According to a study published Thursday, Aug. 8 federal authorities pulled veterans from a Van Nuys assisted living home after discovering the facility had reported visiting a veteran who had been dead for four days.

The United States inquiry at the California Villa home, the Veterans Affairs Department also discovered severe medication errors. A 100-year-old sepsis veteran was refused prescribed antibiotics because they were “not covered by Medicare” and ended up being hospitalized for the second time, the study said.

Another veteran got a double dose of the drug and a third was refused prescription medicines and charged $5 a meal as he preferred to eat in his room instead of the cafeteria.

Washington, D.C. authorities blamed the VA’s Greater Los Angeles Healthcare System for failing to explore and solve the facility’s “serious residential care concerns,” but added that program administrators had not reported the issues to upper management.

The United States launched an inquiry and special counsel based the complaints from a whistleblower.

“I am shocked that such lax oversight of facilities providing critical care for vulnerable veterans ever occurred,” said Special Counsel Henry J. Kerner in a letter to the White House on Thursday. The results of the inquiry were also passed on to boards of congressional oversight.

The California Department of Social Services had sought to withdraw the California Villa permits after discovering that the facility had not resolved severe security problems arising from repeated attacks by a resident against other inhabitants in 2017, resulting in at least one hospitalization, state records show.

The state agency also discovered that the furniture was not properly cleaned of feces by employees.

In March, under the name California Green Tree Villa Ast Lvg & Memory Care, a fresh facility permit was awarded. It is licensed for 200 residents.

Administrator Jacqueline Beltran said the facility changed hands Aug. 1, adding that she was going to relay questions to the new owners who didn’t answer.

For citizens with Alzheimer’s disease or dementia, or at danger of wandering, the veteran was living in a closed ward. When a caseworker came for a visit, the inquiry discovered that the employees of California Villa directed her to the incorrect resident. An addendum was added to the case notes of the veteran after the mix-up was found saying “Please delete, the wrong veteran.”

Investigators said the confusion called into question whether other inhabitants had received medication that was wrong.

The VA researchers failed to uphold a complaint from the whistleblower that a VA manager had inappropriate patient relationships.

Werner commended the whistleblowers and said one of them hoped that the VA would investigate further claims of a bedbug infestation and other issues.

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