Veterans Home of California - Fresno

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 19, 2021

  Based on interview and record review, the facility failed to provide adequate supervision for the prevention of an accident for one of three sampled residents (R 1), when R 1 was not provided staff supervision for toileting. This failure resulted in R 1 falling and sustaining a laceration to the back of his head. Findings: A review of R1's clinical record titled, Admission Face Sheet (record containing resident personal information), indicated Resident 1 was [AGE] years old. R 1 had multiple diagnoses which included [CONDITION(S)] (temporary loss of consciousness caused by fall in blood pressure), wandering and Alzheimer's disease (a disorder that affects memory, judgement, and the ability to communicate). […]

• No harm, potential for more than minimal, widespreadF755Jan 30, 2026

  Based 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. Findings:During an interview with Supervising Registered Nurse (SRN) 2 on 1/29/26 at 9:32 am, SRN 2 stated there was no pharmacist reviewing medications monthly for residents since October 2025.During an interview with Skilled Nursing Facility Administrator (SNF Admin) on 1/29/26 at 10:34 am, SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. […]

• No harm, potential for more than minimal, widespreadF756Jan 30, 2026

  Based 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.Findings:During a review of Resident 3's admission Face Sheet Record, undated, indicated Resident 3 was admitted to the facility with diagnoses of vascular dementia (a form of memory loss due to impaired supply of blood to the brain), hyperlipidemia (high level of fats in the blood), and diabetes mellitus (high blood sugar).During a review of Resident 7's admission Face Sheet Record, undated,… […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based 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. […]