Douglas Jacobson State Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Douglas Jacobson State Veterans Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 11, 2025

  Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy on Abuse, Neglect and Exploitation/Misappropriation of Resident Property last revised 3/1/24 revealed abuse is defined as, any willful act or failure to act which causes or is likely to cause significant injury to a resident's physical, mental or emotional health. Abuse can also include threats, intimidation, unreasonable confinement or punishment. Review of the clinical record revealed Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE]. […]

• Actual harm, isolatedF600Oct 29, 2024

  Based on observation, record review, resident and staff interviews the facility failed to protect the residents' rights to be free from neglect by failing to follow the hot liquid safety procedures to ensure hot beverages were served at a safe temperature to prevent thermal burn for 1 (Resident #65) of 3 sampled residents. The findings included: The facility policy #1001 Abuse, Neglect and Exploitation/Misappropriation of resident Property, revised 3/01/2024 documented, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. […]

• Actual harm, isolatedF689Oct 29, 2024

  Based on observation, record review, review of facility's policy and procedure, the facility failed to serve hot beverages at a safe temperature to prevent avoidable thermal burn for 1 (Resident #65) of 3 residents reviewed for accidents. On 10/17/24 staff reheated a cup of hot chocolate and gave it to Resident #65 without ensuring the beverage was at a safe temperature. Resident #65 spilled the hot chocolate on his lap and sustained an avoidable second degree burn (affects the both the outer layer of skin and the layer beneath) to the left anterior thigh. The findings included: The facility policy #3124 Hot Liquid Safety, effective 7/15/24 documented Food and drinks will be served at a temperature that is appetizing to residents, but also minimizes the risk for scalding and burns . […]

• Actual harm, isolatedF580Sep 6, 2024

  Based on interview and record review The facility failed to ensure staff notified the physician of a change in condition for one resident (Resident #114) of seven resident surveyed for falls when after a head injury the resident's systolic blood pressure dropped and the resident's mental status changed. Findings included: Resident #114 was an [AGE] year-old male who was admitted to the facility on palliative care with a history of Type 2 Diabetes, Dementia, Anxiety Disorder, Hypertension, Atrial Fibrillation, Makor Depressive Disorder, seizures, Anemia, with a Cardiac Pacemaker. According to the timeline provided by the facility, on 8/20/24 at 2:40 p.m. Resident #114 was redirected from an exit in the facility and while walking away from the exit had a witnessed fall with a head injury. […]

• Actual harm, isolatedF689Jun 2, 2023

  Based on record review, review of the policies and procedures, and resident and staff interviews, the facility failed to provide the appropriate supervision, and assistance to prevent avoidable accidents for 2 (Resident #27, and #76) of 8 residents reviewed who were identified as being at risk for falls and sustained falls at the facility, including falls with major injury. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/2017, documented The facility will ensure that the residents environment remains as free from accident hazards as possible and each resident receive adequate supervision and assistance devices to prevent accidents. […]