Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Douglas Jacobson State Veterans Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's and Alzheimer's, who was alert and oriented, was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode and a missed medical appointment. Therapy staff did not provide direct toileting assistance or seek help from nursing, instead blocking the bathroom door and insisting the resident return to his unit. The resident reported feeling angry and embarrassed by the incident.
Two residents received controlled substances with documentation showing more doses administered than prescribed, and medication logs were found to be illegible and inconsistent. An LPN was associated with multiple discrepancies, including altered dates and unclear signatures, leading to inaccurate records of medication administration.
A resident with intact cognition and overactive bladder reported that call lights were ignored and care was not provided during the night shift, resulting in the resident being found in the morning with a full urinal, wet bed, and soiled brief. Staff interviews revealed inconsistent accounts of care, and documentation was lacking to confirm that care was provided or refused. The facility's investigation verified the neglect allegation due to insufficient evidence to disprove the resident's claim.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive timely toileting assistance during the night shift, resulting in being found wet and soiled in the morning, with no documentation of care or refusals. Additionally, two residents experienced discrepancies in the administration and documentation of controlled substances, with records showing more doses given than prescribed and illegible, altered logs. Staff interviews confirmed these failures, and one LPN was linked to multiple documentation issues.
Two residents receiving scheduled Oxycodone-based pain medications experienced discrepancies in the administration and documentation of their controlled substances. The medication logs showed more doses signed out than prescribed, with illegible and altered entries, and dates out of order. An LPN was associated with these documentation errors, admitting to changing dates and being unable to account for multiple signatures, resulting in a failure to protect residents from misappropriation of their property.
A resident with dementia, Parkinson's disease, and overactive bladder was found with a full urinal and wet bedding after reporting that call lights were not answered during the night. Staff interviews provided conflicting accounts, and there was no documentation of incontinence care or refusals for the shift in question or for several other days. The lack of records prevented verification that care was provided, leading to a substantiated finding of neglect.
A resident with Parkinson's and dementia was reportedly bruised during an incident where staff attempted to clean him after he smeared feces on his bed. The resident became combative, and staff held his hands and wrists to prevent him from falling and to protect themselves. The resident's family reported concerns about bruising, and the resident confirmed staff had grabbed him, although he did not feel it was intentional harm. The facility's investigation did not verify abuse, but the Risk Manager noted staff should not have forcibly removed the resident from the bed.
A facility failed to protect residents from neglect by not following hot liquid safety procedures, leading to burns for two residents. One resident spilled hot coffee, causing redness, while another with severe cognitive impairment suffered a second-degree burn from hot chocolate. An LPN reheated the drink without checking its temperature, violating policy. No audits ensured staff compliance, resulting in injuries.
A resident with cognitive impairments suffered a second-degree burn after a staff member reheated hot chocolate without checking the temperature, contrary to facility policy. The resident accidentally spilled the hot beverage, resulting in an avoidable injury. The staff member had been trained on safe serving practices but failed to adhere to them.
A resident with a complex medical history fell and sustained a head injury, leading to a significant drop in blood pressure. The LPN failed to notify the physician of the change in condition or perform a complete neurological assessment, resulting in the resident being found with no vital signs. The medical director stated that he would have sent the resident to the ER if informed of the mental status change.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced multiple falls due to inadequate supervision in an LTC facility. Despite a care plan requiring assistance, the resident was often left unsupervised, leading to injuries. The facility failed to update the care plan with new interventions after each fall, as acknowledged by the DON.
A resident with Parkinson's disease and dementia, identified as a high fall risk, experienced 18 falls without adequate updates to their care plan. Despite multiple falls, the facility only added new interventions twice. The DON noted the resident's cognitive limitations and the challenge of implementing effective interventions without compromising independence.
The facility failed to provide an ongoing activity program to meet the interests and support the well-being of its residents. A resident with dementia and Parkinson's was observed restless and disengaged from activities. Another resident with Alzheimer's was found sleeping or passively sitting without structured activities. A third resident with severe cognitive and sensory impairments was not engaged in meaningful activities. Staff shortages and lack of qualified personnel contributed to the deficiency.
The facility failed to have a qualified Activity Director, impacting the activities program. Staff lacked necessary credentials, and the absence of a qualified director since early August led to limited activities, especially for residents in secured units. An interim director was present for a week, but the deficiency affected all residents' well-being.
A resident with multiple medical conditions experienced a fall with a head injury. The LPN failed to complete necessary neuro checks, noting the resident was asleep and did not want to wake him, despite a significant drop in blood pressure. The facility lacked a policy for neuro checks, and the resident was later found with no vital signs.
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) in a timely manner, as per policy. The notice, which should be given at least two days before the end of a Medicare-covered Part A stay, was not documented as provided within the required timeframe. Staff K, the social worker program manager, admitted to sending notices via regular mail without documentation of the timing, leading to the deficiency.
Resident Denied Restroom Access and Assistance in Therapy Department
Penalty
Summary
A deficiency occurred when a resident was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode. The incident took place when the resident, who was on his way to a doctor's appointment, urgently needed to use the restroom and attempted to use the therapy department bathroom. Staff in the therapy department informed the resident that he could not use the restroom without assistance and that he was not permitted to use the therapy bathroom unless he was in treatment. The staff offered to take the resident back to his unit to use the bathroom, but did not offer direct assistance with toileting in the therapy department. Additionally, a wheelchair was placed in front of the bathroom door to block access, and no staff contacted the nursing department for assistance. The resident, who had diagnoses of Parkinson's disease and Alzheimer's disease, was alert and oriented with intact cognition, as indicated by a recent assessment. He required assistance for transfers (stand and pivot) and sometimes used a sit-to-stand lift, but therapy notes indicated he was able to use the restroom with minimal to no assistance. Despite his ability to communicate his needs and his history of being able to toilet himself, the staff did not provide the necessary support or allow him to use the available restroom, leading to the resident soiling himself and missing his scheduled appointment. Staff statements confirmed that the resident expressed urgency and distress, and that the therapy staff did not personally assist him to the restroom nor did they seek help from nursing staff. The Director of Rehab later stated that the facility's verbal policy is to accommodate all residents' restroom needs and that there was no excuse for denying access. The resident reported feeling angry and embarrassed by the incident, which he described as inconsistent with his prior experiences at the facility.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by not maintaining effective processes to prevent the misappropriation of controlled substances for two residents. For one resident, a physician's order specified a controlled substance to be administered four times daily, but pharmacy records and controlled substance logs revealed that the medication was being signed out and documented as administered more frequently than prescribed, with some days showing up to 11 doses. The controlled substance logs were found to have multiple dates scribbled over or written illegibly, making it difficult to determine the actual administration times and dates. Despite the discrepancies, the physical count of medication matched the expected amount, but the documentation did not align with the prescribed administration schedule. A similar issue was identified for another resident, where the controlled substance record of use also showed illegible and out-of-order dates, and the number of tablets signed out did not match the administration history. The logs indicated that more tablets were being signed out than were actually administered according to the administration history, and the documentation was inconsistent and unclear. The facility's investigation found that these discrepancies were associated with a specific LPN, who admitted to changing dates on medication documents and could not account for multiple signatures or events on the medication cart. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The deficiencies were discovered when the pharmacy consultant identified that a refill request for a controlled substance was made earlier than expected, prompting an audit of the controlled substance records. The audit revealed that the documentation did not accurately reflect the administration of medication as ordered by the physician, and the logs were not maintained in a legible or orderly manner. The facility's own investigation confirmed the documentation issues and linked them to the actions of the LPN involved.
Failure to Prevent Resident Neglect Due to Lack of Night Shift Care and Documentation
Penalty
Summary
A deficiency occurred when a resident's right to be free from neglect was not upheld, as the facility failed to ensure the resident received necessary care during the night shift. The resident, who had diagnoses including overactive bladder and required partial assistance for mobility and toileting, reported that he called for help throughout the night but did not receive assistance. Upon morning shift change, staff found the resident with a full urinal, wet bed, and soiled brief, confirming that his care needs had not been met during the previous shift. Interviews with staff revealed inconsistencies in the accounts of care provided. Some CNAs and nurses stated that the resident was checked and attended to multiple times during the night, while others acknowledged that it was not uncommon to find residents with overflowing urinals and soaked beds at the start of the morning shift. The resident himself reported frequent issues with the night shift not responding to call lights, and described an incident where a nurse entered his room, turned off the call light, and left without providing care, despite his bed being soaked. A review of the clinical record and facility documentation showed a lack of evidence that care was provided or that the resident refused care during the night in question. The facility's own investigation verified the allegation of neglect, noting that there was insufficient documentation to disprove the resident's claim. The Director of Nursing confirmed the absence of documentation for care provided to the resident on multiple shifts, and staff interviews indicated that there was no clear policy for documenting such care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Neglect and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect and misappropriation of property, as evidenced by two main deficiencies. One resident, who was care planned for overactive bladder and required a two-person assist for transfers and toileting, reported that he called for help throughout the night but did not receive assistance. Multiple staff interviews and the facility's own investigation confirmed that the resident was found in the morning with a full urinal, wet bed, and wet brief, and that there was no documentation of care provided or refusals during the night shift. Staff acknowledged that it was not uncommon to find residents wet and call lights on at shift change, and the Director of Nursing confirmed a lack of documentation for care provided on multiple shifts. Additionally, the facility failed to have effective processes in place to prevent the misappropriation of controlled substances for two residents. Pharmacy records and controlled substance logs revealed that one resident received more doses of a controlled medication than prescribed, with documentation showing up to 11 doses in a single day when only four were ordered. The logs were found to be illegible, with dates scribbled over and not in order, and similar discrepancies were found for another resident's controlled medication. The pharmacy consultant and facility staff confirmed that the counts were correct, but the administration records were inaccurate and not properly reconciled. Interviews with staff, including the DON, Risk Manager, and LPNs, revealed that one LPN was associated with multiple documentation discrepancies, including altered dates and signatures she could not recall. The facility's investigation verified these issues, and the LPN denied taking any pills or overmedicating residents. The lack of accurate documentation and oversight led to the inability to ensure that residents received medications as ordered and that their property was safeguarded.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property by not maintaining effective processes to prevent the misappropriation of controlled substances. Specifically, for two residents with physician orders for scheduled doses of Oxycodone-based pain medications, discrepancies were found in the administration and documentation of these controlled substances. The controlled substance logs showed that more doses were signed out than prescribed, with some days reflecting up to 11 doses when only 4 were ordered. Additionally, the logs contained multiple instances of dates being scribbled out, written over, or entered out of order, making it difficult or impossible to accurately track medication administration. For one resident, pharmacy records indicated that 120 tablets of Oxycodone-APAP were delivered as a 30-day supply, but the medication was requested for refill eight days early. Upon review, it was found that the administration history did not match the expected dosing schedule, and the controlled substance logs were inconsistent and illegible in places. The count of tablets in the blister packs matched the documented end count, but the daily administration records showed more doses than prescribed, and missed doses were also documented. Similar issues were identified for another resident receiving Oxycodone, with the controlled substance logs again showing illegible entries and dates out of sequence. The facility's investigation revealed that these discrepancies were associated with an LPN, who admitted to changing dates on medication documents and could not account for multiple signatures. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The facility identified that the issues were not isolated to a single resident but affected multiple residents receiving controlled substances, and the documentation practices failed to ensure accurate and legible records of controlled substance administration.
Failure to Provide and Document Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from neglect by not ensuring that incontinence care was provided according to the resident's needs. The resident, who had diagnoses including dementia, Parkinson's disease, and overactive bladder, was assessed as frequently incontinent and required partial to moderate assistance for toileting and hygiene. Despite being care planned for urinary incontinence and having urinals at the bedside, the resident reported that call lights were used throughout the night without response, resulting in a full urinal and wet bed and clothing in the morning. Multiple staff interviews confirmed that the resident was found in this condition at shift change, and the resident expressed dissatisfaction with the care received during the night shift. The facility's investigation into the incident revealed conflicting staff accounts regarding the care provided during the night in question. While some staff stated that the resident was attended to multiple times, there was no documentation in the clinical record to support that incontinence care was provided or that the resident refused care during the relevant shift. The lack of documentation extended to several other days and shifts, as verified by the Director of Nursing, indicating a broader issue with record-keeping for incontinence care and resident refusals. The facility's policies required identification and intervention in situations where neglect could occur, but the absence of documentation made it impossible to verify that the resident's needs were met. The investigation ultimately verified the allegation of neglect due to the inability to disprove the resident's claim and the lack of evidence showing that appropriate care was provided during the night shift.
Resident's Right to Be Free from Physical Abuse Not Protected
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. The incident involved a male resident with a history of Parkinson's disease, dementia, bipolar disorder, major depressive disorder, and obsessive-compulsive disorder. On the night of the incident, the resident was reportedly smearing feces on his bed and became combative when staff attempted to clean him. The staff, consisting of an LPN and a CNA, held the resident by his hands and wrists to prevent him from falling out of bed and to protect themselves from being hit by the resident, who was using a reaching tool as a weapon. The resident's family reported concerns about bruising on the resident's hands and wrists, which they believed resulted from staff forcibly removing him from the bed. The resident confirmed to the Risk Manager that staff had grabbed his hands and wrists, causing bruising, although he did not feel the staff intentionally tried to hurt him. The Risk Manager observed the bruising and noted the resident's mental anguish following the incident, indicating psychological support was being provided. The facility's investigation concluded that the allegation of abuse was not verified, citing the resident's combative behavior and the staff's actions to ensure his safety. However, the Risk Manager acknowledged that staff should not have removed the resident from the bed against his will and did not fully document or investigate the family's claim about prying the resident's fingers from the handrail. The report highlights a deficiency in the facility's handling of the situation, particularly in protecting the resident from potential abuse and adequately investigating the incident.
Failure to Adhere to Hot Liquid Safety Procedures Results in Resident Burns
Penalty
Summary
The facility failed to protect residents from neglect by not adhering to its hot liquid safety procedures, resulting in thermal burns to two residents. The facility's policy required that hot beverages be served at a safe temperature to prevent scalding and burns, with temperatures recorded daily. However, an incident occurred where a resident spilled hot coffee on himself, resulting in redness to his abdomen and upper thigh. This incident highlighted the facility's failure to ensure staff followed the hot liquid safety procedures. Another incident involved a resident with Alzheimer's disease and severe cognitive impairment, who sustained a partial thickness thermal burn after hot chocolate spilled onto his lap. The resident's cognitive skills were severely impaired, requiring setup and cleanup assistance at meals. Despite this, the hot chocolate was served at an unsafe temperature, leading to a burn that evolved from a first-degree to a second-degree burn. The resident reported that the hot chocolate was very hot and spilled from the table onto his lap. The facility's investigation revealed that an LPN reheated the hot chocolate without rechecking its temperature, contrary to the facility's policy. The LPN had previously signed an in-service form acknowledging the requirement to check temperatures before serving. The facility confirmed that no audits were conducted to ensure staff compliance with the hot liquid safety procedures, resulting in the resident's injury.
Failure to Ensure Safe Serving of Hot Beverages
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in an avoidable thermal burn for a resident. On the specified date, a staff member reheated a cup of hot chocolate for a resident without verifying that the beverage was at a safe temperature. The resident, who had severe cognitive impairments and required assistance during meals, accidentally spilled the hot chocolate on his lap, leading to a second-degree burn on his left anterior thigh. The facility's policy on hot liquid safety was not followed, as the temperature of the beverage was not checked after reheating, and the resident was not adequately supervised. The resident involved was an elderly male with Alzheimer's disease, dementia, and other health conditions, which impaired his cognitive skills and decision-making abilities. The incident occurred when the resident was in his wheelchair, and the hot chocolate was placed on a bedside table. Despite the resident's preference for cooler beverages, the staff member reheated the drink and added ice chips without ensuring the temperature was safe. The resident reported that he did not request the reheating and that the cup tipped over from the table, causing the burn. The facility's incident investigation revealed that the staff member involved had previously received training on serving hot liquids safely, including checking temperatures before serving. However, the staff member did not adhere to these guidelines, as the temperature was not checked after reheating the beverage. The Director of Nursing and the Risk Manager confirmed that the staff member did not follow the facility's policy, leading to the resident's injury.
Failure to Notify Physician of Change in Condition After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced a fall resulting in a head injury. The resident, an elderly male with a complex medical history including Type 2 Diabetes, Dementia, and a cardiac pacemaker, fell and sustained a head injury. Following the fall, the resident complained of a headache and was observed with a reddened spot on his head. Despite these signs, the facility did not adequately monitor or document the resident's neurological status, as evidenced by missing documentation of pupil reaction and hand grasp. The resident's blood pressure showed a significant drop from 152/80 to 100/50, which was not recognized as concerning by the LPN on duty. The LPN did not notify the physician of this change, nor did she perform a complete neurological assessment, citing the resident's sleep as a reason. The resident was later found with no vital signs, and the medical director indicated that had he been informed of the change in mental status, he would have recommended sending the resident to the emergency room.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent avoidable fall-related accidents for a resident identified as being at high risk for falls. The resident, who had a history of falls and a hip fracture, was diagnosed with Parkinson's disease, dementia, and other mobility issues. Despite being assessed as requiring assistance for transfers, ambulation, and toileting, the resident experienced multiple falls, both witnessed and unwitnessed, over several months. Observations revealed that the resident was often left unsupervised, contrary to the care plan interventions, which included keeping personal items and call lights within reach and using anti-roll backs on the wheelchair. The facility's fall risk assessments consistently indicated a high risk for falls, yet the care plan was not updated with new interventions following each fall. The Director of Nursing acknowledged the lack of documentation for new interventions after falls, except for a few instances. The resident sustained injuries, including skin tears and a rib fracture, following falls. Despite the facility's fall program encouraging frequent rounding, the resident was often found alone in various locations without supervision. The DON expressed uncertainty about further interventions, citing the resident's cognitive limitations and the desire to maintain the resident's independence.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident based on ongoing clinical assessments and identified risks for falls. The resident, who was admitted with diagnoses including Parkinson's disease, dementia, and mobility issues, was identified as a high fall risk. Despite this, the care plan was not updated with new interventions following multiple falls, except on two occasions. The resident experienced 18 falls, both witnessed and unwitnessed, over a period of time, with some resulting in injuries such as skin tears. The Director of Nursing (DON) acknowledged the lack of documentation for new interventions after each fall, except for the addition of nonskid footwear and a protective bumper on specific dates. The DON expressed uncertainty about further interventions due to the resident's cognitive limitations, suggesting that one-on-one supervision might be necessary but was not implemented to maintain the resident's independence. The facility's fall program included purposeful rounding, but it was not sufficient to prevent the resident's repeated falls.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the interests and support the physical, mental, and psychosocial well-being of its residents. This deficiency was observed in three residents who were not engaged in meaningful activities. Resident #109, diagnosed with dementia, Parkinson's disease, and other conditions, was frequently observed sitting in front of a TV without awareness or interest in the program. Despite the presence of an activity calendar, the resident was not involved in any activities and required frequent redirection for safety due to restlessness and attempts to climb out of the wheelchair. Resident #31, with diagnoses including dementia and Alzheimer's disease, was observed sleeping or sitting passively without engagement in scheduled activities. Although music was played, there was no structured activity, and the resident did not respond to attempts at interaction. Staff confirmed that no activity personnel were present on the unit during certain shifts, and activities were limited to passive entertainment like music or TV. Resident #62, with severe cognitive impairment and sensory losses, was also observed sitting in front of a TV without engagement. Staff acknowledged the lack of individualized activities for residents with vision and hearing impairments and confirmed that activities were not consistently provided due to staffing shortages. The facility had not had a qualified Activity Director since early August, and the current staff lacked the necessary credentials in therapeutic recreational activities, further contributing to the deficiency.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The position description for the Activity Director outlined responsibilities including the development, implementation, supervision, and evaluation of activity programs tailored to meet the interests and well-being of each resident. However, interviews with staff revealed that the current activity staff lacked the necessary credentials in therapeutic recreational activities. Activity Staff A confirmed she did not possess the required qualifications, and Activity Supervisor Staff G admitted that no one in the department held the necessary credentials. The facility had been without a qualified Activity Director since early August, and the absence of qualified personnel affected the ability to conduct activities, particularly for residents in secured units. The Administrator acknowledged the deficiency, stating that the facility was actively seeking to hire a qualified Activity Director. Although a regional interim Activity Director was present for a week to oversee the program, this was not a permanent solution. The lack of qualified staff led to limited activity offerings, with staff unable to adhere to the activity calendar or provide individualized activities for residents with specific needs, such as those with vision and hearing impairments. The deficiency had the potential to impact all residents in the facility, as the activities program is integral to their physical, mental, and psychosocial well-being.
Failure to Conduct Proper Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff were competent in conducting neurological checks for a resident who experienced a fall with a head injury. The resident, a male with a history of multiple medical conditions including Type 2 Diabetes, Dementia, and Hypertension, was admitted on palliative care. After a fall, the resident complained of a headache and had a noticeable reddened spot on his head. Initial neuro checks showed a blood pressure of 161/96, which later dropped significantly to 100/50. However, the Licensed Practical Nurse (LPN) did not complete the neuro checks, as she documented the resident as asleep and did not want to wake him, failing to check pupil reaction and hand grasp. The LPN did not recognize the drop in blood pressure as significant and did not take further action. The resident was later found with no vital signs. The facility did not have a policy for completing neuro checks, and the Director of Nursing confirmed that neuro checks were not completed as required. The Director also stated that residents with head injuries should be awakened to complete neuro checks, which was not done in this case.
Failure to Provide Timely Notice of Non-Coverage
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) to inform them of potential liability for payment and their right to appeal. According to the facility's policy, this notice should be given at least two days before the end of a Medicare-covered Part A stay or when all Part B therapies are ending. However, for Resident #48, the last covered day of Part A service was on 2/29/24, but the durable power of attorney signed the form on 3/13/24. Similarly, for Resident #220, the last covered day was on 05/15/24, and the form was signed on 5/20/24. There was no documentation indicating that either resident received the notice prior to the end of their services. During an interview, Staff K, the social worker program manager, admitted that the process involved giving notice via regular mail, not certified mail, and there was no documentation of when the notice was sent. Staff K also mentioned that notice was provided verbally, but again, there was no documentation to confirm that this was done within the required timeframe of two days prior to the end of service. This lack of documentation and adherence to the facility's policy resulted in the deficiency noted in the report.
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 28 citations issued within 25 miles in the last 12 months — including the 2 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 Port Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Place Healthcare And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Sun Harbor Healthcare | 3.1 mi | ★★★★★ | 0 | 0 |
| Charlotte Bay Rehab And Care Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Port Charlotte Rehabilitation Center | 4.2 mi | ★★★★★ | 3 | 2 |
| Harbour Health Center | 4.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Douglas Jacobson State Veterans Nursing Home.
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 July 2026) and official state health department websites.