Douglas Jacobson State Veterans Nursing Home
Inspection Findings
F-Tag F0557
F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
personally assisting (Resident #1) to the restroom. The therapists are professionally trained to assist with standing and pivoting individuals. (Resident #1) was offered assistance to get back to his room but never assistance with the toilet nor was he allowed to toilet himself due to placing a wheelchair in front of the bathroom door. The three individuals never requested assistance from the nursing department nor notified them of his need. (Resident #1) is alert and oriented and is capable of toileting himself but is recommended by therapy to have staff present to prevent falls per therapy notes.On 8/20/25, review of the clinical record for Resident #1 revealed an admission date of 3/4/21. Diagnoses included Parkinson's disease, Alzheimer's disease.Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 7/28/25 revealed Resident #1 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The care plan initiated on noted the resident assistance of 1 for transfers (stand and pivot). Resident #1 also used a sit to stand lift when requested. On 8/20/25 at 10:30 a.m., in an interview the Regional Administrator, Risk Manager, and Assistant Director of Nursing said they were aware of the incident of Resident #1 not being allowed to use the restroom in the Physical Therapy Department which resulted in Resident #1 soiling himself. They said all three therapists involved in the incident were contracted from an outside company to provide Physical Therapy services to all state facilities. On 8/20/2025 at 12:45 p.m., in
an interview Resident #1 said the incident on 7/25/2025 made him very angry. He said that he was dressed and, on his way up front to catch his ride for a doctor's appointment. He said he suddenly realized he needed to poop and the Physical Therapy room was right there. They wouldn't let him use the restroom. He said PT Staff D threw a wheelchair in front of the bathroom door to block him from entering. He said he tried to make his way back to his room but soiled himself before he made it back. Resident #1 said the incident made him feel angry and embarrassed. He said that behavior cannot be tolerated. He said he has been a resident at the facility for 9 years now and has always been treated with respect and dignity by all the employees except for this incident. Resident #1 said he did not require assistance to use the restroom. Due to his back issues, he can only stand for about 10 seconds before he loses his balance. On 8/21/2025 at 9:45 a.m., in an interview the Director of Rehab said she was not working on 7/25/25 but was told Resident #1 stopped in and said he needed to use the restroom. She said their verbal policy is to accommodate all residents to use the restroom. She said she even has tape in front of the bathroom door to ensure it stays free of clutter and not blocked. She said there was no excuse for denying the resident access to the therapy bathroom.
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DOUGLAS JACOBSON STATE VETERANS NURSING HOME in PORT CHARLOTTE, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORT CHARLOTTE, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DOUGLAS JACOBSON STATE VETERANS NURSING HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.