Douglas Jacobson State Veterans Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 112.3 residents a day — about 94% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.95 hrs/resident/day on weekends vs 4.96 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.33 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 15 most serious are shown; the remaining 5 are one tap away and print in full.

• Actual harm · Gcited before2025-02-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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]. Diagnoses included Parkinson's disease without dyskinesia (involuntary, erratic movements), Dementia, Bipolar Disease (significant shifts in mood energy and behavior), Major Depressive Disorder, and Obsessive Compulsive Disorder. Review of the Significant Change Minimum Data Set (MDS) assessment with a target date of 12/10/24…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Additionally, neglect may also be defined as failure to make reasonable effort to protect a resident from abuse, neglect or exploitation by others and or carelessness which causes or could reasonably cause a serious physical or psychological injury or a substantial risk of death to a resident. The facility policy #3124 Hot Liquid Safety, effective 7/15/2024 documented Food and drinks will be served at a temperature that is…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 . Hot liquids will be monitored at the point of service prior to distribution from the kitchen or pantry and temperature will be recorded daily on the Daily Temperature Log. Residents will be assessed for their ability to handle…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-09-06 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the Fall Occurrence (Form 110514) dated 8/20/24 revealed after the fall the Resident #114 complained of a headache. The resident was observed holding his head and a quarter size reddened spot was noted to the left…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-06-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force. Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-21 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included:Review of the facility provided incident investigations revealed on 7/25/25 the facility initiated an investigation for Resident #1 related to staff denying him access to the bathroom in the therapy department. The facility's investigation noted that on 7/25/25 at approximately 11:30 a.m., Resident #1 needed to use the bathroom and stopped in the therapy department to use their restroom. Resident #1 stated that staff denied him access and assistance to the therapy department bathroom, resulting in an incontinence episode, causing the resident to miss a doctor's appointment. Resident #1 stated that he was embarrassed and angry. The facility's investigation included statements of staff involved. Review of the facility provided staff statements revealed:Physical Therapist (PT) Staff D stated that on 7/25/25 at approximately 11:00 a.m., she entered the therapy room…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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.The findings included:Review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation/Misappropriation of Resident Property with a revised date of 3/01/2024 revealed, The goal is to achieve and maintain an abuse-free environment for the residents . Abuse means 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 . Prevention . Identify, correct and intervene in situations in which abuse . is more likely to occur . This includes an analysis of . The supervision of staff to identify inappropriate behaviors such as . rough handling .Review of the clinical record for Resident #899 revealed an admission date of 2/14/25. Diagnoses included restlessness, dementia with psychotic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-25 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: Review of the facility's policy titled Abuse, Neglect and Exploitation/Misappropriation of Resident Property with a revision date of 3/1/24 revealed Exploitation and Misappropriation of Resident Property means a deliberate misplacement, wrongful, temporary or permanent use of a resident's belongings without the resident consent. Examples included: stealing from a client/resident. Review of the clinical record for Resident #1 revealed a physician's order for Oxycodone-APAP 10 mg/325 mg (Controlled substance), 1 tablet ever 6 hours for non-acute pain. The medication was scheduled to be administered each day at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Review of the Controlled Substance Record of Use logs for Resident #1 revealed on 5/15/25 the pharmacy…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Review of the Facility's Abuse, Neglect and Exploitation/Misappropriation of Resident Property policy (last revised 3/1/2024) revealed, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy noted under prevention to, identify, correct and intervene in situation in which abuse, neglect and/or exploitation/misappropriation of resident property is more likely to occur. The facility policy noted to, identify the staff member(s), the length of time involved, and any outcome of the victim. Be specific. Review of the clinical record revealed Resident #2 was admitted on [DATE]. Diagnoses included Dementia, Parkinson's Disease and overactive bladder. Review of the Brief Interview for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-06 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/24 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 assistive devices to prevent accidents .A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force .Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize complications if a fall does occur . Facility staff will identify appropriate resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-06 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: The facility policy #1303 Activity Program (revised 7/1/23) documented Activity programs are designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. The activity programs are designed to support the well-being of residents and to encourage independence and community interaction. 1. Review of the clinical record revealed Resident #109 had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-06 · tag F0680 — pattern
  Ensure the activities program is directed by a qualified professional.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: The Position Description for the Activity Director Duties and Responsibilities specified, The Activities Director is responsible for the development, implementation, supervision and ongoing evaluation of the activity programs. Provides and properly documents an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being of each resident on a daily basis. On 9/4/24 at 3:15 p.m., in an interview, Activity Staff A confirmed she did not have the necessary credentials in therapeutic recreational activities as required. Staff A said I'm an Activity Staff member and I do activities. On 9/4/24 at 3:15 p.m., in an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-06 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: The facility policy titled Advance Beneficiary Notice of Medicare Non-Coverage with effective date 12/18/2009, Revised date 04/2/2024, specified Skilled Nursing Facilities are required to notify residents before .services are .terminated and Medicare is not expected to pay. The Notice of Medicare Non-coverage (NOMNC) is given by the facility to all Medicare residents at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The resident's appeal rights must be explained to the representative. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on the same day. Place a dated copy of the notice in the beneficiary's medical file and document the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/24 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 assistive devices to prevent accidents .A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force .Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-06 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The 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. Review of the Fall Occurrence (Form 110514) show after the fall the resident complained of a headache. The resident was observed holding his head and a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$114,162 in federal fines across 7 penalties. 1 Medicare payment denial on record.

• $7,660 — penalty dated 2025-06-25
• $8,490 — penalty dated 2025-06-25
• $18,425 — penalty dated 2025-06-25
• $46,937 — penalty dated 2025-02-11
• $5,346 — penalty dated 2024-09-06
• $11,333 — penalty dated 2024-09-06
• $15,971 — penalty dated 2024-09-06
• Medicare payment denial — starting 2024-10-22 for 34 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to FLORIDA DEPARTMENT OF VETERANS' AFFAIRS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL