Devon Gables Rehabilitation Center

Based on observations, interviews, facility documentation, and policy, the facility failed to ensure safeguards and systems were in place to ensure three medication-cart controlled substances reconciliation logs reflected two nurse signature verifications without missing entries, and to ensure a reconciliation of one resident’s (# 1) controlled medication was accurate. The deficient practice could result in inventory loss and potential diversion. The facility census was 176 and the sample was 9 residents.Â

Based on clinical record review, observations, resident and staff interviews and review of policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident. The deficient practice could result in resident's advanced directives not being followed.Â

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure one resident (#250) was administered blood pressure medications according to provider orders. The sample size was 4. This deficient practice can result in further blood pressure mismanagement, and risk of hypotensive distress.

Based on closed clinical record review, staff interviews, and policy review, the facility failed to maintain a sanitary kitchen environment free from pests in one out of seven observed kitchen storage areas, ensure proper food storage in one of the seven observed kitchen storage areas, and serve food at required temperatures in one out of one meal services observed. This deficient practice placed residents at risk for unsanitary food preparation conditions and potential health hazards.Â

Based on observation, the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm tothe patients and/or staff.

Based on observation, it was determined that the facility failed to fill penetrations in multiple areas of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in the event of a fire.

Based on observations, the facility failed to ensure that all exposed electrical panels were closed and protected, as well as provide a protective guard on light bulbs located in the kitchen and dining storage rooms.   Failure to ensure electrical circuit breakers are protected could cause accidental damage or possibly a fire, which could cause harm to staff and residents.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This could affect the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm the residents and staff. Â

Based on observation, the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release the exit doors could cause harm to patients and/or staff in an emergency

Based on observation, the facility failed to ensure that a restraint chain was appropriately installed on the kitchen oven in order to protect the gas connection and that exhaust hoods were inspected and cleaned on a semi-annual basis. Failure to protect connections on appliances that are on casters or wheels can result in a rupture of gas or electric connections, resulting in the risk of fire events. Failure to inspect and clean exhaust hoods for commercial kitchen equipment can result in grease build-up and/or system malfunction, leading to a fire event.

Based on observation and staff interviews, the facility failed to ensure that the electrical breaker for the fire alarm system had visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to harm to residents and staff in an emergency.

Based on observation, it was determined that the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.Â

Based on observation, it was determined that the facility failed to maintain the sprinkler heads and ensure that all parts of the sprinkler system were in accordance with the UL Listing. Failing to maintain sprinkler heads and missing escutcheon plates, which are part of the U.L. Listing of the sprinkler assembly, could allow heat and smoke to affect other areas of the building. This could cause harm to the patients.

Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50). The deficient practice could lead to residents suffering from physical and psychosocial harm. Findings include: Review of Resident #26's record reveals he was admitted to the facility on February 9, 2022 with diagnosis that included dementia with behavioral disturbances and repeated falls. The Minimum Data Set (MDS) dated June 3, 2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the assessment. A Nursing Progress Note dated July 9, 2023, revealed a resident to resident altercation between resident #26 and resident #50. It explains that resident #26 went into a room and got into bed. Resident #50 and another resident, were in this room eating lunch together. Resident #50 attempted to get resident #26 out of bed and out of the room, and began yelling at resident #26. Resident #50 then attempted to pull resident #26 out of the bed. Resident #50 told staff when they entered that there had been "a schoffel" and that he did not remember what he did to resident #26 however, he did remember "putting his hands on him." Resident #26 was noted to have a lump to the left eye and it was red in the sclera. Review of Resident #50's record reveals he was admitted to the facility on March 21, 2023 with a diagnosis of dementia with behavioral disturbances, and repeated falls. The quarterly MDS dated June 14, 2023 revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact. The care plan dated March 29, 2023, revealed the resident was to be assessed for behavioral symptoms that present a danger to the resident and/or others. An update to the care plan, dated May 11, 2023, revealed the resident was noted to be intrusive with peers. The short term goal noted stated "Resident will not invade residents personal space, hand and feet will remain to self". A Nursing Progress Note dated July 9, 2023 revealed the same resident to resident altercation. However, it also states that resident #26 stated "he hit me in the eye." The staff escorted resident #50 to the hallway where he stated "I don't know what happened and where my room is". Staff escorted resident #50 back to this room where facility implemented a 1:1 sitter for monitoring of aggressive behaviors. On July 9, 2023 a Facility Reported Incident was submitted to the State Agency (SA) regarding the resident to resident altercation between both residents #26 and #50. On July 12, 2023 the Facility Investigation was submitted. The report reveals that the incident was unwitnessed by staff. However, the only resident witness to the event has advanced dementia and was unable to recall any details of the event. The Director of Nursing (DON) interviewed resident #26 after the incident, an

Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. Failure to ensure the resident's safety could lead to resident harm.

Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50).Findings include:Review of Resident #26's record reveals he was admitted to the facility on February 9, 2022 with diagnosis that included dementia with behavioral disturbances and repeated falls.The Minimum Data Set (MDS) dated June 3, 2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the assessment.A Nursing Progress Note dated July 9, 2023, revealed a resident to resident altercation between resident #26 and resident #50. It explains that resident #26 went into a room and got into bed. Resident #50 and another resident, were in this room eating lunch together. Resident #50 attempted to get resident #26 out of bed and out of the room, and began yelling at resident #26.Resident #50 then attempted to pull resident #26 out of the bed. Resident #50 told staff when they entered that there had been "a schoffel" and that he did not remember what he did to resident #26 however, he did remember "putting his hands on him."Resident #26 was noted to have a lump to the left eye and it was red in the sclera.Review of Resident #50's record reveals he was admitted to the facility on March 21, 2023 with a diagnosis of dementia with behavioral disturbances, and repeated falls.The quarterly MDS dated June 14, 2023 revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact.The care plan dated March 29, 2023, revealed the resident was to be assessed for behavioral symptoms that present a danger to the resident and/or others. An update to the care plan, dated May 11, 2023, revealed the resident was noted to be intrusive with peers. The short term goal noted stated "Resident will not invade residents personal space, hand and feet will remain to self".A Nursing Progress Note dated July 9, 2023 revealed the same resident to resident altercation. However, it also states thatresident #26 stated "he hit me in the eye." The staff escorted resident #50 to the hallway where he stated "I don't know what happened and where my room is". Staff escorted resident #50 back to this room where facility implemented a 1:1 sitter for monitoring of aggressive behaviors.On July 9, 2023 a Facility Reported Incident was submitted to the State Agency (SA) regarding the resident to resident altercation between both residents #26 and #50. On July 12, 2023 the Facility Investigation was submitted. The report reveals that the incident was unwitnessed by staff. However, the only resident witness to the event has advanced dementia and was unable to recall any details of the event. The Director of Nursing (DON) interviewed resident #26 after the incident, and he stated that resident #50 did not have a closed fist but he was struck by the back of his hand and that it was an accident. The DON also spoke with resi

Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe.Â