Devonhouse Senior Living

An incident report regarding a medication error (Gabapentin administration) was not submitted to the Department within 24 hours.

Resident privacy coding was attached to a visible inspection summary, and an unlocked computer with confidential information was left unattended.

The home's License Inspection Summary from 12/19/24 and other recent reports were not posted in a conspicuous place and were stored in an unlabeled drawer.

A carbon monoxide detector was not located at least 15 feet from the fossil fuel boiler as required by law.

A staff member used vulgar language, a taunting tone, and made derogatory remarks toward a resident. Additionally, the staff member was reported to be extremely rough during care, hitting the resident in several areas.

A resident's support plan was not signed, and there was no documentation indicating whether the resident declined to sign.

A resident's support plan lacked critical information regarding gastric tube care, transfer assistance needs, wheelchair use, and behavioral issues.

The facility failed to adequately document attempts to flush a resident's gastric tube and the education provided regarding the importance of following physician orders.

The home failed to update safe management training for staff following a resident's physical aggression and failed to implement positive interventions to manage behaviors.

The resident's support plan was not updated to reflect reported incidents of aggression, irritability, or agitation.

A staff member was administering prescription medications without having completed the required biannual Medication Administration Audits and Record Reviews.

The home failed to report a physical altercation between two residents to the Department of Human Services Licensing.

Staffing levels during the 11pm-7am shift were insufficient to safely evacuate residents with mobility needs during a fire emergency.