March 18, 2024 when the pureed cheesecake was served with a #16 scoop (1/4 cup) and the menu indicated it should be served with a #12 scoop (1/3 cup). This failure resulted in residents receiving less dessert and had the potential to affect the nutritional status of the 10 residents who were assigned to receive pureed dessert from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 34 sampled residents (Resident 34, 49) were treated with dignity, when Certified Nursing Assistant (CNA) 1 was standing while feeding the residents during a dining meal observation. This failure had the potential to violate Resident 34 and 49's dignity by being rushed to eat that could have lead to psychosocial harm while eating.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 34 sampled residents (Resident 10) activities of daily living (ADL) care plan was revised and updated based on his needs. This failure had the potential for the facility to not meet Resident 10's ADL needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 10) was re-evaluated to maintain or improve his activities of daily living (ADL). This failure had the potential for Resident 10 to not receive appropriate treatment and services to prevent further decline in range of motion and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate pain management for one of 34 sampled residents (Resident 88) when the physician progress notes were not followed up on and the comprehensive care plan was not updated. This failure had the potential to negatively impact the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an opened probiotic medication (medication used to improve digestion) bottle was stored at an appropriate temperature in one of eight medication carts. This failure had the potential for the medication to be less effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition when there was a leak at the water hose connection site, located under a food preparation table. This failure had the potential to negatively affect the ability of the dietary staff to prepare residents' meals in a safe and sanitary manner.

Inspectors wroteBased on observation, interview, and administrative policy review, the facility failed to maintain an infection prevention and control program when: 1. Two resident rooms did not have signs posted outside their room indicating precautions before entering the rooms. 2. Certified Nurse Assistant (CNA) 1 incorrectly wore a surgical mask under a N95 respirator mask in an isolation unit for COVID-19. 3. Staff wore the same personal protective equipment (PPE) while working with both positive COVID-19 residents and non-positive COVID-19 residents in the isolation unit. These failures had the potential risk for spreading transmission-based infections to residents, staff, and visitors.