Inspection Reports for
Devon Gables

The complaint investigation involved multiple incidents of resident-to-resident abuse, including physical altercations between residents #22 and #125, #26 and #50, and #27 and #145. Additionally, there was a safety incident involving resident #33 leaving the facility with an unauthorized individual. The allegations were substantiated based on interviews, clinical records, and facility investigations.

The facility failed to protect residents from physical abuse by other residents, resulting in multiple altercations causing physical and psychosocial harm. The facility also failed to ensure the safety of a resident who left the premises with an unauthorized individual.

The investigation was complaint-driven, focusing on the incident where Resident #5's hoyer sling tore during transfer causing a fall and hip fracture. The complaint was substantiated with findings of impaired sling integrity and failure to remove the faulty sling from use despite staff concerns.

The facility failed to ensure the integrity of a hoyer sling used during transfers, resulting in the sling breaking and causing a resident to fall and sustain a right intertrochanteric hip fracture. Multiple staff interviews revealed concerns about the sling's condition prior to the incident, and the Director of Nursing acknowledged the sling should have been removed from service.

The investigation was triggered by complaints and reported incidents including a fight between residents #24 and #33 on May 14, 2024, and inappropriate sexual behavior involving residents #24 and #11 on June 11, 2023. Staff interviews and family member statements were collected. The complaints were substantiated with findings of abuse and inadequate care planning.

The facility failed to protect residents from abuse, including a physical altercation between residents #24 and #33, and inappropriate sexual behavior involving residents #24 and #11. Additionally, the facility failed to ensure adequate fall prevention measures for resident #24, who sustained fractures from a fall. Care plans and interventions were found to be inadequate or inconsistently applied.

The facility failed to maintain comfortable ambient temperatures in resident rooms and common areas, with temperatures ranging from 78 to 88 degrees Fahrenheit. Residents and staff reported the facility was too hot, and although some interventions like fans and portable air conditioning units were mentioned, the issue persisted without effective resolution.

The facility failed to maintain comfortable ambient temperatures in resident rooms and common areas, with temperatures frequently exceeding comfortable levels. Residents and staff reported the facility was too hot, and although some interventions like fans and portable air conditioners were mentioned, the issue persisted.

The facility was found deficient in multiple areas including failure to provide Skilled Nursing Advanced Beneficiary Notice (SNFABN) to residents, failure to update PASRR screenings for residents with serious mental illness, improper medication administration practices including leaving medications unattended, inadequate personal hygiene care for a resident, failure to provide restorative nursing services as ordered, and improper medication storage with expired and undated medications present.

The visit was complaint-related involving allegations of resident abuse, failure to notify ombudsman of hospital transfers, failure to inform residents of bed hold policies, inadequate supervision, staffing posting deficiencies, medication errors, and medication security issues. The abuse allegation was substantiated with findings of resident-to-resident physical aggression.

The facility was found deficient in protecting residents from abuse by other residents, failing to notify the Long-Term Care Ombudsman of hospital transfers, not informing residents in writing about bed hold policies, inadequate supervision leading to resident altercations, failure to post nurse staffing data daily, administering insulin outside physician orders, and unsecured medications in resident rooms.