Veterans Home Of California - Fresno
VETERANS HOME OF CALIFORNIA - FRESNO in FRESNO, CA — inspection on January 30, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included compression fracture (a bone in the spine collapsed or flatten due to pressure) and hypertension (high blood pressure).During a review of Resident 113 Physician Orders, dated 1/5/26, the Physician Orders indicated, May discharge to RCFE [Residential Care Facilities for the Elderly- non medical residential setting for elderly persons] due to goals met.Review of Resident 113's chart indicated there was no documentation that the ombudsman was notified of Resident 113's discharge.
During an interview on 1/29/26 at 11:54 am with Quality Registered Nurse (QRN)1, QRN 1 stated the ombudsman was not notified when residents were discharged from the facility to RCFE.
During an interview on 1/29/26 at 4:18 pm with the Standards Compliance Coordinator (SCC), the SCC stated the facility did not send notification of Resident 113's discharge to the ombudsman. SCC also stated the facility did not have policies and procedures on ombudsman notification process.2.
During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included compression fracture (a bone in the spine collapsed or flatten due to pressure) and hypertension (high blood pressure).During a review of Resident 113 Physician Orders, dated 1/5/26, the Physician Orders indicated, May discharge to RCFE [Residential Care Facilities for the Elderly- non medical residential setting for elderly persons] due to goals met.During a concurrent interview and record review on 1/29/26 at 10:09 am with Quality Registered Nurse (QRN)1, QRN 1 stated that medication reconciliation was not performed and documented as part of the facility's discharge process when a resident was discharged to the RCFE. QRN1 confirmed that there were no physician orders for Resident 113's discharge medications in the resident's record.
During an interview on 1/29/26 at 4:48 pm with Nurse Educator (NRS ED) 2, NRS ED 2 stated upon discharge from the facility, the resident's current medications should be reconciled with the medications the resident will require at discharge. NRS ED 2 further stated the physician should document an order for the resident's discharge medication in the record.
During an interview on 1/30/26 at 9:20 am with the Medical Director (MD Director), the MD Director stated that when a resident was discharged from the facility, the nurse should call the physician to ask about medication changes for the resident's discharge; however, a complete medication list was not usually reviewed during call. MD Director stated that the medication reconciliation and discharge medication list was not performed during discharge from the facility to RCFE.Review of Resident 113's chart indicated there was no documentation the medication reconciliation was conducted and no documentation of physician's orders for discharge medications for Resident 113's discharge from the facility.Requested a policy related to discharge medication reconciliation. A policy was not provided during survey.
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706
catheter care, and appropriate care to prevent urinary tract infections.
appropriate treatment and services to prevent urinary tract infections for one of 24 residents, when
resident's bladder) was observed on the floor.This failure had the potential to result in catheter-associated urinary tract infection (CAUTI) [an infection that can occur when germs enter the bladder through the tube].Findings:During an observation on 1/28/26 at 11:11 am in Resident 4's room, Resident 4 was observed lying in bed with the urinary catheter drainage bag resting directly on the floor.During a concurrent observation and interview on 1/28/26 at 11:17 am with Registered Nurse (RN) 2, RN 2 confirmed that the catheter bag was on the floor, acknowledging it posed an infection risk.
During an interview on 1/28/26 at 11:33 am with Infection Preventionist (IP) IP confirmed that the urinary catheter bag should not be on the floor. IP stated, It should be hanging above the floor. It should not be sitting on the floor.
During an interview on 1/29/26 at 10:22 am with RN Nurse Instructor (NRS ED) 1 and RN Nurse Instructor (NRS ED) 2, NRS ED 1 and NRS ED 2 confirmed the urinary catheter bag should not be on the floor. NRS ED 2 stated, That is not what we teach. NRS ED 2 confirmed the facility does not have a specific policy for urinary catheter maintenance, but they teach and follow the Lippincott Nursing Procedure Manual.During a review of the professional reference titled, Lippincott Nursing Procedure 8th Edition published 2019, page 387 indicated, Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI.
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706
During a review of the facility's policy and procedure titled, Pharmaceutical Services dated 9/25/25, indicated, .Pharmaceutical Services will include, but not limited to, the following: Providing consultative and other services furnished by pharmacists, which assist in the development, coordination, supervision, and review of the pharmaceutical services within the SNF .
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706
During an interview on 1/29/26 at 11:45 am with Quality Registered Nurse (QRN) 1, QRN 1 stated there were no pharmacy reviews of the residents' medications for a few months because there was no pharmacist on staff to complete them.
During an interview with Skilled Nursing Facility Administrator (SNF Admin) on 1/29/26 at 10:34 am, SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. SNF Admin stated pharmacist reports were not completed during this time.During a review of the facility's policy and procedure titled, Drug Regimen Review, dated 4/1/25, indicated, A pharmacist will review the drug regimen of each Resident at least monthly and prepare appropriate reports.
The goal is to promote positive outcomes and to minimize adverse consequences associated with medication.
The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or any other irregularities.
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706
facility's policy and procedure (P&P) titled, Drug Storage dated [DATE], the P&P indicated, .Drugs and
such a manner so as to maintain their security and integrity.Drug storage containers must not
writing by the SNF.Discontinued drug and biological containers.will be stored in a separate location which will be identified solely for this purpose in the medication room.During a review of a list of classifications authorized to access medications dated [DATE], the list indicated that Licensed Vocational Nurses, Registered Nurses, Supervising registered Nurses, Supervising Nurse II, and Pharmacy Technician.
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706
During an interview with Standards Compliance Coordinator (SCC) on 1/30/26 at 8:21 am, SCC stated the QAPI meetings occur at least quarterly and as needed. SCC stated the last QAPI meeting was on 10/30/25.
SCC stated there were no specific issues that were discussed regarding pharmacy services.
There was no plan created for pharmacy services during the meeting. SCC stated communication between leadership and headquarters regarding the termination of pharmacy services with the contracted pharmacy company was not discussed with other members in QAPI during the last meeting.During a review of the facility's QAPI plan dated 2/2025, indicated, .QAPI Purpose: The purpose of QAPI is to take a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.
During a review of the policy and procedure (P&P) titled Enhanced Barrier Precautions dated 12/30/25, the P&P indicated, .Enhanced Barrier Precautions: Infection control interventions requiring gown and glove use during high-contact resident care activities to reduce the spread of MDROs.High Contact Activities: These include dressing, bathing, transferring, providing hygiene, changing linens, assisting with toileting, caring for indwelling medical devices, and performing wound care.Medical Devices: Identify residents with indwelling medical devices. (e.g., central venous catheters, urinary catheters).
Implement EBP for residents with indwelling medical devices, regardless of MDRO status, due to the risk of contracting an MDRO.Focus on the use of gown and gloves during high-contact resident care activities.
555900 01/30/2026
Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706