Devine Health & Rehabilitation

Inspectors wroteBased on observations, interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 (07/21/2026) of 2 days reviewed in that: The daily posted nurse staffing data was not posted for the correct date in the facility on 07/21/2026. This failure could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents (Resident #11) reviewed for quality of care. The facility failed to ensure Resident #11's oxygen nasal cannula was changed weekly per physician orders. This failure could place residents at risk of cross contamination and infection and illness.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure treatment and care was provided in accordance with the comprehensive assessment and professional standards of practice that met the physical, mental and psychological needs for 1 of 6 residents (#10) reviewed for pacemakers in that: The facility did not maintain physician orders and medical information needed to monitor Resident #10's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #10), reviewed for quality of care. Resident #10's oxygen nasal cannula was visibly soiled. This failure could result in cross contamination and could result in infection, and illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 1 of 6 Residents (Resident #10) reviewed for pharmacy review in that: The facility failed to implement to monitor Resident #10 for edema. This failure could place resident as risk of not having their pharmacy consultations reviewed or recommendations implemented.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that the comprehensive person-centered care plan described services that are to be furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being for one of 14 residents (Resident #5) reviewed for care plans in that: The facility failed to ensure Resident #5's care plan indicated that Resident #5 had abrasions on her left 2nd, 3rd and 4th toe and her right 2nd and 3rd toe that required a daily wound treatment, when the care plan record was reviewed on 10/21/2024. This deficient practice could place residents who had wounds at risk for not receiving treatment and services.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents for 1 (Resident #5) of 14 residents reviewed for controlled medication use, in that: The facility failed to ensure LVN A, LVN B, and LVN C failed to follow facility policy to ensure all controlled medications were accurately reconciled at the start and end of the shift which resulted in a controlled medication discrepancy. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 meal (lunch 10/21/24) observed, in that; The facility failed to identify a food item held below proper holding temperature prior to surveyor intervention This failure could place residents, who consumed food prepared in the facility kitchen, at risk of reduced meal satisfaction, diminished nutritional intake, food borne illness and weight.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain clinical records in accordance with accepted professional standard and practices that are complete and accurately documented for 1 (Resident #5) of 4 residents reviewed for treatment administration. The facility failed to ensure the treatment administration records (TAR) for Resident #5 reflected that the administration of the treatment orders was accurately documented evidenced by the lack of documentation of Resident #5's wound treatments provided on 10/21/2024. This deficient practice could place residents receiving treatments at risk for not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the kitchen These failures could place residents at risk for cross-contamination and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 16 residents (Resident #23) reviewed for resident rights in that: Resident #23 was not served her meal timely with respect to residents sitting at the same table and was served 9 minutes later than other residents sitting at the same table. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan after each assessment for 1 (#12) out of 8 residents reviewed for comprehensive care plans in that: Resident #12's comprehensive care plan inaccurately reflected she had an indwelling urinary catheter. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care.