Inspection Reports for
Devon Gables

An onsite complaint survey was conducted on February 25, 2026 for intake #00159877. There were no deficiencies cited.

This inspection resulted in no deficiencies or citations.

An onsite complaint survey was conducted on January 2, 2026 for the following intakes: 00152150, 00154437, 00152946, and 00149861. Federal intakes 2681963, 2701636, 2690477, and 2661158 were also investigated. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on October 27, 2025 through October 28, 2025 for the investigation of intakes #2649827, #2646950, #2647848, #2645429, #2637354, and #2636262. There are no deficiencies cited.

This inspection resulted in no deficiencies cited.

The inspection found ten deficiencies related to fire safety and building maintenance, including issues with exit door locks, kitchen equipment safety, fire alarm system identification, sprinkler system coverage and maintenance, fire extinguisher availability, door maintenance, smoke barrier penetrations, electrical panel protection, and emergency generator controls.

The state re-licensure survey was conducted September 30 through October 2, 2025, in conjunction with investigation of complaint #2609840. Four deficiencies were cited.

The inspection found four deficiencies related to inaccurate code status documentation, improper medication administration, inadequate controlled substances reconciliation, and unsanitary kitchen conditions. Plans of correction were provided for all deficiencies.

The onsite complaint survey was conducted on September 18, 2025 and investigated complaints #00143319, 00143320, 00143043, 2608406, 2609143, and 2606129. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on July 21, 2025 for the investigation of intake #00136502, 2561092 and #2564028. There were no deficiencies cited.

This inspection found no deficiencies.

A $500.00 penalty was assessed and paid in full on 12 September 2025.

An onsite complaint survey was conducted from June 24 through June 26, 2025, investigating numerous complaint intakes including AZ00185955, AZ00196025, AZ00188831, AZ00201574, AZ00202814, AZ00206740, and others. The investigation focused on allegations of resident abuse and safety concerns.

The inspection found four deficiencies related to resident safety and abuse. The facility failed to prevent resident-to-resident abuse and ensure a safe environment for residents.

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 complaint survey was conducted on June 3, 2025 through June 3, 2025 of the following complaint numbers: AZ00224582, SF00131551, AZ00224614, SF00131250, AZ00224637 and SF00131578. There were no deficiencies cited.

This inspection resulted in no deficiencies or citations.

An onsite complaint survey was conducted on February 18, 2025 for the investigation of intake # AZ00223392 and AZ00223431. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on February 7, 2025 for the investigation of intake # AZ00223178. An onsite complaint survey was conducted on February 7, 2025 for the investigation of intake # AZ00223175.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on January 31, 2025 for the investigation of intake # AZ00222123, AZ00200670, AZ00199219, AZ00198987. Federal comments note investigation of intake # AZ00222120, AZ00200669, AZ00199218, AZ00198987. There were no deficiencies cited.

This inspection found no deficiencies.

An onsite complaint survey was conducted for the investigation of intake # AZ00218867, AZ00218883 and AZ00218948. There were no deficiencies cited.

No deficiencies were cited during this complaint investigation.

An onsite complaint survey was conducted on November 13, 2024 for the following intakes: AZ00218533, AZ00218046 and AZ00218045. No deficiencies were cited. Federal comments also note an onsite complaint survey on November 13, 2024 for intakes AZ00218532, AZ00218462, and AZ00217960 with no deficiencies cited.

No deficiencies were cited during this complaint investigation.

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.

A complaint survey was conducted on September 23, 2024 through September 24, 2024 for the investigation of intake #s: AZ00158187, AZ00164020, AZ00170117, AZ00172766, AZ00178600, AZ00179631 and AZ00182849.

The facility failed to ensure four residents were free from abuse, resulting in one deficiency cited. The deficient practice could result in physical and/or psychosocial harm to residents.

An onsite complaint survey was conducted on September 5, 2024 for the investigation of intake # AZ00215252, AZ00215131, and AZ00215251. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on August 29, 2024 for the investigation of intake # AZ00214583, AZ00214445 and AZ00214581. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

The investigation of complaint AZ00205043, AZ00205124, AZ00213428, AZ00180846, AZ00144030, and AZ00213072 was conducted on July 31, 2024. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

An onsite complaint survey was conducted on June 17, 2024 for the investigation of intake AZ00205920. An onsite complaint survey was conducted on June 17, 2024 for the investigation of intake AZ00205915.

No deficiencies were cited during this complaint investigation.

A complaint survey was conducted on March 21, 2024 for the investigation of the intake #AZ00207570. A complaint survey was conducted on March 21, 2024 for the investigation of the intake #AZ00207569.

This inspection found no deficiencies.

The investigation of complaint AZ0020890 was conducted on November 8, 2023. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

The investigation of complaints AZ00153549 and AZ00156912 was conducted on October 11, 2023. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

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 inspection identified three deficiencies related to delayed egress door locking force, obstructed fire alarm pull stations, and poorly maintained corridor doors. The facility acknowledged these findings during the exit conference.

The State compliance and Recertification surveys were conducted July 10-14, 2023, in conjunction with investigation of complaints AZ0018597, AZ00185220, AZ00185035, AZ00184981, AZ00184317, AZ00184315, AZ00183648, AZ00183553 and AZ00183465.

The inspection found two deficiencies related to failure to maintain a safe, comfortable, homelike environment due to elevated ambient temperatures in resident rooms and common areas. The facility did not adequately address resident and staff complaints about excessive heat.

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.