Staff members of a California assisted living facility were unable to correctly identify a veteran in their care when a case manager from the Department of Veterans Affairs visited, resulting in the case manager reporting that she had visited with the resident — four days after he had died, according to the U.S. Office of Special Council.

The OSC sent a report detailing that incident and others occurring at California Villa in Van Nuys, CA, to President Donald Trump and leaders of Senate and House Veterans Affairs committees on Thursday. The incidents are part of a larger issue with the care of veterans in assisted living, according to the office.

California Villa was approved to care for veterans by the VA Greater Los Angeles Healthcare System, according to the OSC. When a case manager visited in October 2017 looking to meet with a specific veteran, however, staff members referred her to the wrong resident, a VA investigation found. The resident she had come to see actually had died four days before her visit.

“The agency identified this error as one of concern, noting that if staff cannot properly identify residents, it could be an indication that veterans are not receiving their proper medications,” Special Counsel Henry J. Kerner wrote in a letter to the president that accompanied the report.

The VA investigation also “confirmed longstanding and well-known” issues at the home, including a general state of disrepair and a disorganized medication room, the OSC said. Between 2015 and 2018, several veteran residents experienced “serious” medication errors, according to investigators. For instance, staff members did not provide physician-prescribed antibiotics to a 100-year-old veteran with sepsis, the report said. In another case, staff members allegedly did not update records related to physician-canceled prescriptions, resulting in a veteran receiving double doses of medication on two occasions. And in a third case, staff members allegedly did not provide medication to a resident who did not leave his room.

Referrals to California Villa were halted, but the alleged incidents there are examples of how VA employees in Los Angeles “compromised patient care” because they “failed to take action on repeated allegations of patient care deficiencies and employee misconduct” at assisted living facilities where veterans live, Kerner said in his letter. The VA investigation, he said, concluded that because veterans, not the VA, pay assisted living facilities, VA officials did not oversee those facilities as “vigorously” as they did other programs funded directly by the VA.

Whistleblowers first alerted officials to the issues, Kerner said.

“I am shocked that such lax oversight of facilities providing critical care for vulnerable veterans ever occurred, and I commend these whistleblowers for coming forward to shine a light on this serious issue,” he wrote.

The VA has agreed to begin monitoring more closely the assisted living communities caring for veterans. Also, the VA agreed to make the community care program coordinator a full-time position, and the person in the role now will visit all VA-approved assisted living facilities every month, according to the OSC. All facilities also will be independently reviewed, too, the office said.

California Villa is under new ownership since the incidents cited in the report.