Inspection visit

Health inspectionJuly 13, 2023

Veterans Home Of California - BarstowCMS #5558536 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Some 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. A review of the iQIES Report MDS 3.0 Final Validation Reports for Residents 8, 13, 14, 36, 43, 50, 56, and 58 indicated a warning message, Assessment Completed Late: an Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or quarterly) was due every quarter, unless the resident is no longer in the facility. A prior record within 92 days of the submitted record could not be found. During a concurrent record review and interview on 7/13/23 at 8:25 a.m. with the MDS Coordinator, the MDS Coordinator reviewed the transmission data for Residents 8, 13, 14, 36, 43, 50, 56, and 58 in the computer. The MDS Coordinator confirmed the MDSs were submitted timely. However, upon submitting the MDS to IQIES database, she received a warning message indicating failure of transmission for those residents, meaning that the residents' assessments did not synchronize with the iQIES database. The MDS Coordinator stated the transmission system was new and she hoped it will work in the future. The MDS Coordinator stated synchronization with iQIES was always a problem. During a follow-up interview on 7/13/23 at 9:42 a.m. with the MDS Coordinator, when asked what to do when CMS sends a warning message indicating that the MDS transmission was submitted late, the MDS Coordinator stated she should have contacted CMS for a ratification. Review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, under the section for Validation Edits, indicated the Internet iQIES provides validation edits to monitor the timeliness and accuracy of MDS record submissions. If the transmission of the MDS's records did not meet the edit requirements, the system will provide error and warning messages on the provider's Final Validation Report. Each time a user accesses the iQIES and transmits an MDS file, the iQIES performs three types of validation including Warnings which flags missing or (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 555853 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 questionable data such as timing errors. The provider must evaluate each warning to identify necessary corrective actions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident 55's Minimum Data Set (MDS, a resident assessment and care-screening tool) accurately reflected the resident's status regarding an indwelling catheter (a flexible plastic tube (a catheter) inserted into the bladder, to provide continuous urinary drainage). Residents Affected - Few This failure had the potential to result in inadequate monitoring of the resident's care and support needs. Findings: During a review of Resident 55's face sheet (demographics) indicated, Resident 55 was admitted to the facility on [DATE] with a diagnosis of obstructive uropathy (which occurs when urine cannot drain through the urinary tract). During a concurrent observation and interview on 7/11/23 at 9:32 a.m. with Resident 55 in his room, he was observed lying on his bed and did not have an indwelling catheter. Resident 55 stated he had a catheter for about a year but no longer had one. During a review of Resident 55's Physician Orders, dated 3/23/23 at 10:30 a.m. the Physician Orders indicated to discontinue Foley Catheter (indwelling catheter) per Urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) status post Urolift (procedure that lifts enlarged prostate tissue, so it no longer blocks the flow of urine). During a concurrent interview and record review on 7/13/23 at 9 a.m. with the MDS Coordinator, Resident 55's MDS-Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set, dated 5/3/23 was reviewed. The MDS, under section H for Bladder and Bowel, indicated Resident 55 had an indwelling catheter. The MDS Coordinator stated that the Bladder and Bowel section which included the indwelling catheter was missed. During a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, Section 2.1 Introduction to the Requirements for the RAI, indicated the RAI process is the basis for the accurate assessment of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement Resident 6's care plan (detailed plan for a resident which includes specific interventions) when a floor mat was not used when Resident 6 was in her bed. This failure had the potential for injury for Resident 6. Findings: During a review of Resident 6's Falls: Morse Fall Scale dated 7/5/23, the scale indicated she had a history of falling and was at a high risk for falls. Resident 6's Plan of Care dated 6/17/23, indicated to prevent falls Place floor mat next to bed when using low bed. During an observation on 7/12/23 at 9:55 a.m. of Resident 6's room and in the presence of Certified Nursing Assistant (CNA) 1, there was no floor mat in her room. CNA 1 stated, I don't think she has it [mat] because she transfers herself and we help her. She is very vocal too, and will shake her head and say [NAME]. CNA 1 further stated, The wheelchair would get in the way. During an observation on 7/12/23 at 10 a.m. with Registered Nurse (RN) 1, he confirmed there was no floor mat in Resident 6's room, and stated, If she [Resident 6] requested to take it [mat] away we should have removed it from the care plan. This is an oversight. During a review of the facility policy and procedure titled, Comprehensive SNF [skilled nursing facility] /ICF [intermediate care facility] Care Plans (All Homes), dated 7/10/23, it indicated, An individualized plan of care designed to ensure a systematic and compreshensive approach for meeting a Resident's specific needs. It further indicated the care planning process includes, 4. Implementation: Delivery of actual nursing care, nursing activities, putting approaches or solutions to work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities, for three out of 17 sampled residents (Residents 63, 48, and 17): Residents Affected - Some 1. For Resident 63, the facility failed to notify the physician to obtain an optometrist (eye doctor) referral to replace or fix his broken prescription glasses and his backup (second pair of glasses). This failure had the potential for Resident 63 not being able to see things clearly, read, or watch television. 2. For Resident 48, the facility failed to process an audiology (hearing doctor) consult. This failure had the potential for a decrease in his quality of life when Resident 48 was in need of hearing aids. 3. For Resident 17, the facility failed to reschedule a missed audiology appointment. This failure had the potential for Resident 17 not to attain his highest practicable physical, mental and psychosocial well-being. Findings: 1. During a review of the admission face sheet record, indicated Resident 63 was admitted to the facility on [DATE]. During a review of Resident 63's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date 5/31/23, indicated the resident had a Brief Interview for Mental Status (BIMS), score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident 63 had moderate limited vision, and used corrective lenses (glasses). During a review of Resident 63's care plan to address Visual Problems related to macular degeneration (vision impairment resulting from deterioration of the central part of retina), the approaches included to schedule eye checks as needed. During an observation and interview with Resident 63 on 7/10/23 at 3:33 p.m., Resident 63 inquired about getting a new pair of glasses. Resident 63 was wearing a pair of spare glasses, the spare glasses were broken and unrepaired with (missing nose pads, a safety pin was holding the missing screws to keep the hinge together, and no temple protection, adhesive tape was applied around the frame). Resident 63 stated his prescription glasses and lenses were accidentally broken, two weeks ago. Resident 63 stated he gave the glasses to the nurses, who informed him they would either make an appointment with an optometrist, or send the glasses to be fixed. The resident reported the accident occurred at least two weeks ago; however, as of the current date, no action had been taken to repair or replace the broken glasses. During an interview with RN 1 on 7/10/23 at 10 a.m., RN 1 stated Resident 63's broken glasses were kept in a plastic bag at the nurses' station. An observation of the broken prescription glasses indicated the lens were entirely cracked and fragmented, and the frame was broken in multiple places, no parts of the glass were intact. RN 1 stated they forgot to request a referral for an optometrist consultation, or to send the glasses for repair. There was no documented evidence a follow up had occurred over a two week period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with RN 2 on 7/13/23 at 10:09 a.m., when asked for the facility's Policy & Procedures related to vision appointments and follow ups, RN 2 stated there was no policy in place. RN 2 stated they typically ask for a referral from the physician, schedule appointments, and provide transportation for the residents. 2. During a review of Resident 48's medical record, it indicated he was admitted to the facility on [DATE] with diagnoses which included Chronic A-fib (atrial fibrillation- an irregular heart rate that can cause decreased blood flow), legal blindness and that Resident 48 was hard of hearing. During a review of physician's order dated 7/1/23 at 10:20 a.m., indicated LLVA [[NAME] Veterans Administration] Audiology; Annual hearing test and to obtain new hearing aids .Schedule resident to LLVA audiology . During an interview on 7/12/23 at 11:47 a.m, with Office Technician (OT) 1, she was unable to locate where Resident 48's audiology referral was processed. OT 1 stated, she was the person to input the information and stated, I don't see it, I will put it in now. During an interview on 7/12/23 at 2:01 p.m., with Resident 48 and with the assistance of Certified Nursing Assistant (CNA) 2, CNA 2 had to speak loud to ask Resident 48 if he had hearing aids in his possession. Resident 48 stated he did not. CNA 2 stated she had not seen him with hearing aids, and stated he was hard of hearing. During a review of the policy and procedure titled, Physician Orders and Progress Notes, dated 10/24/22, it indicated, .All orders, written by a person lawfully authorized to prescribe, will be carried out unless contraindicated. 3. During a review of Resident 17's face sheet (demographics), the face sheet indicated Resident 17 had been readmitted to the facility on [DATE], with diagnoses that included hearing loss. During a concurrent observation and interview on 7/10/23 at 11:23 a.m. in Resident 17's room, Resident 17 was observed lying in bed watching television. Resident 17 stated to talk louder because he was hard of hearing in both ears. Resident 17 was questioned if he had hearing aids that he could wear. Resident 17 stated he had hearing aids that did not work. Resident 17 stated the staff, Know but don't care. During a concurrent observation and interview on 7/12/23 at 8:18 a.m. in Resident 17's room, Resident 17 was observed lying in bed without wearing hearing aids. Resident 17 stated his hearing aids were in a box and, I would show them to you if I knew where they were. During a review of Resident 17's Progress Note, dated 5/23/23, the Progress Note indicated, Resident 17 had completed an audiology appointment on 8/5/22. During the appointment, Partially occluding cerumen (earwax) was removed, and the tubing was replaced on Resident 17's hearing aids. The Progress Note further indicated, RTC (return to center) 4-5 months for tubing replacement. During a review of Resident 17's care plan titled, Communication Deficit R/T (related to) Moderate Hearing Problem, dated 10/30/22, the care plan indicated, Resident referred to (name of facility) to check hearing aids evaluate if new ones are needed. During a concurrent interview and record review on 7/12/23 at 8:39 a.m. with Registered Nurse (RN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1, RN 1 stated there was not an audiology progress note in Resident 17's clinical record dated 8/5/22. In addition, RN 1 stated he did not know if Resident 17 wore hearing aids. During a concurrent interview and record review on 7/12/23 at 2:02 p.m. with the Nurse Instructor (NI), Resident 17's Past Clinic Visits, were reviewed. The Past Clinic Visits, indicated Resident 17 had completed an audiology appointment on 8/5/22, and was a NO-SHOW for the 12/7/22 audiology appointment. NI stated there had not been follow up to reschedule the missed 12/7/22 appointment. The facility was unable to provide a policy and procedure for rescheduling missed appointments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure Resident 39's clinical record was maintained in accordance with accepted professional standards and practices, when the hospice (a program providing compassionate comfort care for people facing a terminal illness with a prognosis of six months or less) agency care plan was not contained in the clinical record. This failure resulted in the hospice agency care plan not being available for review by all health care providers, and the potential to adversely affect coordination of care. Findings: During a review of Resident 39's face sheet (demographics), the face sheet indicated Resident 39 had returned from the acute care hospital on 5/2/23. Resident 39's admitting diagnoses upon readmission to the facilty included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and acute and chronic respiratory failure. During a review of Resident 39's physician's (MD) orders, dated 5/3/23, the MD orders indicated Resident 39 was admitted to hospice agency. During a concurrent interview and record review on 7/11/23 at 9:59 a.m. with Registered Nurse (RN) 1, Resident 39's hospice care plan was reviewed. RN 1 stated the facility had developed Resident 39's hospice care plan. RN 1 was unable to locate a care plan developed by the hospice agency. RN 1 stated, We have our own care plan for him and the hospice agency usually follows it. I think they're following our care plan. During a concurrent interview and record review on 7/11/23 at 2:54 p.m. with Nurse Instructor (NI), NI stated facility staff developed a hospice care plan, and the hospice agency developed their own care plan. NI reviewed Resident 39's clinical record and stated she did not know why the hospice agency's care plan was not in the clinical record. NI stated, It's not in the chart. We need to make sure it's in the chart. That's how we coordinate care. During a review of the facility's policy and procedure (P&P) titled, Medical Records, dated 6/19/23, the P&P indicated, . 3. Medical records will be current and kept in detail consistent with good medical and professional practice based on the service provided to each Resident. 4. All current clinical information pertaining to the Resident will be centralized in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Barstow 100 East Veterans Parkway Barstow, CA 92311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to provide a safe environment, when the hot water temperature of a hand washing sink registered above 165 degrees. This failure had the potential for the facility residents to burn their hands. Findings: During the initial kitchen tour on 7/10/23 at 10:43 a.m., a hand washing sink (with foot pedals) was observed directly behind the resident serving area (a cafeteria style service area used for resident meals). The sink appeared approximately 10 feet from the resident serving area. Near the resident serving area and directly in front of the sink, was a movable rack with chips on it, in which the residents could get their own chips/snacks. Next to the resident serving area a red line was painted on the floor which indicated, Employees Only. However, there were no physical barriers between the resident serving area and the hand wash sink. A sign posted above the sink indicated, Caution Water Temperature Exceeds 120 Degrees. On 7/10/23 at 10:44 a.m., when Surveyor accessed the water it was immediately very hot to touch. During a concurrent observation and interview on 7/10/23 at 11:35 a.m., the temperature of the hand washing sink was checked, using the facility's thermometer in the presence of the Food Service Manager (FSM) and the Registered Dietician (RD). The hot water of the sink registered 165.4 degrees Fahrenheit, and had steam coming from the running water. The FSM confirmed the water was hot. During a concurrent observation and interview on 7/12/23 at 3:24 p.m. with the Food Service Technician (FST), she stated in the evening around 6 p.m. they have a single chain they put across one of the two entrances to the food service area to block the residents from entering after hours where the handwashing sink was located. The FST stated the other entrance was Open all night, but I've never seen them go back there. During a review of the policy and procedure (P&P) titled, Plumbing and Water Supply Maintenance, dated 2/9/2023, the P&P indicated under the section titled Hot Water, .Hot water temperature controls will be maintained to automatically regulate temperature of hot water delivered .to attain a hot water temperature between 105 degrees and 120 degrees Fahrenheit during normal business hours, a work order is submitted. Plant Operations staff will be dispatched to the area for corrective action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555853 If continuation sheet Page 9 of 9

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0640GeneralS&S Epotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0685GeneralS&S Epotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0921GeneralS&S Dpotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the July 13, 2023 survey of Veterans Home Of California - Barstow?

This was a inspection survey of Veterans Home Of California - Barstow on July 13, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Veterans Home Of California - Barstow on July 13, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·July 13, 2023