Devonshire Care Center

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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 dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

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

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Miscellaneous Deficiencies

Have restrictions on the use of flammable curtains.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

A survey for Incident #40101 was conducted on 5/20/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of three residents reviewed for accidents/hazards out of three sample residents.Specifically, the facility failed to prevent Resident #1 from eloping on 4/27/25.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/20/25, resulting in the deficiency being cited as past noncompliance with corrective action date of 4/27/25.I. Elopement incident on 4/27/25Resident #1 who was at risk for elopement, required 15-minute checks related to his elopement risk. The staff on the long term care (LTC) side of the facility, where Resident #1 resided, were to observe Resient #1 and document his behaviors every 15 minutes.On 4/27/25 at approximately 9:58 a.m. Resident #1 was taken to the church service that was held in the assisted living (AL) community by certified nurse aide (CNA) #2. The AL side of the community did not have a wanderguard system in place. Resident #1 was left unattended and out of staff sight on the AL side of the facility, where he exited the facility via a door which led to an unsecured area of the facility grounds. Resident #1 was able to leave the facility without staff supervision. At approximately 11:15 a.m. the nursing home administrator (NHA) and the director of nursing (DON) were notified by the staff that Resident #1 was missing. The facility began a search of the facility for Resident #1. When Resident #1 was not located inside the facility the search was extended to the facility grounds outside. Family and local police notified Resident #1 was missing. Facility staff then began to search for Resident #1 in the surrounding neighborhood via automobiles. The DON went towards the residents previous living address which was seven blocks from the facility, Resident #1 was not located. At approximately 12:15 p.m. Resident #1 was found three blocks (0.3 miles) away from the facility by staff in the opposite direction from his prior living ad..

A complaint survey, prompted by #CO39369 and #CO39519 was conducted on 3/19/25 to 3/20/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#7, #17, #18 and #13) of seven residents out of 16 sample residents.Specifically, the facility failed to ensure Resident #7, Resident #17, Resident #18 and Resident #13' s call lights were answered in a timely manner.Findings include:I. Facility policy and procedureThe Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 3/20/25 at 11:08 a.m. It read in pertinent part,"Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident' s request is something you can fulfill, complete the task within five minutes if possible. Document any significant requests or complaints made by the resident and how the request or complaint was addressed."II. Observations and resident interviewsResident #7 was interviewed on 3/19/25 at 11:45 a.m. Resident #7 said at times, she waited for 20 to 40 minutes for the staff to answer her call light. Resident #7 said she filed a grievance about the long call light response times. Resident #7 said when staff did not respond to call lights in a timely manner, it made her anxious and insecure that something serious could happen while she waited. Resident #7 was ob.. Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for three (#7, #8 and #13) of five residents reviewed for notifications out of 16 sample residents.Specifically, the facility failed to provide Resident #7, Resident #8 and Resident #13 with.timely written and/or verbal notification of room and/or roommate changes.Findings include:I. Facility policy and procedureThe Room Change/Roommate Assignment policy, undated, was provided by the assistant director of nursing (ADON) on 3/20/25 at 9:33 a.m. The policy revealed changes in room or roommate assignments were made when the facility deemed it necessary or when the resident requested the change. Resident preferences were taken into account when such changes were considered. Prior to changing a room or roommate assignment, all parties involved in the change/assignment (residents and their representatives) were given at least a five-day advance written notice of such change. Advance written notice of a roommate change included why the change was being made and any information that would assist the roommate in becoming acquainted with his or her new roommate.Residents had the right to refuse to move to another room in the facility if the purpose of the move was to relocate the resident from a skilled ..

A compalint survey, prompted by #CO37133, #CO37138, #CO37141 and #CO37394 was conducted on 9/16/24 to 9/17/24. Three deficiencies were cited. Based on interviews and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (#1 and #5) of three residents out of 11 sample residents. Specifically, the facility failed to:-Ensure the as needed (PRN) pain medication had parameters for Resident #1; and, -Appropriately assess pain for Resident #5.Findings include:I. Professional referenceThe American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline. Columbia, MD (2021), was retrieved on 9/18/24 from www.paltc.org, read in pertinent part, "When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options t.. Based on record review and interview, the facility failed to develop and implement an effective discharge plan for one (#5) out of three residents reviewed for discharge planning out of 11 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #5' s electronic medical record (EMR); and,-Ensure Resident #5' s representative was informed of the discharge planning process.Findings include:I. Facility policy and procedureThe Transfer and Discharge policy, dated 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 3:36 p.m. It read in pertinent part,"It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. "Once admitted, the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: the transfer or discharge is necessary for the resident' s welfare and.. Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for four (#1, #5, #6 and #8) of five residents reviewed for hospice services out of 11 sample residents.Specifically, the facility failed to: -Obtain a complete physician' s order for hospice care for Resident #1 and Resident #8;-Ensure hospice agency notes were easily accessible to facility staff and have consistent documentation of hospice care visits and updates for Resident #5, Resident #6 and Resident #8; -Initiate a hospice care plan timely for Resident #6.Findings include:I. Facility policy and procedureThe Hospice policy, dated 2/29/24, was provided by the regional clinical director (RCD) on 9/16/24 at 5:39 p.m. It read in pertinent part,"When a facility resident elects to have hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of t..