Inspection Reports for
Devonshire Oaks Nursing Center
3635 Jefferson Ave, Redwood City, CA 94062, United States, CA, 94062
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 29
Deficiencies: 6
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication management, food safety, hospice services, and overall resident care at Devonshire Oaks Nursing Center.
Findings
The facility failed to develop and implement timely baseline and comprehensive care plans for several residents, did not ensure proper witnessing of controlled medication destruction, provided unpasteurized eggs and insufficient warm water for handwashing in the kitchen, and lacked coordinated hospice care plans and communication with hospice agencies for hospice residents.
Deficiencies (6)
Failed to develop and implement a baseline care plan within 48 hours of admission for two new admissions (Residents 18 and 36).
Failed to complete a comprehensive care plan for one resident (Resident 4) regarding Foley catheter care.
Failed to assess and review resident's status after a change of condition for one resident (Resident 12), with no care plan or interdisciplinary documentation.
Failed to ensure controlled medications were destroyed with witness signatures for two residents (Residents 1 and 2).
Failed to offer snacks to every resident without contraindications; provided unpasteurized eggs for breakfast; and kitchen handwashing sink water temperature was insufficiently warm.
Failed to develop a coordinated hospice care plan and communication process with the hospice agency for two hospice residents (Residents 4 and 28).
Report Facts
Residents census: 29
Controlled medications without witness signatures: 5
Unpasteurized eggs: 12
Water temperature: 96.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged lack of comprehensive care plan for Resident 4 and no care plan for UTI and dehydration for Resident 12; also noted lack of coordinated hospice care plan. |
| MDS Coordinator | Minimum Data Set Coordinator | Acknowledged no baseline care plans for Residents 18 and 36. |
| Social Services | Social Services (SS) | Reported no Interdisciplinary Team meeting for Resident 4 and discussed hospice communication. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant (CNA1) | Observed urinary bag placement for Resident 4. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Acknowledged requirement for two signatures on controlled substance destruction. |
| Consulting Pharmacist | Consulting Pharmacist (CP) | Confirmed signing other narcotic destruction logs but had no recall of unwitnessed medications for Residents 1 and 2. |
| Registered Nurse 1 | Registered Nurse (RN1) | Reported no physician order for hospice admission and lack of hospice care plan communication. |
| Dietary Manager | Dietary Manager | Reported residents must ask for snacks, provided unpasteurized eggs, and confirmed cold water temperature at kitchen sink. |
Inspection Report
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding timely notification to residents and their representatives before transfer or discharge, including appeal rights.
Findings
The facility failed to provide written notice of discharge to one of three discharged residents (Resident 177) before the discharge date, lacking a discharge summary and post-discharge plan in the resident's record. This failure has potential to affect the resident's knowledge of appeal rights and continuity of care.
Deficiencies (1)
Failed to provide notice of discharge in writing to resident and/or family member before discharge date for Resident 177.
Report Facts
Residents discharged without proper notice: 1
Date of discharge: Apr 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding discharge procedures and confirmed lack of discharge summary and post-discharge plan |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 27, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including resident rights, care planning, dietary services, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care and timely feeding, inadequate respect and dignity for residents, failure to accommodate resident needs, lack of baseline and updated care plans, missing discharge summaries, failure to post nurse staffing schedules, expired medical supplies, insufficient qualified dietary staff and inadequate dietary service practices, improper food safety and sanitation practices, and failure to maintain a safe and clean environment.
Deficiencies (14)
Failed to provide Resident 227 with a dignified existence by delaying lunch feeding, resulting in the resident being the last to eat.
Failed to treat Resident 16 with respect and dignity; resident was found in a bare room with no pillow, no reachable call light, and blocked bathroom door.
Failed to accommodate Resident 127's needs due to improperly functioning television for over ten days.
Women's bathroom in main hallway was not working properly for four days with no maintenance personnel available.
Failed to create a baseline care plan for Resident 3 addressing breast cancer diagnosis and treatment.
Failed to revise fall care plan for Resident 9 after fall incidents on 7/29/23 and 8/3/23.
Failed to provide discharge summaries for Residents 24 and 25, risking lack of continuity of care.
Failed to post daily nurse staffing assignment schedule in a prominent, accessible location.
Failed to ensure medical supplies were not expired; multiple supplies found expired.
Failed to employ a full-time qualified individual to manage and oversee dietary services; Dietary Staff 2 lacked required qualifications.
Failed to provide sufficient dietary support personnel; Director of Food Services routinely covered food production duties; staff lacked competency in thermometer use and did not follow standardized recipes.
Failed to ensure meals met nutritional needs and physician ordered diets; vegetarian and mechanical soft diets not properly followed.
Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures; test tray temperatures below policy standards and food quality issues noted.
Failed to ensure food safety standards including thawing meats without time/temperature monitoring, improper sanitizer use, wiping sanitized equipment with cloths, lack of air gaps in food production equipment, poor kitchen cleanliness, storage of unlabeled and spoiled foods, and presence of open rodent bait station.
Report Facts
Residents sampled: 14
Residents affected: 30
Expired medical supplies: 5
Dietary contract hours: 15
Temperature readings: 129
Temperature readings: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff 2 | Director of Food Services | Named in dietary service deficiencies for lack of qualifications and covering food production duties |
| Dietary Staff 1 | Dietary Staff | Named in deficiencies related to improper thermometer use and failure to follow standardized recipes |
| Director of Nurses | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including staffing and resident care |
| Resident 227 | Resident affected by delayed feeding deficiency | |
| Resident 16 | Resident affected by dignity and respect deficiency | |
| Resident 127 | Resident affected by unmet needs for functioning television | |
| Resident 3 | Resident affected by lack of baseline care plan for cancer diagnosis | |
| Resident 9 | Resident affected by failure to revise fall care plan | |
| Resident 24 | Resident affected by missing discharge summary | |
| Resident 25 | Resident affected by missing discharge summary |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1, who fell out of bed and sustained injuries due to inadequate supervision by staff.
Complaint Details
The investigation was triggered by a complaint related to a fall incident on February 25, 2023, where Resident 1 was left unsupervised by a single CNA and fell out of bed, sustaining a skin tear and bruising. The complaint was substantiated with documentation including interviews, care plans, and medical records.
Findings
The facility failed to prevent a fall for Resident 1, who required extensive assistance and was left unsupervised, resulting in a fall with injuries including a skin tear and bruising. The care plans were not updated to reflect the resident's needs for two-person assistance, and staff training was implemented after the incident.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident 1 falling out of bed and sustaining injuries.
Report Facts
Fall risk score: 10
Date of fall incident: Feb 25, 2023
Date of care plan initiation: Nov 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Facility Educator | Provided inservice training requiring two CNAs present when giving care to Resident 1 after the fall incident |
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding Resident 1's condition and care needs |
| Certified Nurse Assistant 2 | CNA | Reported leaving Resident 1 unsupervised leading to fall incident |
| Certified Nurse Assistant 3 | CNA | Stated it is safer for Resident 1 to lay on his back and that two CNAs are now required for care |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 10, 2021
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews related to complaints and concerns about resident safety during smoking, medication administration errors, food service quality, and facility quality assurance practices.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety during smoking, medication errors, food quality, and facility quality assurance. The report documents substantiated deficiencies in these areas.
Findings
The facility was found deficient in providing adequate supervision for safe smoking for a resident, medication administration errors with an 8.57% error rate, failure to follow standardized recipes affecting food palatability, improper food storage and sanitation practices, and failure to implement corrective actions in the Quality Assurance and Performance Improvement program.
Deficiencies (6)
Failed to provide supervision for safe smoking for one resident, resulting in potential accident hazards.
Medication error rate of 8.57% with 3 errors out of 35 opportunities during medication passes.
Failed to ensure competency of kitchen staff when standardized recipes were not followed during meal preparation.
Food served lacked flavor and did not meet nutritional requirements; recipes not followed for two lunch items affecting 23 residents.
Improper storage of chemical sanitizer bucket adjacent to single-use articles and scoop left inside uncooked rice bin.
Failed to implement Quality Assurance and Performance Improvement program corrective actions related to food preparation and palatability issues.
Report Facts
Medication error rate: 8.57
Residents affected: 1
Residents affected: 23
Medication doses: 15
Medication doses: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Administered medications with errors; confirmed resident smoking supervision requirements |
| Licensed Vocational Nurse 2 | LVN | Administered eye drops incorrectly during medication pass |
| Certified Nursing Assistant 2 | CNA | Acknowledged resident smoking supervision needs and food tray issues |
| Dietary Supervisor | DS | Acknowledged food preparation and recipe adherence issues |
| Administrator | ADM | Interviewed regarding ongoing food complaints and QAPI program deficiencies |
| Director of Nursing | DON | Interviewed regarding QAPI program and food complaints |
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