DJ Jacobetti Home for Veterans

In the surveyor’s words

From the most serious findings on record at DJ Jacobetti Home for Veterans, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 1, 2021

  Based on observation, interview and record review, the facility failed to provide supervision, staff education, assessment, and monitoring of the physical plan to prevent the elopement of one Resident (#5) and the potential for elopement for nine Residents (#4, #12, #15, #16, #21, #31, #35, #46, #52) out of 63 residents reviewed for supervision/elopement. This deficient practice resulted in the elopement of Resident #5 who was witnessed leaving the building by staff and was outside of the building for 48 minutes, and the likelihood of elopement for the other elopement risk residents while exits were unlocked/unsupervised, with the potential for severe injury or death. […]

• Actual harm, isolatedF689Aug 20, 2026

  This citation pertains to Intake #3124682 Based on observation, interview, and record review, the facility failed to supervise to one Resident (#12) of three residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in Resident #12 (R12) wandering unsupervised for approximately 2 1/2 hours before being discovered on the floor after sustaining a fall in a non-resident area where it was later discovered R12 sustained a fractured left femur requiring surgical intervention. Findings include:According to the facility reported incident (FRI), dated 7/26/26, which read in part At approximately 1643 [4:43 PM on 7/26/26], the Director of Nursing was notified that the supervisor in charge had called a code green [missing member] for member [R12]. […]

• Actual harm, isolatedF600Dec 11, 2025

  This citation pertains to intake 1361257.Based on observation, interview, and record review the facility failed to prevent staff to resident physical abuse for one Resident (R18) out of one reviewed for abuse. This deficient practice resulted in a fall, emotional distress, and fear based on the reasonable person.Findings include: R18 Review of R18's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including frontotemporal neurocognitive disorder, aphasia, and adjustment disorder with mixed disturbance of emotions and conduct. R18's Brief Interview for Mental Status (BIMS) score in October 2025 was unable to be completed, but staff noted R18 to be severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2025

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/10/2025 at 1:40 PM During a facility main kitchen tour with Certified Dietary Manager (CDM) B and Assistant Dietary Manager (ADM) C, the vegetable wash sink was observed without an air gap. A tin can was observed surrounding the outlet drain, sitting on the floor drain. When asked about the tin can, CDM B stated the can was in place as a splash guard since before he came on board at the facility. […]

• No harm, potential for more than minimal, widespreadF812Oct 16, 2024

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 61 residents of the facility. Findings include: On 10/14/24 at approximately 12:05 PM, Kitchen Staff (KS) B was observed cleaning cook ware at the three compartment sink. KS B was observed to wash utensils (food whip; spatulas; stirring spoons, sheet pans) and other food contact surfaces in the wash compartment, then rinsed in the center rinse compartment. […]