Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Veterans Home Of California - Barstow during CMS and state inspections, most recent first.
Failure to use PPE during cleaning in an EBP room: A custodian was observed cleaning the room of two residents under EBP without wearing gloves or a gown. One resident had a wound on the left leg and the other had a chronic suprapubic catheter. The custodian touched the beds, curtains, and dresser while cleaning, and later stated she knew the EBP signs were posted and should have worn PPE.
Surveyors found that for five residents prescribed psychotropic medications for conditions such as anxiety, depression, and schizophrenia, staff failed to document any non-pharmacological interventions during episodes of behavioral symptoms, despite care plans and facility policy requiring such interventions to be implemented and recorded.
Two residents received unnecessary medications when nursing staff failed to follow physician-ordered hold parameters for blood sugar and blood pressure. Despite clear orders to withhold diabetes and antihypertensive medications under certain clinical conditions, the medications were administered on multiple occasions, as confirmed by MAR reviews and staff interviews. Facility policy required adherence to orders and proper documentation when medications were withheld, but these procedures were not followed.
A resident with orders for blood sugar monitoring and as-needed Glutose 15 gel for low blood sugar did not receive the medication on three occasions when blood sugar readings were below the ordered threshold. The DON confirmed that physician orders were not followed, and facility policy required medications to be administered as ordered.
Two boxes of eye drops were found stored in a bin labeled and filled with ear drops in the medication room, contrary to facility policy requiring separate storage. The DSD and DON both acknowledged that eye and ear drops should be stored separately.
A facility failed to implement its Theft and Loss Reporting policy when a resident's loss of $100 and a $50 gift card was not reported using Form SOC 341. The resident, with hypertension and emphysema, could not recall the incident due to memory issues. Despite the CNA's report, the required form was not completed, potentially leading to an inadequate investigation.
The facility failed to maintain sanitary conditions in the food service department. A spatula with cracks and a yellow substance was found, posing a contamination risk. Additionally, food items in the freezer were not labeled or dated, which staff acknowledged could lead to food-borne illnesses. The facility's policies required utensils to be in good repair and food to be properly labeled and dated.
The facility failed to maintain a safe water temperature at the kitchen's hand washing station, with a recorded temperature of 156.1 degrees Fahrenheit. This posed a risk of burns to staff and potential poor handwashing practices. The Director of Dietetics and Food Manager confirmed the issue, noting no work order had been submitted despite the facility's policy requiring action if temperatures exceed 120 degrees Fahrenheit.
A resident's wheelchair was found in poor condition with a torn and cracked armrest, causing discomfort. The LRN acknowledged the need for a replacement, but the facility lacked a policy for maintaining wheelchairs.
A facility failed to label an opened bottle of Polyethylene Glycol with the open date for a resident with dementia and chronic pain. During a medication storage observation, an LVN confirmed the absence of the label. The DON acknowledged the oversight, which was against the facility's policy requiring the open date to be recorded on multi-dose containers.
Two residents' MARs were not accurately documented by an LVN, who failed to sign for administered medications. This included treatments for high blood pressure, diabetes, and other conditions. The DON confirmed the expectation for nurses to document medication administration as per facility policy.
The facility failed to maintain the kitchen dishwasher in a safe condition, as it was observed spraying water and creating a pool on the floor. The issue was due to missing multi-flap curtains, essential for keeping moisture inside and preventing hot water injuries. The facility's policy requires equipment to be maintained according to the manufacturer's specifications, which was not followed.
Failure to Use PPE During Cleaning in an EBP Room
Penalty
Summary
The facility failed to ensure that staff followed infection prevention and control practices when Custodian 1 did not use appropriate PPE while cleaning a room under Enhanced Barrier Precautions (EBP). In the room of Resident 6 and Resident 25, two EBP signs were posted at the entrance. Resident 25 was on EBP for a wound on the left leg, and Resident 6 was on EBP for a chronic suprapubic catheter. During observation, Custodian 1 was seen sweeping the floor and touching the beds, curtains, and dresser without wearing gloves and a gown. In a later observation with the HGSA present, Custodian 1 was again observed cleaning the room without any PPE. The HGSA stated custodians need to wear a gown and gloves when cleaning and disinfecting rooms with EBP, and Custodian 1 stated she knew the EBP signs were posted and that she should have worn PPE before performing her cleaning tasks. The IPRN stated custodians were expected to wear PPE before entering the room of any resident under EBP for cleaning and disinfecting.
Failure to Document Non-Pharmacological Interventions for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to document non-pharmacological interventions (NPIs) for five residents who were prescribed psychotropic medications. For each of these residents, physician orders specified the use of medications such as alprazolam, bupropion, olanzapine, fluoxetine, escitalopram, lorazepam, quetiapine, divalproex sodium, and risperidone to manage conditions including anxiety, depression, schizophrenia, bipolar disorder, and schizoaffective disorder. Behavior Monitoring Records (BMRs) for these residents documented episodes of behaviors such as irritability, mood changes, sadness, delusions, anxiousness, agitation, angry outbursts, mood swings, and auditory hallucinations. However, the corresponding Non-Pharmacological Intervention (NPI) Flow Sheets for each resident were found to be blank for the relevant months, indicating that no NPIs were documented as provided during these behavioral episodes. Care plans for each resident included specific interventions requiring the use of non-drug approaches to address behaviors in addition to the ordered medications. These care plans also directed staff to document any non-drug interventions on the appropriate non-medication intervention sheets whenever resident behaviors occurred. Despite these documented care plan requirements, there was no evidence in the medical records that NPIs were implemented or recorded for any of the behavioral episodes noted in the BMRs for the sampled residents. During interviews and concurrent record reviews, the Director of Nursing (DON) and a Supervising Registered Nurse (SRN) acknowledged that the medical records did not show any NPIs provided as required by the care plans and facility policy. The facility's policy on psychotropic medication management also specified that behavioral interventions should be implemented and documented in an attempt to decrease target behaviors. The lack of documentation and apparent lack of implementation of NPIs for residents receiving psychotropic medications constituted the deficiency identified by surveyors.
Failure to Follow Medication Hold Parameters Results in Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications by not adhering to physician-ordered hold parameters for blood sugar and blood pressure when administering certain medications. For one resident with diabetes, physician orders specified that diabetes medications, including Januvia, should be held if the blood sugar (BS) was less than 110 at 6:00 a.m. Despite this, the medication was administered on multiple occasions when the resident's BS was below the specified threshold, as documented in the Medication Administration Records (MAR) for January through April 2025. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the orders were not followed and that the resident received unnecessary doses on at least ten occasions. Another resident with hypertension had physician orders for three blood pressure medications, each with specific parameters to hold the medication if the systolic blood pressure (SBP) or diastolic blood pressure (DBP) fell below certain levels. The MARs showed that these medications were administered even when the resident's blood pressure readings were below the hold parameters. The DSD and DON both acknowledged that the medications were given when they should have been withheld, as indicated by the lack of circled initials and documentation on the MAR. The facility's policy on administering medications required that medications be given according to physician orders and that any withheld medications be properly documented with circled initials and a reason for withholding. The failure to follow these procedures resulted in the administration of unnecessary medications to both residents, as confirmed by staff interviews and record reviews.
Failure to Administer Hypoglycemia Medication as Ordered
Penalty
Summary
The facility failed to ensure the accurate provision of medication for one resident when the resident did not receive Glutose 15 gel, a medication prescribed to treat hypoglycemia, as ordered by the physician. The resident had physician's orders to check blood sugar twice daily and to administer Glutose 15 by mouth if blood sugar was less than 80. Medical records showed that on three separate occasions, the resident's blood sugar was below 80, but the medication was not administered as required. The Director of Nursing confirmed during interview and record review that the physician's orders were not followed on these dates. Facility policy required medications to be administered in accordance with orders.
Improper Storage of Eye and Ear Drops in Medication Room
Penalty
Summary
During an observation and interview in the medication room of the skilled nursing facility, eight boxes of ear drops were found stored in a bin labeled 'EAR DROPS,' along with two boxes of eye drops (Refresh and Visine). The Director of Staff Development confirmed that the eye drops were stored in the ear drop bin. A review of the facility's medication storage policy, last reviewed on 5/31/24, indicated that eye medications are required to be kept separate from ear medications. The Director of Nursing acknowledged that eye drops and ear drops should be stored separately, confirming that the observed storage practice did not comply with facility policy.
Failure to Report Theft and Loss of Resident's Property
Penalty
Summary
The facility failed to implement its policy for Theft and Loss Reporting and Investigation for a resident when the Report of Suspected Dependent Adult-Elder Abuse (Form SOC 341) was not completed and sent to the ombudsman. This deficiency was identified during an unannounced visit to investigate a reported incident involving the loss of one hundred dollars and a fifty-dollar gift card belonging to a resident. The resident, an elderly male with diagnoses of hypertension and emphysema, was unable to recall what happened to his money and gift card due to memory issues. The incident was initially reported by a CNA, who confirmed the resident had the money and gift card in his wallet, which were now missing. Despite the facility's policy requiring such losses to be reported to the Highway Patrol, California Department of Public Health, and the Ombudsman, the necessary form was not completed, leading to a potential inadequate investigation of the loss.
Food Storage and Equipment Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the food service department, as observed during a survey. A spatula with cracks and a yellow dried substance was found in the kitchen, which the Food Manager confirmed was unsafe due to the risk of food contamination and food-borne illnesses. The facility's policy and procedure on sanitation required all utensils and equipment to be kept clean and in good repair, free from breaks and cracks. Additionally, the facility did not ensure proper labeling and dating of food items in the kitchen freezer. Six popsicles and an opened meatball package were found without labels or dates, which staff acknowledged could lead to food-borne illnesses. The Director of Dietetics stated that all foods should be labeled and dated to ensure safety. The facility's policy on leftover and extra food required labeling, dating, and monitoring of refrigerated food to ensure it was used by its use-by date or properly stored.
Excessive Water Temperature at Kitchen Handwashing Station
Penalty
Summary
The facility failed to ensure a safe and comfortable working environment for staff in the kitchen due to excessively high water temperature at the hand washing station. During an observation and interview with the Director of Dietetics (DOD) and the Food Manager (FM), the water temperature was measured at 156.1 degrees Fahrenheit, which was confirmed to be too hot and posed a risk of burns to staff. The DOD acknowledged that the hot water had always been out of range, and there was no work order to address the issue. The FM stated that the hand washing water temperature should be 120 degrees Fahrenheit, but no work order had been submitted. A review of the facility's policy and procedure on Plumbing and Water Supply Maintenance indicated that a work order should be submitted if water temperature exceeds 120 degrees Fahrenheit during normal business hours. Additionally, the 2022 Federal Food and Drug Administration (FDA) Food Code specifies that inadequate water temperature can lead to poor handwashing practices, and the International Plumbing Code defines tempered water as having a temperature range between 85 F and 110 F.
Deficiency in Wheelchair Maintenance
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for one of the residents, identified as Resident 29, whose wheelchair was not in good working condition. During an observation and interview, it was noted that the wheelchair had a large tear on the right armrest, with the cushion exposed, and multiple rough raised cracks with frayed edges. Resident 29 reported that the armrest was already torn when they received the wheelchair from the facility and expressed discomfort and dissatisfaction with its condition. The Lead Registered Nurse acknowledged the issue, stating that Resident 29 needed a new wheelchair. The facility was unable to provide a policy and procedure related to maintaining residents' wheelchairs in good working condition during the survey.
Failure to Label Medication with Open Date
Penalty
Summary
The facility failed to properly label an opened bottle of Polyethylene Glycol, a medication used to treat constipation, for a resident who was not part of the sampled group. This oversight was discovered during a medication storage observation and interview with an LVN, who confirmed that the bottle was not labeled with the open date. The resident in question had been admitted with diagnoses of dementia and chronic pain, and the medication was administered as per the Medication Administration Record. The Director of Nursing acknowledged that the medication should have been dated when opened, as per the facility's policy and procedure for administering medications. The policy clearly states that the date of opening a multi-dose container must be recorded on the container. This failure to label the medication had the potential to result in the resident receiving expired and less effective medication.
Medication Administration Documentation Lapses
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for two residents on June 2, 2024. For Resident 19, a licensed nurse did not document the administration of medications for the 8 a.m. dose. The medications included treatments for high blood pressure, blood clots, high cholesterol, constipation, nerve pain, bone health, depression, and vitamin deficiencies. During an interview, the Licensed Vocational Nurse (LVN) admitted to forgetting to sign the MAR for the medications given to Resident 19. The Director of Nursing (DON) confirmed that the expectation is for the nurse to prepare, administer, and sign the MAR as per the facility's policy. Similarly, for Resident 48, the MAR lacked documentation for the 10 a.m. dose of medications, which included treatments for high blood pressure, constipation, fluid retention, and type 2 diabetes mellitus. The same LVN acknowledged forgetting to sign the MAR for Resident 48's medications. The DON reiterated the facility's policy that requires the individual administering the medication to record it in the resident's medical record, including their signature and title. These documentation lapses had the potential to result in inaccurate medication administration for both residents.
Dishwasher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen dishwasher in a safe operating condition, as observed during a survey. On 6/4/2024, a Food Service Technician (FST) noted that the dishwasher was spraying water, creating a pool on the floor when turned on. The Chief Plant Operations (CPO) confirmed on 6/5/2024 that the issue was due to missing multi-flap curtains, which are essential for keeping moisture inside the machine and preventing hot water injuries. The Food Manager (FM) acknowledged the expectation to prevent water spraying for infection control and safety reasons. The facility's policy, dated 11/5/2023, requires equipment to be maintained in good working order according to the manufacturer's specifications, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Barstow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Post Acute | 2.4 mi | ★★★★★ | 0 | 0 |
| Spring Valley Post Acute Llc | 28.6 mi | ★★★★★ | 7 | 0 |
| Knolls West Post Acute Llc | 29.7 mi | ★★★★★ | 5 | 0 |
| Apple Valley Care Center | 30.3 mi | ★★★★★ | 15 | 0 |
| Desert Ridge Transitional Care Center, Lp | 31.6 mi | — | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Veterans Home Of California - Barstow.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.