Devon Gables Rehabilitation Center

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure that appropriate infection prevention and control practices were followed regarding catheter bag placement, dining services and meal tray delivery services for 5 residents (#9, #117, #110, #52 and #145) The deficient practice could result in the spread of infection.

Inspectors wroteBased on observation, staff and residents interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered and stored according to policy for one out of 34 sampled resident (#13). The universe was 171. The deficient practice could result in overdose, negative medication interactions and other residents having unrestricted access to medications.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one three resident's (#20) to be free from abuse by another resident. The deficient practice had the potential to result in further abuse of residents.-Regarding Resident # 35:Resident #35 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including unspecified dementia, altered mental status, and brief psychotic disorder. A quarterly Minimum Data Set (MDS) assessment, dated February 11, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, no behaviors of wandering were exhibited during the assessment period. A psychosocial well-being care plan, initiated on November 18, 2025, revealed the following problem area: [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure three residents (#22, #26 and #27) were not abused by other residents (#125, #50 and#145). The deficient practice could lead to physical and psychosocial harm of residents.-Regarding Resident #22 (alleged victim):Resident #22 was re-admitted to the facility September 20, 2023, with diagnoses that included dysphagia, catatonic schizophrenia, cerebral infarction, hyperlipidemia, vascular dementia with behavioral disturbance, schizoaffective disorder, major depressive disorder with severe psychotic symptoms, and restlessness and agitation. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interviews and review of facility protocol and policies the facility failed to ensure one resident (#5) was free from accidents during a hoyer transfer. The deficient practice could lead to major injury.

Inspectors wroteBased on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that three residents (#33, #24, #11) were not abused. This deficient practice could result in further incidents of abuse.

Inspectors wroteBased on clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#24) is free from preventable falls. This deficient practice could result in increased morbidity and mortality.

Inspectors wroteBased on observations, resident and staff interviews and review of policy, the facility failed to maintain a safe, comfortable homelike environment related to ambient temperatures. The facility census was 227. The deficient practice may result in uncomfortable ambient temperature levels.

Inspectors wrote-Resident #109 was admitted [DATE] with diagnoses that included a tear of the medial meniscus, age related physical debility, hemiplegia and hemiparesis of the left side. Review of the clinical record revealed an order dated January 7, 2019 for restorative nursing (RNA) 3 to 5 times per week to prevent a decrease in range of motion. A care plan dated March 12, 2019 revealed that the resident is receiving restorative nursing services to maintain functional ability. The goal is that the resident will maintain joint function. Approaches including AROM (Active Range of Motion) to the lower extremity as tolerated 3- 5 times per week. Review of the care plan dated July 17, 2020 revealed the resident is at high risk for falls related to limited function. Approaches included implementing an exercise program that targeted strength, gait and balance. [...]

Inspectors wroteBased on observations, staff interviews, and review of the policy and procedures, the facility failed to ensure that medications were dated according to the standard of practice, and failed to ensure that expired medications were not available for administration. The deficient practice could result in expired medications being administered to residents.

Inspectors wroteBased on clinical record review, staff interviews, policy review and the Form Instructions for the Facility Advanced Beneficiary Notice (SNFABN), the facility failed to provide evidence that the Skilled Nursing Advanced Beneficiary Notice (SNFABN) was issued to one (#108) of three sampled residents. The deficient practice could result in residents not being informed of their potential liability for payment.

Inspectors wroteBased on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that one resident (#43) with a diagnosis of a serious mental illness was referred to the appropriate State-designated mental health or intellectual disability authority for review once the resident's stay exceeded 30 days. The sample size was 3. The deficient practice could result in necessary specialized services not being provided for residents that need it.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure that one resident (#71) received a Level I Pre-admission Screening and Resident Review (PASRR) after remaining in the facility for longer than the predetermined 30-day convalescent stay. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on observation, staff interviews, and review of policy, the facility failed to ensure medications were not left in the room of one resident (#95). The deficient practice could negatively impact residents' care, and could result in residents not receiving medications as ordered by the physician.

Inspectors wroteBased on resident and staff interviews, clinical record review, and review of policy and procedure, the facility failed to provide one sampled resident (#335) the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in the resident's hygiene needs not being met.