The Department of Veterans Affairs pulled all residents from an assisted living home in Van Nuys, California, after finding a veteran who had been dead for four days. The incident followed several complaints of mistreatment in the region.

A VA social worker visited the Van Nuys assisted living home and found a veteran who died four days earlier, according to a Department of Veterans Affairs investigation reported by Military.com. The investigation also detailed abuses of veterans including a 100-year-old diagnosed with sepsis. The California Villa home denied prescribed antibiotics because they were “not covered by Medicare.” The patient had to be hospitalized a second time due to the error.

The report cited a double dose of medication to another veteran. A third person was denied prescription drugs and charged him $5 per meal because he preferred to eat in his room, the article states.

“I am shocked that such lax oversight of facilities providing critical care for vulnerable veterans ever occurred,” Special Counsel Henry J. Kerner wrote in a letter Thursday to the White House. Kerner told White House officials the VA investigators found “disrepair” in the California Villa home and its medicine room was disorganized.

VA officials blamed the VA’s Greater Los Angeles Healthcare System after it failed to investigate complaints and correct “serious residential concerns.” During one inspection, investigators found feces on furniture due to improper cleaning.

The healthcare system suspended the California Villa home and removed the residents under their care during the 2018 inspection. It appears that facility program managers failed to report incidents to upper management, according to the article.

The investigation began after whistleblowers brought the problems in these homes to light. Kerner praised them and said he hoped the VA would investigate other allegations including a bedbug infestation.