Federal officials pulled veterans from a Van Nuys assisted living home after finding that the facility had reported a social worker visiting a veteran who had been dead for four days, according to a report released Thursday.

The investigation by the U.S. Department of Veterans Affairs also found serious medication errors at the California Villa home. A 100- year- old veteran with sepsis was denied prescribed antibiotics because they were "not covered by Medicare " and ended up hospitalized a second time, the report said.

Another veteran received a double dose of medication and a third was denied prescription drugs and charged $5 a meal because he preferred eating in his room rather than the cafeteria.

Authorities from Washington, D.C., blamed the VA 's Greater Los Angeles Healthcare System for failing to investigate and address "serious residential care concerns " at the facility, but added that program administrators had not reported the problems to upper management.

Related: More Vets Will Be Headed to Nursing Homes, and VA May Not Be Ready: Report

The healthcare system had California Villa on an approved list, and helped place veterans there, but suspended referrals and relocated most of their clients during the investigation in 2018.

The investigation was initiated by the U.S. Special Counsel based on whistleblower complaints.

"I am shocked that such lax oversight of facilities providing critical care for vulnerable veterans ever occurred, " Special Counsel Henry J. Kerner said in a letter Thursday to the White House. The investigation findings were also relayed to congressional oversight committees.

The California Department of Social Services had sought to revoke California Villa's license after finding that the facility in 2017 had not addressed serious safety issues stemming from a resident 's repeated assaults on other residents, which resulted in at least one hospitalization, state records show.

The state agency also found that staff did not adequately clean feces from the furniture.

A new license for the facility was issued in March under the name California Green Tree Villa Ast Lvg & Memory Care. It is licensed for 200 residents.

Administrator Jacqueline Beltran said the facility changed hands Aug. 1, and added that she would relay questions to the new owners, who did not respond.

Kerner, in his letter, said VA investigators found California Villa facilities in "disrepair" and its medicine room disorganized.

The false report of the visit to a dead veteran stemmed from a misidentification by California Villa staff, investigators said.

The veteran was living on a locked ward for residents with Alzheimer's disease or dementia, or who were at risk of wandering. When a case worker arrived for a visit, California Villa staff directed her to the wrong resident, the investigation found. After the mix- up was discovered, an addendum was added to the veteran's case notes saying "Please delete, wrong veteran."

Investigators said the confusion called into question whether other residents had received incorrect medication.

The VA investigators did not uphold a whistleblower complaint that a VA manager had improper relationships with patients.

Werner praised the whistleblowers for bringing the problems to light and said one of them hoped the VA would investigate further allegations of a bedbug infestation and other problems.

This article is written by Gale Holland from The Los Angeles Times and was legally licensed via the Tribune Content Agency through the NewsCred publisher network. Please direct all licensing questions to legal@newscred.com.