Jacob Healthcare Center

In the surveyor’s words

From the most serious findings on record at Jacob Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF693Aug 27, 2026

  Based on interview, and record review, the facility failed to verify the correct placement of Resident 1's gastrostomy tube (G-tube-a flexible tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). The nursing staff failed to verify Resident 1's G-tube had not migrated further into or out of the stomach, by not observing through assessment a printed number or measurable level on the tubing that exited Resident 1's abdomen (G-tube length). […]

• No harm, potential for more than minimal, patternF550Apr 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for six of six residents (1, 2, 3, 4, 5, 6) while providing care when:1. Certified Nursing Assistant (CNA) 1 was rude and used a vulgar ( F) word when Resident 1 asked for assistance and threw soiled towels and linens after care leaving stains on the wall.2. Resident 2 verbalized CNA 1 was rude and had an attitude when CNA 1 entered the room and stated, What do you want?3. Resident 3 verbalized CNA 1 would leave him wet all night and was rude and rough while changing him. 4. Resident 4 verbalized he preferred not to ask CNA 1 for help because CNA 1 was rude and rough in her patient care and would say, What the 'F.ck' do you want?5. […]

• No harm, potential for more than minimal, patternF677Sep 12, 2024

  Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) were provided to two of three residents (Resident 28 and Resident 30) reviewed for ADL care when: 1. Resident 28 were not provided with incontinence (loss of bladder and/or bowel control) care in a timely manner and, 2. Resident 30 was not provided with nail care. This deficient practice placed Resident 28 and Resident 30 at risk for skin breakdown and decreased quality of life. Findings: 1. […]

• No harm, potential for more than minimal, patternF697Sep 12, 2024

  Based on interview and record review, the facility failed to implement non-pharmacological interventions (NPIs - ie. positioning, dark room, ice/heat, massage), as ordered by the physician, prior to the administration of PRN (as needed) pain medications for three of three residents (Residents 22, 99 and 312) reviewed for pain management. This failure had the potential for Residents 22, 99 and 312 not to receive non-prescription pain relief, prior to receiving narcotic pain medications with added side effects. Finding: 1. […]

• No harm, potential for more than minimal, patternF725Sep 12, 2024

  Based on interviews and record reviews, the facility failed to provide sufficient staffing to meet care needs, when call lights were not answered timely for three of six confidential residents (CR 1, 2, 3) interviewed for sufficient staffing. This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and psychosocial harm. Findings: On 9/9/24, a review of the offsite survey record indicated, the facility had low weekend staffing on the 3rd quarter of 2024. An interview on 9/9/24 at 8:27 A.M., with CR 2 was conducted. CR 2 stated he had a left heel wound and cannot see well. CR 2 stated he needed assistance in going to the bathroom, transfers, or going to bed. CR 2 stated staff ignored his call light when he needed help. […]