Devonshire Oaks Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to 1. offer snacks to every resident who did not have contraindications. Total residents' census on 1/13/2025 was 29 residents. 2. Unpasteurized eggs were provided to residents who wanted fried eggs for breakfast on 1/14/2025. 3. The temperature of the water at the handwashing sink in the kitchen did not reach a level warm enough for washing hands. This failure resulted in possible contaminated food to residents, residents who did not receive a snack, and insufficient warm water for kitchen staff to wash their hands with.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for two of two new admissions: Residents 18 and 36. This failure had the potential to negatively affect continuity of care and communication for nursing staff, decreasing resident safety, and an inability to monitor the resident's progress based on their changing needs and preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a comprehensive care plan for one of three sampled resident (Resident 4) when there was no evidence of documentation of a completed comprehensive care plan for foley catheter for Resident 4 This deficient practice had the potential to result in inadequate care and services rendered to Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and review resident's status after an identified change of condition on one resident (Resident 12), when resident 12 had a change of condition on 1/5/25, no care plan and no interdisciplinary documentation and monitoring of change of status. This failure has potential for resident's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (medications that can be easily abused and are under strict government control) without witness signatures for two residents, Resident 1 and Resident 2. This failure had the potential for controlled drug abuse or diversion (when the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a coordinated plan of care and communication process with the Hospice agency, when there was no care plan to address what services Hospice will provide and for facility and when to notify Hospice for two of two Hospice residents, (Resident 4 and Resident 28). This failure has the potential to place residents health and well -being at risk of harm.

Inspectors wroteBased on observation, interview and, record review, the facility failed to ensure food safety standards of practice when 1) frozen meat was thawed using water with no system for time/temperature control monitoring; 2) use of sanitizer that was not in accordance with manufacturer's recommendations; 3) use of drying cloth on cleaned/sanitized food production equipment and utensils; 4) lack of an air gap in food production related equipment; 5) lack of overall kitchen cleanliness; 6) storage of unlabeled, undated and spoiled foods; and 7) presence of an open rodent bait station. Failure to implement and maintain food safety standards may put the facility census of 30 residents at risk for foodborne illness or contamination of food which may result in decreased intake and weight loss further compromising medical status.

Inspectors wroteBased on interview and record review, the facility failed to provide discharge summaries for two (Resident 24, Resident 25) of three discharged patients reviewed when Residents 24 and 25 did not have discharge summaries in their clinical records. This failure had the potential for residents not to have follow up care in their homes and could lead to a lack of continuity of care in the community.

Inspectors wroteBased on food production observations, dietary staff interview and dietary department document review the facility failed to ensure adequate staffing and staff competency when 1) dietary department staffing did not allow for adequate food production staff which resulted in the Director of Food Services routinely covering food production positions/duties and 2) Dietary Staff 1 was unable to demonstrate proper thermometer use and 3) Dietary Staff 1 did not prepare meals in accordance with standardized recipes. Failure to ensure adequate staff and staff competency may result in meals not prepared in accordance with resident preferences and acceptable standards of practice further compromising medical status.

Inspectors wroteBased on meal distribution observations, dietetic staff interview and departmental document review the facility failed to ensure meals were distributed in accordance with resident preferences and physician ordered diets when 1) staff did not follow a vegetarian menu/plan and 2) three residents with physician ordered mechanical soft received the same lettuce as those on regular diets in a feeding census of 29. Failure to ensure residents receive meals in accordance with approved menus may result in compromising nutritional and/or medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot food was served that is palatable, in proper temperature and appetizing texture, when test tray temperature was not in range per policy. This practice had the potential to negatively impact the resident's dining experience which may result in poor dietary intake potentially compromising health and nutritional status of 30 residents. Definitions: 1. Food palatability - refers to the taste and/or flavor of the food acceptable to the taste. 2. Proper (safe and appetizing) temperature - both appetizing to the resident and minimizing the risk for scalding and burns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident 227, one of 14 sampled residents, with a dignified existence when the resident was the last resident to be fed lunch after all the other residents. This failure has the potential for physical and psychosocial harm by neglecting and delaying meals to resident.

Inspectors wroteBased on observation. interview, and record review, the facility failed to treat Resident 16, one of 14 sampled residents, with respect and dignity when the residents room door was found closed, and the resident, who was non-speaking, was observed in bed, wide awake, with one blanket, no sheets, or bed pillow, in a bare, two bed room, with minimal furniture, bare walls, with the residents nurse call light on the other side of the room, no drinking water or water pitcher, a bare over-bed table which was standing in the middle of the room and the bathroom door was blocked, from entering the bathroom, with a medium-sized nightstand. This failure had the potential to depress and isolate the resident resulting in mental distress and causing the resident to feel helpless, excluded and outcast from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accomodate resident needs for Resident 127, one of 14 sampled residents, when the resident, who is bed-bound, had an improperly functioning television since his admission, over ten days ago. This failure had the potential to cause the resident feelings of depression (feeling of sadness and loss of interest), frustration, and resentment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, environment when the women's bathroom, in the main hallway of the facility, was not working properly for four days and there was no maintenance personnel available to maintain equipment. This failure had the potential to cause frustration, impatience, and disappointment for staff, visitors, and residents who utilize and require facility services.

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan based on Admitting orders for one of three residents (Resident 3) reviewed when Resident 3 admitted [DATE] with Diagnosis of Cancer (abnormal cells) of the Breast, had no initial care plan. This failure could result in Resident 3 not getting the follow up care needed for Cancer treatment.

Inspectors wroteBased on interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 9) after her fall incident on 7/29/23 and 8/3/23. This failure had the potential not to prevent from another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily Staffing Assignment Schedule, in a prominent place, at the beginning of each shift, in a clear and readable format, accessible to residents and visitors, when the schedule was kept stored in a binder, behind the nurses desk, on a shelf, instead of an easily located place for everyone, etc., to find and read. This failure had the potential for visitors, family, staff, residents, etc., not to find the appropriate assigned staff who should provide needed care to a resident and could lead to inadequate care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure medical supplies were not expired when review of stored medical supplies showed some supplies had an expired date. This failure would have resulted in questionable integrity of the medical supplies and deliver poor quality of care to the residents.

Inspectors wroteBased on dietetic staff observations, dietary staff interview and departmental document review the facility failed to ensure employment of a full-time qualified individual to manage and oversee dietary services. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with physician's orders and standards of practice may jeopardize the health and well being of the 30 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of discharge in writing to resident and or family member, when one of 3 discharged residents (Resident 177) did not have discharge summary and notice of discharge in writing before the discharge date . This failure has potential for resident not knowing her appeal rights and not receiving treatment and services due to lack of continuity of care.

Inspectors wroteBased on food production observations, resident and dietary staff interview, and dietary document review, the facility failed to ensure meal palatability and menu meets nutritional requirement when: 1. The noon meal on 11/9/21 lacked flavor; 2. The recipes were not followed for two lunch items per the planned menu on 11/9/21 for 23 residents. These deficient practices could negatively affect the caloric and nutrient intake needs of the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Program when corrective actions were not developed to address issues about food preparation and food palatability (refers to the taste and/or flavor of the food). (Refer to F804) Failure to develop quality assurance plan and corrective actions had the potential to negatively affect the resident's nutrition and hydration status.

Inspectors wroteBased on observation, interview and record review, the facility had an 8.57 % error rate when 3 medication errors out of 35 opportunities were observed during a medication pass for Resident 11 and Resident 13. These deficient practice resulted in medications not given in accordance to the manufacturer's specification which may result in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on dietetic services observation, dietary staff interview, and dietary record review, the facility failed to ensure dietetic services were implemented in accordance with facility policy and acceptable standards of practice when: 1. A red bucket with chemical sanitizer was directly adjacent to single-use articles; 2. Scoop for uncooked regular rice was kept inside the bin. These deficient practices had the potential to subject residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for safe smoking for one of 12 sampled residents (Resident 11). The deficient practice had the potential to result in accidents, including burns, harm and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the competency of one kitchen staff (KS) when the standardized recipes were not followed during the noon meal on 11/9/21.