Devon Gables Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Devon Gables Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 10, 2025

  Based 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. Findings include: Resident #5 was admitted originally on October 5, 2020 and readmitted on [DATE] with diagnosis that included epilepsy, transient cerebral ischemic attach, other mechanical complication of internal fixation device of right femur, bipolar disorder, acute respiratory failure, non-ST elevation myocardial infraction. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 02. indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF880Jun 26, 2026

  Based 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.Findings include:-Regarding Resident #9Resident #9 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, major depressive disorder-recurrent, other cerebrovascular disease, vascular dementia-unspecified severity without behavior disturbance, psychotic disturbance, mood disturbance, schizoaffective disorder-bipolar type, essential… […]

• No harm, potential for more than minimal, patternF600Jun 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF600Oct 25, 2024

  Based 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. Findings include: Regarding resident #33 and resident #24 A facility reported incident was made on May 14, 2024. This report included Staff responded to visitor calling for help, stating those two men are fighting. She states that she heard raised voices coming from the room across the hallway. […]

• No harm, potential for more than minimal, patternF584Jul 14, 2023

  Based 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. Findings include: During a survey of the facility conducted 07/11/23 through 07/14/23, temperature findings were identified in common areas to include the following: -On 07/11/23 at 09:43 AM the fire door outside of room [ROOM NUMBER] measured 83.5 degrees Fahrenheit (F). -On 07/12/23 at 09:55 AM the Saguaro Room curtain temperatures ranged from 82-83 degrees F. -On 07/12/23 at 09:56 AM the air conditioner units in the hall by room [ROOM NUMBER] measured 82 degrees F. […]