Devonshire Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#11) of four residents out of 36 sample residents remained free from accidents. Resident #11 was admitted to the facility on [DATE] with diagnoses including parkinsonism, dementia, muscle weakness, a history of falls, and dysphagia (difficulty swallowing). On 1/28/26, Resident #11 sustained an unwitnessed fall from her electronic reclining chair. The facility recommended unplugging the resident's chair to prevent her from using the remote control due to cognitive impairments. The director of nursing (DON) said on 3/26/26, at some time before the fall on 2/14/26, the resident's electric chair was plugged back in (see interview below). On 2/14/26, the resident used the remote to the electronic reclining chair and sustained an additional unwitnessed fall. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#30 and #11) of 11 residents out of 36 sample residents received the nutritional care and services necessary to maintain their highest practicable level of well-being. Resident #30 was admitted to the facility on [DATE] with a diagnosis of dementia. Upon admission, the resident weighed 141.5 pounds (lbs) and was not identified to have nutritional concerns. On 12/10/25, the resident weighed 134.5 lbs, indicating a 7 lbs weight loss. The facility failed to address the residents' weight loss. On 12/17/25, the resident weighed 131 lbs, which indicated the resident sustained a 7.4% (10.5 lbs) weight loss in 30 days, which was considered severe. Per interviews with the registered dietitian (RD), the facility failed to identify the resident's weight loss until 1/30/26. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure: -Food was held at the correct temperature;-Hand hygiene was conducted during meal service and dishwashing; -The kitchen was clean and sanitary; and, -Food was labeled and stored correctly in the walk-in refrigerator, freezer, reach-in refrigerator, and dry storage area.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents' personal funds accounts were managed adequately for the facility and accessible to the residents for three (#7, #27 and #44) of three residents out of 36 sample residents. Specifically, the facility failed to ensure residents were educated on how to access their money on the weekends.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#45, #58 and #27) of five residents were kept free from abuse out of 36 sample residents. Specifically, the facility failed to:-Protect Resident #45 and Resident #58 from physical by Resident #80; and,-Protect Resident #27 from physical abuse by Resident #21.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain proper storage of medications for three out of three medication carts and one of three medication storage rooms. Specifically, the facility failed to:-Label insulin pens with the date they were opened;-Label inhalers with the date they were opened;-Discard opened medications for residents who had been discharged

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide tube feeding management according to professional standards for one (#6) of one resident reviewed out of 36 sample residents. Specifically, the facility failed to:-Ensure the correct tube feeding formula was administered;-Ensure tube placement before tube feed administration; and-Provide flushes and water administration according to the physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the past three years. Specifically, the facility failed to ensure three years of survey and investigation

Inspectors wroteBased on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#1) of three residents out of eight sample residents. Specifically, the facility failed to:-Ensure Resident #1's Medical Orders for Scope of Treatment (MOST) form was completed accurately; and,-Ensure Resident #1's MOST form matched the resident's wishes and the physician's order for a do not resuscitate (DNR) code status.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurately documented medical records for two (#1 and #2) of three residents reviewed out of three sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2 wound assessments were documented accurately and include weekly measurements to reflect progression of the wounds in the residents medical records.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, 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 #2) of three residents out of four sample residents. Specifically, the facility failed to: -Offer person-centered non-pharmacological pain interventions for Resident #2; -Ensure pain medication was administered as ordered and the as needed (PRN) pain medication had parameters for Resident #2 and Resident #1; -Follow-up on documented ineffective pain medication for Resident #2; and, -Appropriately assess Resident #1's pain level.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for three (#46, #43 and #25) of six residents reviewed for falls out of 33 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living. The facility failed to provide staff education and increase residents' supervision to prevent falls when all three residents could not ask for staff assistance by using the call light due to severely impaired cognition for Residents #46, #25 and #43. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to follow up with residents' concerns brought up by the resident council during regular meetings.

Inspectors wroteBased on observations, interviews and record review, the facility failed to use a person-centered approach when determining the use of bed rails for ten (#2, #22, #26, #36, #43, #58, #59, #62, #68 and #71) residents with bed rails out of 33 sample residents. Specifically, the facility failed to ensure for Residents #2, #22, #26, #36, #43, #58, #59, #62, #68 and #71: -Assess the resident for risk of entrapment prior to installing bed rails; -Obtain consent from the resident and/or the responsible party prior to bed rail installation; and, -Follow guidelines for maintaining bed rails.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of three units. Specifically, the facility failed to ensure staff maintained wore PPE correctly while the facility had an outbreak of the respiratory syncytial virus (RSV).

Inspectors wroteBased on interviews and record review, the facility failed to provide trauma informed care in order to eliminate or mitigate triggers for one (#68) of one out four of 33 sample residents. Specifically, the facility failed to identify triggers for Resident #68 ' s trauma, who was a Veteran that served during war time.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices in a written description of their legal rights. Specifically, the facility failed to post a sign with how to file a complaint to the State Survey Agency.

Inspectors wroteBased on observations, record review and interviews; the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for three (#76, #68, and #34) of four residents reviewed for nutrition of 35 sample residents. Resident #76 with a diagnosis of dementia exhibited behaviors of putting his (G-tube) down his shirt on 10/1/19. No immediate interventions were put into place to distract or prevent the resident from subsequently pulling out is own G-tube on 10/2/19. After this occurred the failed to; initiate additional interventions to prevent weight loss which contributed to severe weight loss; and implement the registered dietician (RD) recommended interventions to increase caloric intake and prevent severe weight loss. [...]

Inspectors wroteBased on observations, record review, and interviews; the facility failed to store, prepare, and serve food in accordance with professional standards for food service in one of one kitchen. Specifically, the facility failed to: -Ensure foods/supplements were not expired; -Ensure all opened foods were dated; -Ensure food storage refrigerators were held at a safe temperature to prevent the growth of bacteria; and -Ensure foods were prepared and held at safe temperatures to prevent the growth of bacteria.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident rights for two (#28 and #34) of two residents out of 35 sample residents. Specifically, the facility failed to: -Ensure resident privacy and confidentiality of management with cares for Resident #28; and, -Ensure a dependant resident was treated with dignity during meal service for Resident #34.

Inspectors wroteIII. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included hemorrhagic disorder, ventricular fibrillation, atrial fibrillation, and pulmonary embolism. The 8/7/19 minimum data set (MDS) assessment revealed the resident had severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. She did not have any behaviors and did not reject the care. She required extensive assistance with most activities of daily living (ADLs). B. Resident observations Resident's skin was observed on 10/29/19 at 4:36 p.m. in the presence of registered nurse (RN) #3. Upper thighs were observed with no signs of bruising, small bruise about three to four centimeters (cm) observed on right upper forearm. No bruising observed on upper and lower legs. [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to keep the resident's environment as free of accident hazards as possible, and provide adequate supervision to prevent elopement for one (#21) of four residents reviewed for accidents out of 35 sample residents. Specifically, the facility failed to: -Reassess the resident and her elopement risks after an elopement incident; -Determine root causes of the incident; -Revise the care plan interventions for Resident #21; and, -Keep chemicals out of reach of residents in the shower rooms.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#16) of five residents reviewed for unnecessary medications out of 25 sample residents had consistent monitoring. Specifically, the facility failed to: -Ensure side effects of Xanax, Trazodone and Celexa were tracked and documented for Resident #16; -Monitor hours of sleep for Resident #16 who was receiving hypnotic medications for insomnia; and, -Document the rationale for the use of multiple psychotropic medications for Resident #16.