Inspection·August 21, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. 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 to start a group session. Several residents, including Resident #1 were present. Resident #1 wanted to use the bathroom. Physical Therapy Staff C told Resident #1 that he could not use the restroom without assistance, and she had another resident in the room at the time. PT Staff C offered to take Resident #1 to his unit to use the bathroom. He refused her assistance. PT Staff D said Resident #1 began cussing and flailing his arms and she was extremely uncomfortable with his behavior. Physical Therapist Staff E stated that on 7/25/25 at approximately 11:00 a.m., Resident #1 entered the therapy gym and headed for the bathroom stating he was going to use the toilet. PT Staff C told him that he could not use the toilet in the gym because he needed assistance and she was busy treating a patient. PT Staff C told Resident #1 that the Director of Rehab (DOR) had told him that he could not use the toilet independently or use the gym's toilet is he was not in treatment. Resident #1 reposted urgency to use the toilet. PT Staff C said she could take him to his room. PT Staff C asked PT Staff E if she could assist the resident to the toilet. She stated that she could not. PT Staff C and PT Staff D again stated that Resident #1 needed assistance to transfer. Resident #1 began cussing and left the room. Licensed Practical Nurse (LPN) Staff F provided a statement that on 7/25/25 at approximately 11:15 a.m., she heard Resident #1 coming down the hall, cussing. She asked the resident what was wrong. He stated that therapy told him he could not use the restroom, that he had to use the restroom in his room. Resident #1 told her that PT Staff D put a wheelchair in front of the bathroom door to block the entrance. LPN Staff F said that the driver was here to take him to his appointment. He told her to send the driver away because he had to get cleaned up. The investigation noted that Resident #1 was a 1 assist transfer (stand and pivot) as well as using the sit to stand lift when requested. Resident #1's therapy notes stated that the resident was able to use the restroom with minimal to no assistance. Resident #1 was going to therapy 3 times a week at the time of the event but was not on therapy caseload for that day. On 8/4/25 the facility documented in the conclusion of their investigation, This event will be verified due to the 3 therapy staff members not (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 106059 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Douglas Jacobson State Veterans Nursing Home 21281 Grayton Terrace Port Charlotte, FL 33954 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)