Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
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.
Residents Affected - Few
Findings:
During a review of Resident 119's Face Sheet (demographic), the Face Sheet indicated Resident 119 was
admitted on [DATE] with diagnoses including schizotypal disorder (severe mental health condition),
obsessive-compulsive personality disorder (mental disorder that can cause harmful thoughts and
behaviors) and anxiety disorder.
During a review of Resident 119's Preadmission Screening and Resident Review II (PASRR II, federally
mandated review process that screens individuals seeking admission to Medicaid-certified nursing facilities
for mental illness or intellectual and developmental disability), dated 2/24/23, the PASRR II indicated
Resident 119 required specialized services due to a medical and/or mental health condition .
During a review of the CMS's RAI Version 3.0 Manual (RAI manual, a tool used by skilled nursing facilities
to gather information about a resident's needs), dated October 2024, the CMS's RAI Version 3.0 Manual
indicated that code 0 meant that a resident does not have serious mental illness or a referral for PASSR II
screening. The CMS's RAI Version 3.0 Manual indicated that code 1 meant that a resident had a serious
mental illness.
During a concurrent interview and record review on 12/5/24 at 12:00 p.m. with Registered Nurse (RN) 2,
Resident 119's MDS, dated [DATE], was reviewed. The MDS indicated that item A1500 was coded 0 and
that Resident 119 was not currently considered to have a serious mental illness or serious mental disability.
RN 2 stated, I coded 0 [no mental illness].
During an interview on 12/5/24 at 2:03 p.m. with the Director of Nursing (DON), the DON stated RN 2
misinterpreted the PASSR II results and coded MDS item A1500 incorrectly. The DON stated A1500 should
have been coded 1 by RN 2.
During an interview on 12/6/24 at 10:00 a.m. with the Social Worker (SW), the SW stated that Resident 119
did not receive three out of seven PASSR II recommended specialized services. The SW confirmed
Resident 119 did not receive mental health rehabilitation, activities of daily living training, and
psychotherapy (a treatment to manage unhealthy thoughts, emotions, and behaviors) or counseling as
(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 20
Event ID:
555917
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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
recommended by the PASSR II Individualized Determination Report.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 2 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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** 2. During a
review of Resident 142's Face Sheet (demographics), the Face Sheet indicated Resident 142 was admitted
on [DATE] with diagnoses of high blood pressure, chronic kidney disease, and tobacco use.
During an observation on 12/2/24 at 3:41 p.m. in the patio, Resident 142 was smoking a cigarette with staff
present. Resident 142 was not wearing a smoking apron.
During an interview with Resident 142 on 12/3/24 at 8:36 a.m., Resident 142 stated he was not offered a
smoking apron.
During an interview on 12/3/24 at 10:03 a.m. with the Charge Registered Nurse (CN), the CN stated
Resident 142 should have been offered a smoking apron while smoking.
During a review of Resident 142's Smoking Care Plan, effective 10/17/24 to present, the Care Plan
Indicated, Offer apron while smoking to prevent injury.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 2/13/24, the P&P
indicated, The (name of the facility) will develop and implement a person-centered care plan for each
Resident.
Based 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.
Findings:
1. a. During a review of Resident 89's Face Sheet (demographics), the Face Sheet indicated Resident 89
was admitted on [DATE] with diagnoses including nicotine dependence and mild cognitive impairment
(condition that causes memory or thinking difficulties).
During a review of the facility provided document titled, SNF (skilled nursing facility) Resident Smokers2024, current as of 12/2/24, the document indicated Resident 89 could smoke in designated smoking
locations . under supervision.
During a concurrent observation and interview on 12/2/24 at 1:17 p.m. with Resident 89 by the Main
Entrance , Resident 89 was smoking in a non-smoking area with no supervision. Resident 89 stated that he
smoked by himself and denied being told that he had to be with a staff member.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 3 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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
During an interview on 12/2/24 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 89 had to
be supervised when he smoked for safety reasons because he needed to be directed where to smoke and
needed to be reminded where to throw away his cigarette.
During a concurrent interview and record review on 12/5/24 at 1:50 p.m. with Supervising Registered Nurse
(SRN) 1, Resident 89's Safe Smoking Care Plan, effective 11/11/23 to present, was reviewed. The care
plan indicated for staff to escort [Resident 89] to designated smoking area . SRN 1 stated Resident 89
should be taken to the designated smoking area by a supervising staff per Resident 89's Care Plan.
During a review of Resident 89's Interdisciplinary Meeting (IDT) Notes, dated 8/13/24, the IDT notes
indicated Resident 89 was not using designated area for smoking instead doing it in front of the building,
not using smoking apron/jacket, burned part of the wheelchair cushion .
During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 2/13/24, the P&P
indicated, The (name of the facility) will develop and implement a person-centered care plan for each
Resident.
1. b. During a concurrent observation and interview on 12/5/24 at 1:14 p.m. with Certified Nursing Assistant
(CNA) 3 by the entrance to E building, Resident 89 was smoking in a non-smoking area with staff
supervision. CNA 3 confirmed Resident 89 was smoking in a non-smoking area. CNA 3 stated she should
not have given Resident 89 the cigarette and lighter until he was in the designated smoking area.
During a concurrent interview and record review on 12/5/24 at 1:50 p.m. with Supervising Registered Nurse
(SRN) 1, Resident 89's Safe Smoking Care Plan, effective 11/11/23 to present, was reviewed. The care
plan indicated for staff to escort [Resident 89] to designated smoking area . SRN 1 stated Resident 89
should be taken to the designated smoking area by a supervising staff per Resident 89's Care Plan.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 2/13/24, the P&P
indicated, The (name of the facility) will develop and implement a person-centered care plan for each
Resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 4 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a
review of Resident 142's Face Sheet (demographics), the Face Sheet indicated Resident 142 was admitted
on [DATE] with diagnoses of high blood pressure, chronic kidney disease, and tobacco use.
During an observation on 12/2/24 at 3:41 p.m. in the patio, Resident 142 was smoking a cigarette with staff
present. Resident 142 was not wearing a smoking apron.
During an interview with Resident 142 on 12/3/24 at 8:36 a.m., Resident 142 stated he was not offered a
smoking apron.
During an interview on 12/3/24 at 10:03 a.m. with the Charge Registered Nurse (CN), the CN stated
Resident 142 should have been offered a smoking apron while smoking.
During a review of Resident 142's Smoking Care Plan, effective 10/17/24 to present, the Care Plan
Indicated, Offer apron while smoking to prevent injury.
The facility's policy and procedure (P&P) titled, Safe Smoking & Tobacco Use, dated 10/1/24, the P&P
indicated, The (name of the facility) will follow applicable health and safety laws, promote safe smoking
practices, and monitor for unsafe smoking for the protection of residents, staff and visitors.
Based 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.
Findings:
1.a. During a review of Resident 89's Face Sheet (demographics), the Face Sheet indicated Resident 89
was admitted on [DATE] with diagnoses including nicotine dependence and mild cognitive impairment
(condition that causes memory or thinking difficulties).
During a concurrent observation and interview on 12/2/24 at 1:17 p.m. by the Main Entrance with Resident
89, Resident 89 was smoking in a non-smoking area with no supervision. Resident 89 stated that he
smoked by himself and denied being told that he had to be with a staff member.
During an interview on 12/2/24 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 89
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 5 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
had to be supervised when he smoked for safety because he needed to be directed where to smoke and
needed to be reminded where to throw away his cigarette.
During an observation on 12/5/24 at 1:31 p.m. at Area E Designated Smoking Area by the entrance to E
building, there was a partly enclosed space with a bench, chairs, fire extinguisher, and red trash bins. The
space was labeled with signage indicating, DESIGNATED SMOKING AREA . PLEASE USE CIGARETTE
BINS.
During a concurrent interview and record review on 12/5/24 at 1:50 p.m. with Supervising Registered Nurse
(SRN) 1, Resident 89's Safe Smoking Care Plan, effective 11/11/23 to present, was reviewed. The care
plan indicated for staff to escort [Resident 89] to designated smoking area . SRN 1 stated Resident 89
should be taken to a designated smoking area by a supervising staff per Resident 89's Care Plan.
During a review of Resident 89's Interdisciplinary Meeting (IDT) Notes, dated 8/13/24, the IDT notes
indicated Resident 89 was not using designated area for smoking instead doing it in front of the building,
not using smoking apron/jacket, burned part of the wheelchair cushion .
During a review of the facility provided document titled, SNF (skilled nursing facility) Resident
Smokers-2024, current as of 12/2/24, the document indicated Resident 89 could smoke in designated
smoking locations . under supervision.
During a review of Resident 89's Safe Smoking Assessment, dated 10/1/24, the assessment indicated
Resident 89 should not be allowed to smoke independently.
During a review of the facility's policy and procedure (P&P) titled, Safe Smoking & Tobacco Use, dated
10/1/24, the P&P indicated, The (name of the facility) will . promote safe smoking practices and monitor for
unsafe smoking for the protection of residents, staff, and visitors. The P&P indicated, Smoking is prohibited
in the following areas: . in areas on the grounds not identified as an authorized smoking area .
1.b. During a concurrent observation and interview on 12/5/24 at 1:14 p.m. with Certified Nursing Assistant
(CNA) 3 by the entrance to E building, Resident 89 was smoking in a non-smoking area with staff
supervision. CNA 3 confirmed Resident 89 was smoking in a non-smoking area. CNA 3 stated she should
not have given Resident 89 the cigarette and lighter until he was in the designated smoking area.
During an observation on 12/5/24 at 1:31 p.m. at Area E Designated Smoking Area by the entrance to E
building, there was a partly enclosed space with a bench, chairs, fire extinguisher, and red trash bins. The
space was labeled with signage indicating, DESIGNATED SMOKING AREA . PLEASE USE CIGARETTE
BINS.
During a concurrent interview and record review on 12/5/24 at 1:50 p.m. with Supervising Registered Nurse
(SRN) 1, Resident 89's Safe Smoking Care Plan, effective 11/11/23 to present, was reviewed. The care
plan indicated for staff to escort [Resident 89] to designated smoking area . SRN 1 stated Resident 89
should be taken to a designated smoking area by a supervising staff per Resident 89's Care Plan.
During a review of Resident 89's Interdisciplinary Meeting (IDT) Notes, dated 8/13/24, the IDT
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 6 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
notes indicated Resident 89 was not using designated area for smoking instead doing it in front of the
building, not using smoking apron/jacket, burned part of the wheelchair cushion .
During a review of the facility provided document titled, SNF (skilled nursing facility) Resident
Smokers-2024, current as of 12/2/24, the document indicated Resident 89 could smoke in designated
smoking locations . under supervision.
During a review of the facility's policy and procedure (P&P) titled, Safe Smoking & Tobacco Use, dated
10/1/24, the P&P indicated, The (name of the facility) will . promote safe smoking practices and monitor for
unsafe smoking for the protection of residents, staff, and visitors. The P&P indicated, Smoking is prohibited
in the following areas: . in areas on the grounds not identified as an authorized smoking area .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 7 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
Based 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.
Findings:
During an observation on 12/2/24 at 11:39 a.m. in the B307-Food Prep satellite kitchen, the highest
temperature the [brand name] dishwasher, a high temperature dishwasher (dishwasher that used high
temperatures to clean and sanitize), reached during wash cycle was 148 degrees Fahrenheit (unit of
measurement).
During an interview on 12/2/24 at 11:41 a.m. with Food Service Technician (FST) 1, FST 1 stated he did not
know if the dishwasher needed to maintain a minimum temperature of 150 degrees Fahrenheit during the
wash cycle.
During an interview on 12/2/24 at 11:46 a.m. with the Food Service Supervisor (FSS), the FSS stated it
was normal for the dishwasher to not stay at 150 degrees Fahrenheit during the wash cycle, and it did not
need to.
During a concurrent observation and interview on 12/3/24 at 10:04 a.m. with FST 2 in the B207-Food Prep
satellite kitchen, the [brand name] dishwasher completed a wash cycle and temperature read below 150
degrees Fahrenheit. FST 2 confirmed the wash cycle temperature read below 150 degrees Fahrenheit and
stated he was unsure if the wash temperature needed to maintain 150 degrees Fahrenheit the entire time.
During an interview on 12/3/24 at 2:35 p.m. with the Chief of Plant Operations (CPO), the CPO confirmed
the Plant Operation Department was responsible for maintenance of [brand name] dishwashers and stated
it was not normal for the [brand name] dishwasher to not maintain a temperature of 150 degrees Fahrenheit
during the entire wash cycle. The CPO stated staff needed to give one minute between wash cycles to
ensure dishwasher temperature had enough time to rise after each wash cycle.
During an interview on 12/5/24 at 4:18 p.m. with the FSS, the FSS stated she did not get any formal training
on the dishwashers. The FSS stated she observed others operating the dishwasher. The FSS stated that
staff could go back-to-back washing multiple loads of dishes.
During an interview on 12/5/24 at 1:38 p.m. with the Food Manager (FM), the FM stated he did not know if
kitchen staff were trained on how to use the [brand name] dishwashers.
During an interview on 12/5/24 at 2:34 p.m. with the Assistant Director of Dietetics (ADD), the ADD stated
she never received training on how to use the [brand name] dishwashers and the Food Service Supervisors
were responsible for training staff. The ADD further stated she did not oversee the Food Services
Department which referred kitchen staff. The ADD stated she only oversaw the Dietetic Department which
referred only to the Registered Dieticians.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 8 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of FST 1's Duty Statement, dated 4/8/24, the Duty Statement indicated, ESSENTIAL
FUNCTIONS . operate dish washing machines .
During a review of FST4's Food and Nutrition Services: Competency Checklist, dated 5/14/24, the Food
and Nutrition Services: Competency Checklist indicated FST 4 was not evaluated on the ability to state
proper procedure of testing dish machine.
During a review of FST3's Food and Nutrition Services: Competency Checklist, dated 5/14/24, the Food
and Nutrition Services: Competency Checklist indicated, FST 3 was evaluated on the ability to state proper
procedure of testing dish machine and Not Met was checked.
During a review of the FSS's Duty Statement, dated 5/1/24, the Duty Statement indicated, ESSENTIAL
FUNCTIONS . organize, supervise, and lead . proper maintenance of equipment . identify training needs of
employees and conduct in-service training .
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Warewashing
Manual & Mechanical, dated 6/14/24, the P&P indicated, The Food & Nutrition Services Director or
designee is responsible for the training of employees in procedures . DISH MACHINES . Wash temperature
will be between 150-160 degree Fahrenheit .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 9 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
1a. During a review of Resident 102's Face Sheet (demographics), the Face Sheet indicated Resident 102
was admitted on [DATE] with a diagnosis of cerebral infarct (type of stroke that can cause brain injury).
During a review of Resident 102's Diet Order dated 9/10/24, the Diet Order indicated, Resident 102 had an
active order for mechanical soft, finely chopped diet (textured/modified diet that consists of moist and soft
foods that were easier to chew and swallow).
During an observation on 12/3/24 at 11:30 a.m. on Unit C3, a meal tray delivery cart, with a hot and cold
side was parked by the nurse's station. Staff were pulling trays out to serve residents lunch in their rooms.
During a concurrent observation and interview on 12/3/24 at 11:38 a.m. with Registered Nurse (RN) 3 on
Unit C3, a snickerdoodle cookie, approximately 3-4 inches across, on the meal tray on the cold side of the
delivery cart for Resident 102 was hard to touch and was cut in four unequal pieces, approximately 2
inches each piece, and labeled 'FS' (finely chopped-mechanical soft). RN 3 stated she reviewed all meal
trays in the delivery cart against the meal tray ticket (printed out ticket with resident's name, diet order and
food on tray), and the trays were approved to be delivered by nursing staff to the residents. RN 3 confirmed
the meal tray ticket for Resident 102 stated mechanical soft, finely chopped diet. RN 3 confirmed the cookie
did not follow the ordered texture modification.
During an interview on 12/3/24 at 11:40 a.m. with Registered Dietitian (RD), the RD confirmed the cookie
looked hard and not finely chopped per ordered diet. The RD removed cookie from meal tray.
During an interview on 12/3/24 at 11:55 a.m. with the Assistant Director of Dietetics (ADD), the ADD
confirmed cookie was not finely chopped per ordered diet. The ADD stated staff were working on getting a
different cookie and providing better substitutions.
During an interview on 12/4/24 at 9:38 a.m. with the ADD, the ADD confirmed all Residents with a
mechanical soft diet, received a snickerdoodle cookie.
During an interview on 12/4/24 at 1:27 p.m. with Food Service Technician (FST) 5, FST 5 stated the
chopped cookie pieces were big, and she would have followed the pictures posted in the kitchen when
cutting the cookie per the ordered diet. FST 5 described the two pictures in the kitchen, the chopped
example of ¼ inch and the finely chopped example of 1/8 inch.
During an interview on 12/5/24 at 2:34 p.m. with the ADD, the ADD stated the resources that were used for
creating the Diet Manual included: the American Dietetic Association, the Nutritional Care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 10 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0805
Manual and the International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI).
Level of Harm - Minimal harm
or potential for actual harm
During a review of 11 other Residents (14, 28, 51, 67, 71, 76, 99, 117, 125, 133, and 398) medical records
and diet orders, the Face Sheets and diet orders all indicated mechanical soft- chopped was ordered due to
diagnoses related to dysphagia.
Residents Affected - Some
During a review of 13 other Residents (41, 43, 46, 54, 56, 61, 62, 73, 82, 102, 114, 127, and 139) medical
records and diet orders, the Face Sheets and diet orders all indicated mechanical soft- finely chopped was
ordered related to diagnoses related to dysphagia.
During a review of the American Dietetic Association publication titled, Level 2 Dysphagia Mechanically
Altered, dated 2002, the publication indicated, Avoid . dry cookies . Recommended . Slurried cookies or soft
moist cookies that have been 'dunked' in milk, coffee or other liquid .
During a review of facility's Diet Manual, dated 3/7/24, the Diet Manual indicated, 'Finely Chopped' Texture
Modification . In general, hard, sticky and crunchy foods are allowed unless the finely chopped texture
modification is used in conjunction with a mechanical soft diet order. When combined with a mechanical
soft order, foods should be soft and moist .
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Food
Preparation Guidelines, dated 8/7/24, the P&P indicated, Food will be served . in a form to meet individual
needs .
1b. During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61
was admitted on [DATE] with diagnoses of Parkinson's Disease (degenerative condition effecting the
nervous system that worsens over time), dysphagia (difficulty swallowing), disturbance of salivary
secretions (excessive salivation or dry mouth) and hemiplegia following cerebral infarct (type of stroke that
can cause brain injury).
During a review of Resident 61's Diet Order dated 12/3/24, the Diet Order indicated, Resident 61 had an
active order for mechanical soft, finely chopped diet (textured/modified diet that consists of moist and soft
foods that were easier to chew and swallow), aspiration precautions, and to eat small amounts.
During a concurrent observation and interview on 12/3/24 at 11:49 a.m. with the Food Service Supervisor
(FSS) in the B307-Food Prep satellite kitchen, there was a meal tray on a delivery cart with a snickerdoodle
cookie, approximately 3-4 inches across was cut in four, 2-3 pieces for Resident 61. The meal tray ticket
(printed out ticket with resident's name, diet order and food on tray) indicated diet as mechanical soft- finely
chopped. The FSS stated the snickerdoodle cookie did not follow the finely chopped diet order.
During an interview on 12/3/24 at 11:55 a.m. with the Assistant Director of Dietetics (ADD), the ADD
confirmed cookie was not finely chopped per ordered diet. The ADD stated staff were working on getting a
different cookie and providing better substitutions.
During an interview on 12/4/24 at 9:38 a.m. with the ADD, the ADD confirmed all Residents with a
mechanical soft diet, received a snickerdoodle cookie.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 11 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 12/4/24 at 1:27 p.m. with Food Service Technician (FST) 5, FST 5 stated the
chopped cookie pieces were big, and she would have followed the pictures posted in the kitchen when
cutting the cookie per the ordered diet. FST 5 described the two pictures in the kitchen, the chopped
example of ¼ inch and the finely chopped example of 1/8 inch.
During an interview on 12/5/24 at 2:34 p.m. with the ADD, the ADD stated the resources that were used for
creating the Diet Manual included: the American Dietetic Association, the Nutritional Care Manual and the
International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI).
During a review of 11 other Residents (14, 28, 51, 67, 71, 76, 99, 117, 125, 133, and 398) medical records
and diet orders, the Face Sheets and diet orders all indicated mechanical soft- chopped was ordered due to
diagnoses related to dysphagia.
During a review of 13 other Residents (41, 43, 46, 54, 56, 61, 62, 73, 82, 102, 114, 127, and 139) medical
records and diet orders, the Face Sheets and diet orders all indicated mechanical soft- finely chopped was
ordered related to diagnoses related to dysphagia.
During a review of the American Dietetic Association publication titled, Level 2 Dysphagia Mechanically
Altered, dated 2002, the publication indicated, Avoid . dry cookies . Recommended . Slurried cookies or soft
moist cookies that have been 'dunked' in milk, coffee or other liquid .
During a review of facility's Diet Manual, dated 3/7/24, the Diet Manual indicated, 'Finely Chopped' Texture
Modification . In general, hard, sticky and crunchy foods are allowed unless the finely chopped texture
modification is used in conjunction with a mechanical soft diet order. When combined with a mechanical
soft order, foods should be soft and moist .
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Food
Preparation Guidelines, dated 8/7/24, the P&P indicated, Food will be served . in a form to meet individual
needs .
1c. During a review of Resident 139's Face Sheet (demographics), the Face Sheet indicated Resident 139
was admitted on [DATE] with diagnoses of Esophageal obstruction (blocked or narrowed esophaguspreventing food or liquids from passing through to the stomach) and esophagitis (inflammation of the tube
running from the throat to the stomach).
During a review of Resident 139's Diet Order dated 11/22/24, the Diet Order indicated Resident 139 had an
active order for mechanical soft, finely chopped diet (textured/modified diet that consists of moist and soft
foods that were easier to chew and swallow).
During a concurrent observation and interview on 12/3/24 at 11:49 a.m. with the Food Service Supervisor
(FSS) in the B307-Food Prep satellite kitchen, there was a meal tray on a delivery cart with a snickerdoodle
cookie, approximately 3-4 inches across was cut in four, 2-3 pieces for Resident 139. The meal tray ticket
(printed out ticket with resident's name, diet order and food on tray) indicated diet-mechanical soft- finely
chopped. The FSS stated the snickerdoodle cookie did not follow the finely chopped diet order.
During an interview on 12/3/24 at 11:55 a.m. with the Assistant Director of Dietetics (ADD), the ADD
confirmed cookie was not finely chopped per ordered diet. The ADD stated staff were working on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 12 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0805
getting a different cookie and providing better substitutions.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/4/24 at 9:38 a.m. with the ADD, the ADD confirmed all Residents with a
mechanical soft diet, received a snickerdoodle cookie.
Residents Affected - Some
During an interview on 12/4/24 at 1:27 p.m. with Food Service Technician (FST) 5, FST 5 stated the
chopped cookie pieces were big, and she would have followed the pictures posted in the kitchen when
cutting the cookie per the ordered diet. FST 5 described the two pictures in the kitchen, the chopped
example of ¼ inch and the finely chopped example of 1/8 inch.
During an interview on 12/5/24 at 2:34 p.m. with the ADD, the ADD stated the resources that were used for
creating the Diet Manual included: the American Dietetic Association, the Nutritional Care Manual and the
International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI).
During a review of 11 other Residents (14, 28, 51, 67, 71, 76, 99, 117, 125, 133, and 398) medical records
and diet orders, the Face Sheets and diet orders all indicated mechanical soft- chopped was ordered due to
diagnoses related to dysphagia.
During a review of 13 other Residents (41, 43, 46, 54, 56, 61, 62, 73, 82, 102, 114, 127, and 139) medical
records and diet orders, the Face Sheets and diet orders all indicated mechanical soft- finely chopped was
ordered related to diagnoses related to dysphagia.
During a review of the American Dietetic Association publication titled, Level 2 Dysphagia Mechanically
Altered, dated 2002, the publication indicated, Avoid . dry cookies . Recommended . Slurried cookies or soft
moist cookies that have been 'dunked' in milk, coffee or other liquid .
During a review of facility's Diet Manual, dated 3/7/24, the Diet Manual indicated, 'Finely Chopped' Texture
Modification . In general, hard, sticky and crunchy foods are allowed unless the finely chopped texture
modification is used in conjunction with a mechanical soft diet order. When combined with a mechanical
soft order, foods should be soft and moist .
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Food
Preparation Guidelines, dated 8/7/24, the P&P indicated, Food will be served . in a form to meet individual
needs .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 13 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation
guidelines were followed when:
Residents Affected - Many
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.
Findings:
1a. During an observation on 12/2/24 at 11:26 a.m. in the Main Kitchen, Food Service Technician (FST) 6
entered kitchen without hair net and took prepared meal trays from the [brand name] food warmer labeled
SNF (skilled nursing facility) C2.
During an interview on 12/2/24 at 11:46 a.m. with the Food Service Supervisor (FSS), the FSS stated
hairnets are to be worn at all times in the kitchen.
During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated
10/28/24, the P&P indicated, . Hairnets shall be worn before entering the kitchen to prevent food
contamination from falling hair .
1b. During a concurrent observation and interview on 12/3/24 at 11:46 a.m. with the Food Service
Supervisor (FSS) in the B307-Food Prep satellite kitchen, Food Service Technician (FST) 7 was not
wearing a hair restraint. The FSS stated beard covers are necessary and yes he needs one.
During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated
10/28/24, the P&P indicated, Hairnets shall be worn before entering the kitchen to prevent food
contamination from falling hair .
2a. During a concurrent observation and interview on 12/3/24 at 9:22 a.m. with the Chief Engineer (CE) in
Unit C3-common area, the CE instructed the Maintenance Engineer (ME) to take apart the [brand name]
ice machine to visualize cleanliness. Observed ice shoot with thick white build up, metal grill and drain pan
were visually dirty with unknown brown substance, and when the inside of the water dispenser tubing was
wiped with paper towel there was an unknown pink and brown residue. The CE confirmed [brand name] ice
machine was dirty and instructed the ME to notify nursing staff, the ice
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 14 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0812
machine was out of use until it was properly cleaned.
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and
Maintenance Policy, dated 5/15/24, the P&P indicated, The [facility name] is responsible for cleaning,
sanitizing and maintaining all ice machines in the licensed care area and in the kitchens every 3 months,
and as needed .
Residents Affected - Many
2b. During a concurrent observation and interview on 12/3/24 at 9:53 a.m. with the Maintenance Engineer
(ME) in Unit C2-common area, the ME took apart the [brand name] ice machine to visualize cleanliness.
Observed ice shoot with thick white build up, and when the inside of the water dispenser tubing was wiped
with paper towel there was an unknown pink and brown residue. The ME stated that is dirty.
During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and
Maintenance Policy, dated 5/15/24, the P&P indicated, The [facility name] is responsible for cleaning,
sanitizing and maintaining all ice machines in the licensed care area and in the kitchens every 3 months,
and as needed .
3. During an observation on 12/2/24 at 10:02 a.m. in the Main Kitchen, three [brand name] water filters for
the ice machine had an expiration date of 11/22/24.
During an interview on 12/2/24 at 3:29 p.m. with the Maintenance Engineer (ME), the ME stated the
maintenance for the water filters were annual and it was a hiccup. It got missed.
During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and
Maintenance Policy, dated 5/15/24, the P&P indicated, The water filters will be changed annually or as
needed .
4. During an observation on 12/2/24 at 11:39 a.m. in the B307-Food Prep satellite kitchen, the [brand name]
dishwasher highest temperature, during wash cycle, was 147 degrees Fahrenheit.
During a concurrent observation and interview on 12/3/24 at 10:04 a.m. with FST 2 in the B207-Food Prep
satellite kitchen, [brand name] dishwasher completed a wash cycle and temperature read below 150
degrees Fahrenheit. FST 2 confirmed wash cycle temperature read below 150 degrees Fahrenheit and
stated he was unsure if the wash temperature needed to maintain 150 degrees Fahrenheit.
During an interview on 12/3/24 at 2:35 p.m. with the Chief of Plant Operations (CPO), the CPO confirmed
plant operation department is responsible for maintenance of [brand name] dishwashers and stated, No,
that's not normal. The CPO stated staff need to give one minute between wash cycles to ensure
dishwasher temperature has enough time to rise after each cycle.
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Warewashing
Manual & Mechanical, dated 6/14/24, the P&P indicated, DISH MACHINES . Wash temperature will be
between 150-160 degree Fahrenheit .
5. During an observation on 12/2/24 at 11:09 a.m. in the Main Kitchen, there was one bottle of rice wine
vinegar with a use by date of 11/22/24.
During an interview on 12/2/24 at 11:11 a.m. the [NAME] Specialist (CS) 2, the CS 2 confirmed rice
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 15 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0812
wine vinegar was expired and stated, No, we need to throw this away.
Level of Harm - Minimal harm
or potential for actual harm
During a review U.S [United States] Food and Drug Administration (FDA) Food Code dated 2022, the U.S
FDA Food Code indicated, . foods that exceed the use-by date . must be disposed of .
Residents Affected - Many
6. During a concurrent observation and interview on 12/2/24 at 10:33 a.m. with Food Service Technician
(FST) 8 in the Main Kitchen, FST 8 was washing dishes with yellow rubber gloves overtop of blue
disposable gloves. FST 8 removed the yellow rubber gloves and kept the blue disposable gloves on and
picked up clean dishes. FST 8 stated she did not need to wash her hands because she wore two pairs of
gloves.
During an interview on 12/3/24 at 8:44 a.m. the Assistant Director of Dietetic (ADD), the ADD stated the
expectation is for staff to take off both pairs of gloves and wash their hands between handling dirty and
clean dishes.
During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated
10/28/24, the P&P indicated, Proper hand washing shall be done . after removing gloves .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 16 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow safe food handling protocol
for resident personal food when:
Residents Affected - Few
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) .
Findings:
1a. During a concurrent observation and interview on 12/2/24 at 4:01 p.m. with Registered Nurse (RN) 4 on
Unit C2, there was an opened jar of pickles undated in the Residents' communal refrigerator. RN 4 stated, It
should have an expiration date. RN 4 further stated if a food was found in the Residents' communal
refrigerator without a name or date, then the food item should have been thrown away.
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Service- Outside Food
for Residents, dated 12/2/24, the P&P indicated, . All prepared/perishable foods or beverages brought by
resident, family or visitors for resident's use will be store in the unit refrigerator; labeled with the resident's
name and date the item was stored . Any food or beverage that is not labeled with resident name and dated
will be discarded immediately .
1b. During a concurrent observation and interview on 12/2/24 at 3:46 p.m. with Registered Nurse (RN) 5 on
Unit C2, in the Residents' communal refrigerator there was an opened container of dairy free lemon ice
cream unlabeled and undated. RN 5 stated it should have been thrown away.
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Service- Outside Food
for Residents, dated 12/2/24, the P&P indicated, . All prepared/perishable foods or beverages brought by
resident, family or visitors for resident's use will be store in the unit refrigerator; labeled with the resident's
name and date the item was stored . Any food or beverage that is not labeled with resident name and dated
will be discarded immediately .
2a. During a concurrent observation and interview on 12/2/24 at 3:53 p.m. with the Assistant Director of
Nursing (ADON) in Unit C2, the ADON confirmed a container wrapped in plastic bag with date of 11/28, in
the Residents' communal refrigerator, should have been thrown out.
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Service- Outside Food
for Residents, dated 12/2/24, the P&P indicated, . All prepared/perishable foods or beverages brought by
resident, family or visitors for resident's use will be store in the unit refrigerator; labeled with the resident's
name and date the item was stored . Any food or beverage that is not labeled with resident name and dated
will be discarded immediately .
2b. During a concurrent observation and interview on 12/2/24 at 4:03 p.m. with Registered Nurse (RN) 1 on
Unit C2, in the Residents' communal refrigerator there were two brown plastic bags duct-taped
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 17 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0813
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
closed with a date of 7/31/24. RN 1 stated she did not know what it was but staff should have thrown it
away because it's very old.
During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Service- Outside Food
for Residents, dated 12/2/24, the P&P indicated, . All prepared/perishable foods or beverages brought by
resident, family or visitors for resident's use will be store in the unit refrigerator; labeled with the resident's
name and date the item was stored . Any food or beverage that is not labeled with resident name and dated
will be discarded immediately .
Event ID:
Facility ID:
555917
If continuation sheet
Page 18 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings:
During a concurrent observation and interview on 12/3/24 at 10:21 a.m. with the Chief Engineer (CE) in the
loading dock area, two of four large dumpsters did not have a lid to cover the garbage. The CE confirmed
there were no lids for the dumpsters.
During an interview on 12/4/24 at 3:22 p.m. with the Chief of Plant Operations (CPO), the CPO stated, I
have never heard I need a lid for the dumpsters.
During a review of the U.S [United States] Food and Drug Administration's (FDA) Food Code, dated 2022,
the FDA Food Code indicated in Section 5-501.15 Outside Receptacles, (A) Receptacles and waste
handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and
used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids,
doors, or covers .
During a review of the facility's policy and procedure (P&P) titled, Trash Removal, dated 3/7/24, the P&P
indicated, Dumpster lids will remain closed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 19 of 20
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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 0865
Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
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)
Findings:
During a concurrent interview and record review on 12/6/24 at 10:00 a.m. with QAPI representatives
including the Director of Nursing (DON) and the Standards and Compliance Manager (SCM), the QAPI
Meeting Minutes, dated January to November 2024 were reviewed. The minutes indicated no focus on
meeting the staffing need for a Director of Dietetics that would provide qualified oversight over dietary staff
to deliver safe and sanitary food service and ensure kitchen staff was competent in performing their job
duties safely and effectively. The DON and SCM confirmed the vacancy for a Director of Dietetics was not
focused on as a staffing need during QAPI.
During an interview on 12/6/24 at 10:44 a.m. with QAPI representatives including the DON, the SCM, and
the Administrator (ADMIN), the ADMIN stated the current ADD was the defacto (default) person overseeing
dietary services alongside two Food Service Managers.
During a review of the QAPI Meeting Minutes, dated January to November 2024, the minutes indicated no
mention of unmet kitchen staff competency evaluations being identified and addressed.
During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance
Improvement (QAPI) Plan, undated, the P&P indicated, The purpose of QAPI in our organization is to
ensure that residents of [facility name] are provided a high quality of care and services through
multi-disciplinary oversight and that regulatory and corporate compliance is achieved through the
application of a systematic and comprehensive quality management approach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 20 of 20
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
FAQ · About this visit
Common questions about this visit
What happened during the December 6, 2024 survey of VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES?
This was a inspection survey of VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES on December 6, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES on December 6, 2024?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.