Veterans Home of California - West Los Angeles

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard single dose containers of acetic acid 0.25% irrigation solution (sterile rinse solution used to prevent bacteria growth and to reduce calcium buildup) according to manufacturer's guidelines. The irrigation solution was prescribed for one of three sampled residents (Resident 1) for suprapubic catheter (inserted through abdomen into bladder to assist with urinary voiding) irrigation. This failure had the potential to result in increased risk of catheter-associated urinary tract infections (CAUTI- infection that happens when germs enter the urinary tract through a tube used to drain urine) for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to accommodate Resident 1's right to access services outside the facility when transportation for Resident 1's off campus medical appointment was not properly coordinated. This failure resulted in Resident 1 missing his physical therapy appointment and experiencing emotional distress related to feeling neglected and having unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from exploitation and misappropriation of funds for two of three sampled residents (Resident 1 and Resident 2), when Certified Nurse Assistant (CNA) 1 and CNA 2 pursued inappropriate personal relationships, while on duty, with Resident 1 and 2 by accepting gifts of food and money and using their personal cell phones to call and text photos to the resident's personal cell phones and CNA 1 asking Resident 1 to get married. This failure had the potential to cause psychosocial and emotional harm and placed medically fragile and mentally vulnerable residents at risk for personal, monetary, and sexual exploitation.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were competent and adequately trained to safely carry out food services when: Multiple kitchen staff were not trained to intervene or discard hot food items that did not reach 70 degrees Fahrenheit ( F, unit of measurement for temperature) within two hours of the cooling process for potentially hazardous foods. The Food Service Technician (FST) did not receive training on the proper operation of the dishwasher. These failures had the potential to result in the spread of food borne illnesses (a sickness caused by consuming food or drinks contaminated with harmful substances) in a medically fragile population of 142 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and beverage items for resident consumption were stored in a safe and sanitary manner when: Four boxes of Glucose Control drinks were found stored on the floor. One pound of damaged and unsealed butter was found in the Main Kitchen. Brown sticky residue was found in Unit A3's Common Area Kitchenette's ice machine. These failures had the potential to result in residents being served contaminated or expired foods, which may have led to the spread of food borne illnesses (a sickness caused by consuming spoiled food or drinks contaminated with harmful substances) in a medically fragile population of 142 residents. During a concurrent observation and interview on 12/10/2025 at 11:05 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide clinical oversight to 142 vulnerable residents in the skilled nursing facility when:1. There was no Medical Director/Chief Medical Officer for the facility.2. Medical Staff credentialing and performance evaluations were not performed according to policy.3. Medical Staff failed to coordinate care between specialties for one of 29 sampled residents (Resident 64).4. The facility failed to adopt any current professional standards of practice for dental services. These failures resulted in a lack of resident care oversight by a Medical Director/Chief Medical Officer, no approval or adoption of current professional standards of practice for dental services and lack of resident care policies and procedures for dental services.

Inspectors wroteBased on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) in any capacity when the Medical Director/Chief Medical Officer position was vacated on 5/3/2025 with no replacement or interim physician in place. This failure resulted in the state agency being unable to provide timely oversight or intervention and resulted in allowing residents to remain for an extended period without required medical leadership and safeguards, thereby increasing the risk of delayed medical care, inadequate supervision over medical services, and potential harm to a medically compromised population of 142 residents. Refer to related deficiency F0841. During an interview on 12/12/2025 at 11:20 a.m. with the Standards and Compliance Manager (SCM), the SCM stated MD 3 was the interim Medical Director/Chief Medical Officer from January to May 2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) met the minimum quarterly requirements and the minimum requirement of attendees. This failure had the potential to diminish oversight in developing, reviewing, and approving crucial clinical policies that affected a medically fragile population of 142 residents since May 3, 2025.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that Resident 12, one of the 29 sampled residents, was afforded the right to a dignified existence and the right to make decisions regarding his care and services. Resident 12 expressed concerns to the facility staff about feeling unsafe with the facility's bus drivers' use of the mechanical lift for boarding the bus. This oversight led to Resident 12 missing medical appointments due to emotional distress related to safety concerns, thereby violating his rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a physician's order for a fall mat for one of 29 sampled residents, Resident 49. This failure resulted in the potential for Resident 49 sustaining an injury in the event of a fall.

Inspectors wroteBased on interviews and record review, the facility failed to provide routine dental care services to meet the needs of two of 29 sampled residents (Resident 26 and Resident 64). These failures resulted in a delay in care when:1. Resident 26 experiencing an 89-day delay in receiving further treatment for lingering unaddressed dental issues as Resident 26 waited for referral to an outpatient specialty dental provider.2. Resident 64's dental procedure was cancelled and could not be rescheduled for 41 days. 1. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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) .

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.