CHULA VISTA, CA - Federal inspectors cited Veterans Home of California - Chula Vista for multiple serious violations affecting medication management, nutrition care, and infection control practices during a January 2025 inspection.
Widespread Medication Management Failures
The facility faced significant pharmaceutical safety violations that created potential risks for residents receiving critical medications. Inspectors discovered expired medications stored in multiple locations throughout the facility, including outdated Procrit, Mantoux, insulin, and nitroglycerin supplies that remained accessible for patient use.
In one medication room, an expired Procrit vial used to treat low red blood cell counts was found stored in the refrigerator beyond its manufacturer expiration date. Similarly, a Mantoux vial used for tuberculosis testing had exceeded the manufacturer's 30-day use window after opening but remained in storage. These violations occurred despite facility policies explicitly stating that "drugs will not be kept in stock after the expiration date on the label."
The medication safety issues extended to narcotic accountability problems. For one resident requiring pain management, controlled drug records showed mismatched prescription numbers between the actual medication supply and tracking documentation. This created gaps in the chain of custody for narcotic medications, which are strictly regulated due to their potential for abuse and diversion.
Medical Significance: Expired medications can lose potency and effectiveness over time, potentially leaving residents without adequate treatment for serious conditions. The Procrit violation was particularly concerning since this medication treats anemia, and reduced effectiveness could worsen a resident's blood condition. Proper narcotic tracking is essential for preventing drug diversion and ensuring residents receive prescribed pain relief.
Critical Medication Administration Errors
The facility's medication error rate exceeded acceptable standards at 7.14%, well above the required threshold of less than 5%. The errors involved timing violations and improper drug interactions that could compromise treatment effectiveness.
Inspectors observed a nurse administering glipizide, a diabetes medication, directly with a meal rather than following the required 30-minute pre-meal timing. This medication requires advance administration to properly manage blood sugar levels when food is consumed. The facility's own drug references confirmed this timing requirement, yet staff failed to follow established protocols.
Another significant error involved administering fexofenadine, an allergy medication, with orange juice. The drug's manufacturer guidelines specifically warn against fruit juice administration due to reduced absorption and effectiveness. The nurse was observed giving the resident multiple medications simultaneously with 120 milliliters of orange juice, including the contraindicated fexofenadine dose.
Medical Context: Proper medication timing is crucial for therapeutic effectiveness. Glipizide works by stimulating insulin release in response to food intake, so premeal administration ensures the medication is active when blood sugar rises from eating. When given with meals instead of before, the drug may not adequately control post-meal glucose spikes, potentially leading to dangerous blood sugar fluctuations. Similarly, fruit juices can significantly reduce fexofenadine absorption, making allergy symptoms more difficult to control.
Severe Nutritional Decline Goes Unaddressed
One of the most concerning violations involved inadequate response to significant weight loss in a veteran resident. The resident experienced a 10.84% weight loss over six months, dropping from 132.8 pounds in July 2024 to 118.4 pounds by January 2025. This dramatic decline triggered multiple red flags that the facility failed to address adequately.
The resident's food intake records showed concerning patterns, with breakfast consumption averaging only 49% in January 2025, lunch at 51%, and dinner at just 44%. Despite these warning signs and the resident's stated food preferences for items like grilled cheese sandwiches and tuna sandwiches, the facility did not modify meal options to encourage increased intake.
The facility's registered dietitian acknowledged that recommended interventions, including fortified foods that could provide 300-500 additional calories per meal, were not consistently implemented. Care plan documentation remained outdated and failed to reflect the severity of the weight loss or include updated nutritional goals.
Clinical Impact: Research shows that institutionalized elderly patients who lose 5% of body weight in one month are four times more likely to die within one year. Weight loss of this magnitude can lead to muscle wasting, decreased immune function, and increased risk of complications. The resident's physician stated he "wasn't aware Resident 20's weight loss was severe for six or seven months," highlighting communication failures that delayed critical interventions.
Infection Control Protocol Violations
The facility failed to follow Enhanced Barrier Precautions (EBP) for residents with feeding tubes, creating potential risks for spreading multidrug-resistant organisms. Staff members were observed providing care to residents requiring EBP without wearing required gowns during high-contact activities.
Nurses administered medications and tube feedings to residents with gastrostomy tubes while not wearing protective gowns, despite clear signage indicating EBP requirements. When questioned, one nurse stated she "only wear[s] a gown when the resident has an active infection," demonstrating misunderstanding of prevention protocols.
Additional infection control issues included the storage of an opened, single-use syringe attached to a medication bottle with a rubber band. The syringe packaging clearly indicated "Sterile. Do Not Reuse," but it remained accessible for potential reuse. An unsealed saline spray bottle missing its safety neckband was also found in storage, violating manufacturer safety guidelines.
Infection Prevention Importance: Enhanced Barrier Precautions are designed to prevent transmission of multidrug-resistant organisms, which can cause serious infections that are difficult to treat. Medical devices like feeding tubes create entry points for bacteria, making proper protective equipment essential during any manipulation or care activities.
Food Safety and Service Problems
Kitchen operations revealed multiple food safety violations that could expose residents to foodborne illness risks. Unlabeled food items, including a container of white thickening powder and prepared sandwiches, lacked proper identification and dating required by food safety standards.
Temperature monitoring showed meals being served below safe holding temperatures. A test meal measured only 128 degrees Fahrenheit, well below the FDA Food Code requirement of 130 degrees minimum for hot foods. During a resident council meeting, all nine participating residents reported that meals were "often cold, especially the breakfast foods."
Physical kitchen maintenance issues included five broken tiles near dish drying areas, creating potential contamination risks and violating facility sanitation standards requiring surfaces to be "free from breaks, corrosion, holes, cracks, chips, dirt, and/or grime."
Dental Care Delays
One resident experienced significant delays in receiving ordered dental evaluation despite physician orders dating back to November 2024. The resident reported not wearing his dentures due to discomfort and stated he "haven't been seen by dentist in a while." Staff confirmed no dental appointment had been scheduled despite the standing medical order.
Additional Issues Identified
The inspection documented several other violations including improper medication storage temperatures for specialized drugs, inadequate labeling of pharmaceutical supplies, and failure to maintain organized controlled substance records. Food service violations included expired frozen meat substitute products and structural maintenance issues affecting kitchen sanitation standards.
These violations collectively demonstrate systemic issues in medication management, nutritional care, infection prevention, and basic safety protocols that required immediate corrective action to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Veterans Home of California - Chula Vista from 2025-01-30 including all violations, facility responses, and corrective action plans.
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