Baldomero Lopez Memorial Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Baldomero Lopez Memorial Veterans Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804Jun 25, 2026

  Based on observations and staff interviews, the facility failed to maintain the required hot holding temperatures for ready to serve food items during meal service related to multiple bowls of soup held below the minimum required temperature of 135 Fahrenheit, during one of one meal services observed.Findings included: During a kitchen tour on 06/24/2026, at 11:33 a.m., an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated all lunch food items had been fully cooked, prepared, placed in metal pans on the steam table, and were ready to be served to residents. Before demonstrating temperature checks, the CDM stated that hot foods must be held at 140 F or above and confirmed that staff were trained on required holding temperatures. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2026

  Based on observations, record review and interviews the facility failed to store food under sanitary conditions by not labeling and dating prepared food items in three of four reach in refrigerators and by failing to maintain kitchen equipment and walls in a clean and sanitary manner, in one of one kitchen observed.Findings included: On 06/22/2026, at 9:40 a.m., a tour of the kitchen was conducted with Staff B, Assistant Dietary Manager. During the tour of the dishwashing room, three dietary aides-Staff C, Staff D, and Staff E were observed rinsing soiled dishes and operating the dish machine. A large area of the wall measuring approximately three feet by three feet, located on the soiled dish side directly in front of Staff C, was covered with black biogrowth. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based on observations, interviews, and record review the facility failed to ensure the development, revision, and/or implementation of comprehensive care plans was completed for four (Resident #1, #2, #4, and #7) of seven sampled residents.Findings included:1.Review of the resident face sheet for Resident #1 revealed an admission date of 2/20/2025 and a recent admission of 4/1/2026 with diagnoses to include: Alzheimer's disease, dementia without mood disturbance, adjustment disorder with mixed anxiety and depressed mood, post-traumatic stress disorder (PTSD), hypertension, and other co-morbidities. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF689Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident to resident altercation for 6 of 7 residents reviewed (Resident #s 1, 2, 3, 4, 5, 6, and 7). This failure resulted in eight resident-to-resident physical altercations on one of two units. Cross reference F656Findings included:1. During an interview on 4/8/26 at 2:05 p.m. the facility Risk Manager (RM) stated on 2/24/26 Resident #1 was involved in an altercation with another resident (Resident #2) where he was pushed to the floor and hit his head and had skin tears on both hands. The RM stated Resident #1 has been involved in three altercations with Resident #2 (3/30/26 and again on 4/2/26). […]

• No harm, potential for more than minimal, isolatedF604Jun 25, 2026

  Based on observation, record review, and interview, the facility did not ensure residents remained free from the use of physical restraints for one resident (#3) out of one resident observed. Resident #3 was repeatedly observed with pillows placed underneath the fitted sheet on both sides of the resident's body in a manner that restricted movement.Findings included: On 06/22/2026, at 9:52 a.m., Resident #3 was observed lying in bed with pillows placed underneath the fitted sheet on both sides of the body, extending from the shoulders to the waist. The resident was asleep and did not respond to knocking. Later that day, at 3:38 p.m., Resident #3 was again observed with pillows positioned beneath the fitted sheet from shoulders to waist. […]