Devonshire Care Center

In the surveyor’s words

From the most serious findings on record at Devonshire Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure an IV (intravenous - administered into a vein) antibiotic (medication to treat infection) for septic arthritis (a serious joint infection, often caused by bacteria, that can lead to significant joint damage and even sepsis if left untreated) was administered in accordance with the physician's order and the orthopedic surgeon's (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) recommendation, for one of three residents reviewed (Resident 1), when the orthopedic physician ordered for Resident 1 to start on Rocephin (medication to treat infection) on May 23, 2025, for septic arthritis. […]

• No harm, potential for more than minimal, patternF880Apr 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure infection control measures were being implemented, when:1.The sit to stand lift (a mechanical aid designed to help individuals with limited mobility move from a seated to a standing position, reducing physical strain on caregivers) was dirty and dusty. In addition, the sit to stand sling/pad was dirty; and2.The shower rooms were observed to have dirty linen and trash bins filled with linens with urine and stool smell.These failures had the potential for infections to be transferred among residents and staff. […]

• No harm, potential for more than minimal, patternF921Apr 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure the physical environment is safe and sanitary, for 92 residents who could use the shower rooms, when:1.There were missing tiles and peeled off base boards on the shower wall of shower room [ROOM NUMBER];2.The shower walls in shower room [ROOM NUMBER] were dirty with brown/blackish substance on the grout and tiles; and3.There were used razors in the trash bin in shower room [ROOM NUMBER] and overflowing sharps container with used razors in shower room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, patternF726Jul 2, 2025

  Based on interview and record review, the facility failed to ensure appropriate nursing services were provided to carry out the physician and orthopedic surgeon (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) orders to administer IV antibiotic, for one of four residents reviewed (Resident 1), when:1.Registered Nurse (RN) 1 did not clarify with the physician or the OS regarding the IV orders after Resident 1's follow up appointment on May 23, 2025. In addition RN 1 did not endorse to the following RN the need to clarify the IV order, and there was no documentation other licensed nurses (RNs and Licensed Vocational Nurses), followed up or clarified the IV order with the OS from May 23, 2025, to June 11, 2025; 2. […]

• No harm, potential for more than minimal, patternF865Jul 2, 2025

  Based on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improved (QAPI - a systematic, interdisciplinary, comprehensive, and data - driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address issue on carrying out physician's order for IV antibiotics, when the facility identified the resident did not receive the IV antibiotic the orthopedic surgeon (OS - a medical director specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) ordered.This failure resulted to the resident not to receive the appropriate care and treatment after a surgical procedure and had the potential for the resident to develop complications such… […]