Douglas Jacobson State Veterans Nursing Home

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to treat 1(Resident #1) of 3 residents reviewed with dignity by denying the resident access and assistance to the bathroom.

Inspectors wroteBased on review of facility policy and procedures, record review and staff and resident interviews, the facility failed to protect the resident's right to be free from physical abuse by failing to use the proper mechanical lift during a transfer for 1(Resident #899) of 3 residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed to protect the residents' right to be free from misappropriation of resident's property by failing to have effective processes in place to prevent the misappropriation of controlled substances for 2 (Residents #1 and #4) of 3 residents reviewed.

Inspectors wroteBased on observations, records review and interviews, the facility failed to protect the resident's right to be free from neglect by failing to ensure 1 (Resident #2) of 3 residents reviewed received incontinent care to meet their needs.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 resident (Resident #16) based on the resident's ongoing clinical assessments and identified risks for falls.

Inspectors wroteBased on observation, staff interview, review of facility policy and procedure, and record review the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 3 (Residents #109, #31 and #62) of 3 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to anxiety, boredom, agitation, wandering and a decline in the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on review of the facility Position Description for the Activity Directory and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure 2 Residents (#48, and #220) of 3 sampled residents reviewed received the Skilled Nursing Advanced Beneficiary of Non-coverage form (CMS-10123) to inform the resident of potential liability for payment, and right to appeal.

Inspectors wroteBased on observation, record review, review of facility policies and procedures, and staff interviews, the facility failed to provide the appropriate supervision and assistance to prevent avoidable fall related accidents for 1 (Resident #16) of 7 residents identified as being at risk for falls and sustained falls with injury while at the facility.

Inspectors wroteBased on interview and record review The facility failed to ensure nursing staff were competent in completing Neurological (Neuro) checks for one resident who had had a fall with a head injury (Resident #114) of seven resident surveyed for falls by not obtaining a complete neuro check and allowing the resident to sleep after noting a significant drop in blood pressure.

Inspectors wroteBased 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.

Inspectors wroteBased on Review of facility policy and procedures, record review, staff and resident interviews, the facility failed to have documentation of prompt efforts to resolve grievances expressed during resident council meetings.

Inspectors wroteBased on observation, resident and staff interview and record review, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 5 residents (Resident #13, #22, #34, #94, #399) of 5 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents to maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of clinical records, review of facility policy and procedures and resident and staff interviews, the facility failed to develop and implement resident centered care plan and interventions to ensure the residents individualized behavioral health needs were met for 1(Resident #14) of 2 residents reviewed with Post Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to ensure 1(Resident #69) of 1 resident reviewed for accidents was assessed for alternative interventions prior to the use of bed rails. In addition, the facility failed to have ongoing routine maintenance of the bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized.

Inspectors wroteBased on staff interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1(Resident #10) of 4 residents reviewed for dementia and mental health care needs. This led to Resident #10 being sent to the hospital under the [NAME] Act (allows people with a mental illness to be held for 72 hours in a mental health facility).