A list of the most recent deficiencies for Devonshire Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-18 | 2023-11-03 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-10-18 | 2023-11-03 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-09-01 | 2023-10-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-11 | 2023-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-03 | 2023-05-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-04-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-30 | 2023-03-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-26 | 2022-11-10 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-09-06 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-01 | 2022-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-01 | 2022-08-31 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-23 | 2022-07-08 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-04-07 | 2022-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-04-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-07 | 2022-04-26 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-03-22 | 2022-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-09 | 2021-12-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-19 | 2021-08-02 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-09 | 2021-06-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-21 | 2021-06-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-21 | 2021-06-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-21 | 2021-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-21 | 2021-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-21 | 2021-06-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-21 | 2021-06-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-21 | 2021-06-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-21 | 2021-06-21 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-12 | 2019-08-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-27 | 2019-07-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-06-27 | 2019-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-27 | 2019-07-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-27 | 2019-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-07-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-10-19 | 2018-11-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-19 | 2018-11-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-19 | 2018-11-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-07-26 | 2018-08-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-26 | 2018-08-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-26 | 2018-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-26 | 2018-08-22 | N |
