Devon Gables Rehabilitation Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

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 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 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 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, 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 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, 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 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 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, 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.