Veterans Home Of California - Barstow

In the surveyor’s words

From the most serious findings on record at Veterans Home Of California - Barstow, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605May 1, 2025

  Based on interview and record review, the facility failed to document non-pharmacological interventions for five of five sampled residents (Residents 1, 21, 24, 25, and 31) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Alprazolam (generic for Xanax, a medication for anxiety) 0.5 milligrams (mg) OD (orally disintegrating, dissolves in the mouth), take one tablet by mouth and allow to dissolve daily for anxiety, manifested by mood changes, irritability, negative thoughts. […]

• No harm, potential for more than minimal, patternF757May 1, 2025

  Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 31) were free of unnecessary medications when blood pressure (BP) and blood sugar (BS) hold parameters were not followed with the administration of medications. This failure had the potential for unnecessary medications for Residents 1 and 31, which can lead to side effects such as low blood pressure and low blood sugar. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Hold diabetes medications if BS is less than 110 at 6:00 a.m., dated 12/10/24; b. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and c. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure that food was stored in a safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe. 2. The kitchen freezer contained foods that were not dated and labeled. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During a concurrent observation and interview on 6/4/2024 at 9:02 a.m. with Food Manager (FM) in the kitchen, there was a spatula (kitchen utensil used to mix ingredients) with cracks on the right lower side and a yellow dried substance on the top edges. […]

• No harm, potential for more than minimal, patternF921Jun 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure a safe and comfortable working environment for staff when the water temperature of the kitchen's hand washing station was 156.1 degrees Fahrenheit (unit used to measure temperature). This failure had the potential for staff burning their hands and poor handwashing practices, leading to a potential spread of infection. Findings: During a concurrent observation and interview on 6/4/2024 at 11:06 a.m. with the Director of Dietetics (DOD) and the Food Manager (FM) in the kitchen, the Surveyor checked the water temperature at the hand washing station using a thermometer (a device that measures temperature), and the water temperature registered at 156.1 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF640Jul 13, 2023

  Based on interview and record review, the facility failed to properly electronically transmit the Minimum Data Set (MDS, a resident assessment and care-screening tool) to the Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES), for eight out of 17 sampled residents (Residents 8, 13, 14, 36, 43, 50, 56, and 58). This failure had the potential to result in inadequate monitoring of the residents' progress and lack of resident-specific information being provided to CMS for payment and quality measure monitoring. Findings: During an investigation of a triggered task related to Assessment Completed Late, the MDS coordinator was asked to provide CMS submission reports of Residents 8, 13, 14, 36, 43, 50, 56, and 58. […]