A list of the most recent deficiencies for Devonshire Oaks Nursing 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-27 | 2024-01-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-30 | 2023-12-13 | 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 | 2023-10-30 | 2023-12-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-10-30 | 2023-12-13 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-10-27 | 2023-11-29 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-27 | 2023-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-11-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-27 | 2023-11-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-10-27 | 2023-11-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-27 | 2023-11-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-10-27 | 2023-11-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-27 | 2023-10-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-27 | 2023-10-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-27 | 2023-10-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-27 | 2023-10-30 | N |
| Post nurse staffing information every day. | Health | 2023-10-27 | 2023-10-30 | 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 | 2023-10-27 | 2023-10-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-10-27 | 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 | 2023-10-27 | 2023-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-01 | 2023-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2021-12-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-10 | 2021-12-14 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-10 | 2021-12-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-10 | 2021-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-10 | 2021-12-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-10 | 2021-12-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-10-15 | 2021-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-17 | 2021-05-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-09 | 2019-07-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-09 | 2019-07-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-09 | 2019-07-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-09 | 2019-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-09 | 2019-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-09 | 2019-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-09 | 2019-07-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-09 | 2019-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-07-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-09 | 2019-07-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-09 | 2019-07-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-09 | 2019-07-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-09 | 2019-07-25 | 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 | 2019-05-09 | 2019-07-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-09 | 2019-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-09 | 2019-07-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-09 | 2019-07-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-09 | 2019-07-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
