Devonshire Oaks Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 1, 2023

  Based on observation, interview, and record review, the facility failed to prevent a fall for one of one sampled resident (Resident 1) when the Certified Nurse Assistant (CNA, caregiver) left Resident 1 on right side lying position in bed and without supervision. The facility failure resulted to Resident 1 falling out of bed and sustained a skin tear over a bump above the left eyebrow/forehead, bruising of the left eye, left side of the face, to the left side of the neck and the left upper chest). Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including cerebrovascular accident (stroke), epilepsy and tachycardia (abnormally rapid heartbeat). […]

• No harm, potential for more than minimal, widespreadF812Jan 17, 2025

  Based 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. Findings: 1.) During an interview on 1/15/2025, at 10:20 a.m., the Dietary Manager stated, Residents have to ask for snacks because a lot of it gets thrown away and wasted . […]

• No harm, potential for more than minimal, widespreadF812Oct 27, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF837Oct 27, 2023

  Based on observation, interview and record review, the facility failed to ensure an administrator who was licensed by the state, was appointed to run a Long-Term Care Facility after 10/20/23. This failure of not having an Administrator to oversee the day-to-day functions of the facility for all residents and staff, puts all residents and staff at risk for safety. The facility had a census of 30 (29 with one bed hold) residents. Findings: During a concurrent observation and interview on 10/23/23 at 9:33 AM, with the Director of Nursing (DON), the administrator was not seen at the facility. The DON stated, Administrator (ADM) was supposed to be at the facility . today (10/23/23) ., but he did not come when asked. DON stated, ADM's last physical presence at the facility was . […]

• No harm, potential for more than minimal, widespreadF804Nov 10, 2021

  Based 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. Findings: 1. During an initial tour interview on 11/8/21 at 10:05 AM, Resident 10 had concerns about food served. Resident 10 stated, Sometimes the food is salty, sometimes it doesn't have taste. I couldn't eat it it's not food appropriate for nursing home . Resident 10 said that staff were aware of the issues. […]