Devon Gables Rehabilitation Center

Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50). The deficient practice could lead to residents suffering from physical and psychosocial harm. Findings include: Review of Resident #26's record reveals he was admitted to the facility on February 9, 2022 with diagnosis that included dementia with behavioral disturbances and repeated falls. The Minimum Data Set (MDS) dated June 3, 2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the assessment. A Nursing Progress Note dated July 9, 2023, revealed a resident to resident altercation between resident #26 and resident #50. It explains that resident #26 went into a room and got into bed. Resident #50 and another resident, were in this room eating lunch together. Resident #50 attempted to get resident #26 out of bed and out of the room, and began yelling at resident #26. Resident #50 then attempted to pull resident #26 out of the bed. Resident #50 told staff when they entered that there had been "a schoffel" and that he did not remember what he did to resident #26 however, he did remember "putting his hands on him." Resident #26 was noted to have a lump to the left eye and it was red in the sclera. Review of Resident #50's record reveals he was admitted to the facility on March 21, 2023 with a diagnosis of dementia with behavioral disturbances, and repeated falls. The quarterly MDS dated June 14, 2023 revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact. The care plan dated March 29, 2023, revealed the resident was to be assessed for behavioral symptoms that present a danger to the resident and/or others. An update to the care plan, dated May 11, 2023, revealed the resident was noted to be intrusive with peers. The short term goal noted stated "Resident will not invade residents personal space, hand and feet will remain to self". A Nursing Progress Note dated July 9, 2023 revealed the same resident to resident altercation. However, it also states that resident #26 stated "he hit me in the eye." The staff escorted resident #50 to the hallway where he stated "I don't know what happened and where my room is". Staff escorted resident #50 back to this room where facility implemented a 1:1 sitter for monitoring of aggressive behaviors. On July 9, 2023 a Facility Reported Incident was submitted to the State Agency (SA) regarding the resident to resident altercation between both residents #26 and #50. On July 12, 2023 the Facility Investigation was submitted. The report reveals that the incident was unwitnessed by staff. However, the only resident witness to the event has advanced dementia and was unable to recall any details of the event. The Director of Nursing (DON) interviewed resident #26 after the incident, and he stated that resident #50 did not have a closed fist but he was struck by the back of his hand and that it was an accident. The DON also spoke with resident #50 and he stated he did not really remember. He explained "I was trying to get him out of the room. I didn't mean to hit him and if I hurt him I'm truly sorry." A Nursing Progress Note dated July 10, 2023 reveals that resident #50 was noted to have edema to his right hand. Resident's provider applied a brace to the hand. A follow up X-ray revealed that the resident had sustained a right fifth metacarpal neck acute fracture. Resident was ordered a splint. A Nursing Progress Note dated July 10, 2023 reveals that resident #26 was sent to the hospital and did receive an X-ray to his left eye. No fractures were present. However, resident #

Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. Failure to ensure the resident's safety could lead to resident harm.

Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50).Findings include:Review of Resident #26's record reveals he was admitted to the facility on February 9, 2022 with diagnosis that included dementia with behavioral disturbances and repeated falls.The Minimum Data Set (MDS) dated June 3, 2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the assessment.A Nursing Progress Note dated July 9, 2023, revealed a resident to resident altercation between resident #26 and resident #50. It explains that resident #26 went into a room and got into bed. Resident #50 and another resident, were in this room eating lunch together. Resident #50 attempted to get resident #26 out of bed and out of the room, and began yelling at resident #26.Resident #50 then attempted to pull resident #26 out of the bed. Resident #50 told staff when they entered that there had been "a schoffel" and that he did not remember what he did to resident #26 however, he did remember "putting his hands on him."Resident #26 was noted to have a lump to the left eye and it was red in the sclera.Review of Resident #50's record reveals he was admitted to the facility on March 21, 2023 with a diagnosis of dementia with behavioral disturbances, and repeated falls.The quarterly MDS dated June 14, 2023 revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact.The care plan dated March 29, 2023, revealed the resident was to be assessed for behavioral symptoms that present a danger to the resident and/or others. An update to the care plan, dated May 11, 2023, revealed the resident was noted to be intrusive with peers. The short term goal noted stated "Resident will not invade residents personal space, hand and feet will remain to self".A Nursing Progress Note dated July 9, 2023 revealed the same resident to resident altercation. However, it also states thatresident #26 stated "he hit me in the eye." The staff escorted resident #50 to the hallway where he stated "I don't know what happened and where my room is". Staff escorted resident #50 back to this room where facility implemented a 1:1 sitter for monitoring of aggressive behaviors.On July 9, 2023 a Facility Reported Incident was submitted to the State Agency (SA) regarding the resident to resident altercation between both residents #26 and #50. On July 12, 2023 the Facility Investigation was submitted. The report reveals that the incident was unwitnessed by staff. However, the only resident witness to the event has advanced dementia and was unable to recall any details of the event. The Director of Nursing (DON) interviewed resident #26 after the incident, and he stated that resident #50 did not have a closed fist but he was struck by the back of his hand and that it was an accident. The DON also spoke with resident #50 and he stated he did not really remember. He explained "I was trying to get him out of the room. I didn't mean to hit him and if I hurt him I'm truly sorry."A Nursing Progress Note dated July 10, 2023 reveals that resident #50 was noted to have edema to his right hand. Resident's provider applied a brace to the hand. A follow up X-ray revealed that the resident had sustained a right fifth metacarpal neck acute fracture. Resident was ordered a splint.A Nursing Progress Note dated July 10, 2023 reveals that resident #26 was sent to the hospital and did receive an X-ray to his left eye. No fractures were present. However, resident #26 would need follow up care with the Ophthalmologist.An interview was conducted on June 26, 2025 at 1:16 PM with the Administrator, staff #176, and the DON, staff #28. Staff #176 states "y

Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. 

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that three residents (#33, #24, #11) were not abused.

Findings include:

Regarding resident #33 and resident #24

A facility reported incident was made on May 14, 2024. This report included "Staff responded to visitor calling for help, stating those two men are fighting. She states that she heard raised voices coming from the room across the hallway. She looked across the hallway and observed (residents #24 and #33) in the bathroom doorway and appeared to be fighting."

A 5 day report dated May 17, 2024 included "Per staff report (resident #24) had been having increased behavioral episodes the prior day and night. He was seen packing his belongings, pushing at doors and very difficult for the staff to re-direct. Per night staff he had slept very little the previous night. (resident #33 can be very territorial about his room and belongings." This document also included "(resident #24 and (resident #33) have different rooms but share a bathroom between them; it is thought that (resident #33) left the bathroom through the door to (resident #24)'s room by mistake,which created the verbal altercation in the bathroom area."

-Resident #24 was admitted on December 13, 2022 with diagnoses of Alzheimer's disease, Mood disorder due to known physiological condition with depressive features and Vascular dementia

A Quarterly Minimum Data Set (MDS) dated June 7, 2023 included that this resident was moderately cognitively impaired and that the resident was able to independently walk in the corridor and around the room.

A care plan dated December 19, 2022 included Cognitive loss/dementia or alteration in thought processes related to diagnosis as evidenced by impaired decision making, short and/or long term memory loss, and neurological symptoms and included interventions to redirect resident when entering unsafe areas.

-Resident #33 was admitted on August 13, 2019 with diagnoses of Schizoaffective disorder, unspecified dementia with other behavioral disturbance, and mild intellectual disabilities.

A care plan dated May 14, 2023 included this resident has physical behavioral symptoms toward another resident (e.g. hitting, pushing) with a long term goal that this resident will not harm others secondary to physically abusive behavior.

A progress note dated May 14, 2023 included that resident #33 was in bed and a 2 nurse body check was completed. This note included a hematoma forming to the right wrist area 2cm discoloration, with approximated skin tear measuring 0.75 cm and that the resident reports falling. This note stated that it was unclear why resident #33 was in sitting position in rm 117 between conjoined restroom and peers brown recliner with bedside table between both residents.

An interview was conducted on October 22, 2024 at 3:11 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that this is a secured behavioral unit and that they attempt to prevent incidents by giving residents attention, reminding them and making sure they have what they need. This CNA said that resident #24 had a lot of behaviors which included being very forgetful and that he gets aggressive. This CNA said that this resident wanders into people's rooms.

An interview was conducted on October 25, 2024 at 1:52 P.M. with a CNA (staff #43) who said that she remembered that she was in the dining room and heard bang like a bedside table, and she ran to the first room, and resident #33 was with the bedside table on top of resident #24. She said that she did not think it was an altercation, she thinks that the resident went into the wrong room.

An interview was conducted October 25, 2024 at 2:23 P.M. with a family member who said that her husband is in the room across the hall, and that she heard something so she stood up and looked over there. She said that she saw the resident who belonged in the room and a resident who did not. She said that she saw 1 of them striking the other. She said that she then called out for help, and when people started running she sat down. She said that she told facility staff what she saw, and that she heard the yelling, because she was seated beside her husband's bed.


Regarding resident #24 and resident #11

A facility reported incident was made on June 11, 2023. This report included that on June 11, 2023 "Staff observed (resident #24) stroking (resident #11)'s penis. (resident #11) was laying in (resident #24)'s bed. Both residents have advanced Dementia and reside on a locked Dementia unit at the facility. Staff immediately separated the Residents. Implemented 1:1 staffing and 15 minute checks"

-Resident #11 was admitted August 11, 2022 with diagnoses of unspecified dementia, and altered mental status.

A care plan dated June 11, 2023 included that this resident was showing disinhibited behaviors in public and towards others with interventions to re-direct resident to his room when displaying inappropriate behavior and staff to encourage and attempt 6foot rule between him and peers until evaluated and treated by psych. However, this resident had no prior care plan for public disinhibition or public masturbation.

A progress note dated May 3, 2023 included that this resident is being monitored for public masturbation.

Progress notes dated May 11, 2023 and June 9, 2023 included that this resident had an instance of public masturbation.

A progress note dated June 11, 2023 included "upon staff assisting another resident down hall way, staff reports that they observed (resident #11) laying in male peers' bed next to male peer and was observed to have pants pulled down and peer was stroking (resident #11) erected penis. Staff intervened and assisted peer away from (resident #11). (resident #11) pulled pants up over penis and was observed to stand up and adjust self. staff assisted (resident #11) out of peers room and directed him to his room. 1:1 provided to (resident #11) at this time ...".

An interview was conducted on October 25, 2024 at 10:54 A.M. with a CNA (staff #104) who said that resident #24 had dementia and that he was sometimes aggressive but that he was always confused. He said that heard of the incident between residents #11 and #24 and that the residents were separated from then on.

An interview was conducted on October 25, 2024 at 1:52 with a CNA (staff #43) who said that resident #24 had started masturbating in the dining room though he had not previously been directly sexual with staff or residents. She said that the staff were start starting rounds in which they would check on the residents and change briefs if needed. She said that she turned around because resident #24 had left after the meal and she saw resident #11 on edge of bed kind of laying back and that resident #24 was massaging his private and that she said oh, in shock, and that resident #11 pulled his pants on really quick. She said that another CNA was with her and that she went and got a nurse. She said she told them what she had seen and started 1 on 1 supervision with resident #11. She said that resident #24 is really confused and that resident #11 was on 1 on 1 supervision until he left.

An interview was conducted on October 25, 2024 at 10:45 A.M. with a Licensed Practical Nurse (LPN/staff #65) who stated that she remembered hearing about it and that in this situation residents should be separated and the management notified. She said that these residents would not have been capable of consent.

An interview conducted on October 25, 2024 at 2:39 P.M. with a LPN (staff #56) who said that the MDS coordinator does care planning, the floor nurses do not. She said that if the nurses feel that the care plan needs a change, they notify the MDS and that staff will make

Based on clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#24) is free from preventable falls.

Findings include:

Resident #24 was admitted on December 13, 2022 with diagnoses of Alzheimer's disease, Mood disorder due to known physiological condition with depressive features and Vascular dementia

A 5-day Minimum Data Set (MDS) dated August 15, 2023 included that this resident was unable to answer questions for cognition and that the resident had a fall prior to entry.

A care plan dated December 19, 2022 included this resident is at risk for falls related to diagnosis and history of falls.

A progress note dated July 27, 2023 included "Upon entering pts room he was noted laying on back in front of closet. pt stated "I fell". Body check done, no new injuries. Denies hitting head, no red, raised or open areas.Neuro check done due to unwitness fall. Passive ROM to upper and lower extremitys. Pt s/sx pain "dont touch that" refering to left leg 2-person assist to bed. Gripper socks applied"

A care plan intervention dated July 27, 2023 was added of "Give resident verbal reminders not to ambulate/transfer without assistance." However, this intervention was cancelled the same day and no new interventions were put into place.

A progress note dated August 5, 2023 included "Resident found on floor in dining room with head and shoulders resting on wall. Resident stated he was attempting to stand when lost balance. No new injury noted at this time. Assisted back into chair and educated of safety awareness and mechanical lift order, resident smiled. VSS, noreports of new pained areas, skin intact. Neuros initiated and continuing, .... New order for Xray of left hip"to compare from previous fall" per provider, order input in matric and rapid ray. Spoke to Angelica from rapidray order placed STAT."

A progress note dated August 5, 2023 included " Xray of left hip results as follows: "left superior and inferior pubic rami fracture" results related to on call provider, new telephone order to send resident toTMC ER for evaluation via transport, if exceeding 3hr wait please call for emergent transport. MOD and wife ... made aware. Denies pain when asked, smiles and attempts to stand up. 1:1 supervision placed for safety. Call placed to the transport company, result is wait time up to 3 hours."

A care plan intervention dated August 8, 2023 was added of "Floor mat at bedside and bed in knee bend height position for safe entry and exit.." However, this intervention was cancelled the same day and no new interventions were put into place.

An interview was conducted on October 22, 2024 at 3:11 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that this is a secured behavioral unit and that this staff's goal was to make sure everyone had a good day and had no accidents. This staff said they attempt to prevent incidents by giving residents attention, reminding them and making sure they have what they need with pads beside beds and call lights within reach. This CNA said that resident #24 had a lot of behaviors which included being very forgetful and that he had a bad hip. This CNA said that this resident had a pad for beside his bed.

An interview was conducted on October 23, 2024 at 3:10 P.M. with a Licenced Practical Nurse (LPN/staff #89) who said that when a resident falls, the staff report it to her and she does an assessment. She said that if the resident is safe to transfer to bed, they will do so and begin the neurological assessments. She said that they will review the care plan and then the Registered Nurse will update the care plan. This nurse said that resident #24 sundowns and wants to get up in the evenings. She said that the interventions to prevent falls were to position bed to lowest, place a fall mat, and that if the resident was restless we will do a one on one, or the CNA's will put him at the desk.

An interview was conducted on October 25, 2024 at 3:38 P.M. with the Director of Nursing (DON/staff #58) who said falls should be care planned. She said that with resident #24, she would have to find out why they removed the interventions immediately and that for him they use a lot of diversional opportunities. She said that since the left superior and inferior pubic rami fracture that this resident was not as mobile anymore, and that now he requires the assistance of a hoyer for transfer as he is not able to move on his own at all. She said that if there is not an added intervention for each fall then it would not meet her expectation. She said that placing an intervention and cancelling it within a day does not meet the requirement.

A policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, staff interviews, and review of facility documentation, policy and procedures, the facility failed to ensure 4 residents (#156, #149, #151, and #153) were free from abuse. The deficient practice could result in physical and/or psychosocial harm to residents.

Findings include:

Regarding residents #156 and #92

-Resident #92 was admitted on February 14, 2020 with diagnoses of dementia with behavioral disturbance, psychotic disorder with delusions, persistent mood disorder, and schizoaffective disorder.

The quarterly Minimum Data Set (MDS) assessment dated September 22. 2021 revealed the resident had severely impaired decision making and that the BIMS could not be completed because the resident was rarely or never understood. The MDS assessment also indicated that the resident required supervision with transfers and ambulation.

The care plan revealed the resident had problems with cognition and behaviors. Interventions on the care plan included monitoring and recording behaviors, assessing whether the resident's behaviors endanger herself or others, and intervening as needed.

The nursing progress note dated October 6, 2021 included the resident had allegedly pinched another resident (#156) causing a skin tear to the left arm and had pulled the other resident's (#156) hand causing bruising and swelling to the 5th digit of the left hand. Per the documentation, resident #92 was non-vocal and unable to answer any questions about the incident from the nurse and made several attempts to pinch the nurse as the nurse was talking to her.

-Resident #156 was admitted to the facility February 22, 2021 with diagnoses of dementia with behavior disturbance, type 2 diabetes, and major depressive disorder. Resident #156 was discharged on April 16, 2023.

Review of the quarterly Minimum Data Set (MDS) assessment dated August 18, 2021 for resident #156 revealed the resident had severely impaired decision making and that the Brief Interview for Mental Status (BIMS) could not be completed because the resident refused to answer the questions for the interview. The MDS assessment also indicated that the resident required limited assistance with transfers and locomotion using a wheelchair.

The nursing progress note dated October 6, 2021 included that resident #156 reported to a certified nursing assistant (CNA) that another resident (#92) had given her a skin tear and squeezed her hand and arm. Per the documentation, the resident had a skin tear on her left forearm, bruising around the base of the fifth finger of her left hand and had pain in the left hand and finger. The note indicated the physician was notified and orders for treatment of the skin tear and an x-ray of the left hand were received.

The x-ray of the left hand report dated October 7, 2021 revealed a fracture at the base of the 5th finger.

Review of the facility Reportable Event Record/Report dated October 13, 2021 revealed that an interview with resident #156 conducted by the facility revealed that resident #156 demonstrated how she pulled her arm away from resident #92 using a swinging motion. The report also indicated that resident #92 was placed on every 15 minute checks and the plan of care for resident #92 was updated to include target behaviors of going into peer's rooms and aggressive behaviors of hitting or pinching.

Regarding residents #149 and #150

-Resident #149 was admitted on January 11, 2019 with diagnoses of Alzheimer's disease, anxiety disorder, and type 2 diabetes mellitus. Resident #149 was discharged on May 1, 2020.

The quarterly MDS dated February 27, 2020 revealed the resident had short and long term memory problems, moderately impaired decision making, had exhibited behaviors and fluctuating attention span during lookback period and required limited assistance with transfers, and supervision of locomotion / ambulation.

A nursing progress note dated April 14, 2020 included that the resident was standing beside his bed when his roommate (resident #150) walked by and pushed him to the floor. Per the documentation, the resident (#149) landed on his back with his walker on top of him, hit his head on a chair and the floor resulting in bleeding from an abrasion on the top and posterior of his head and a hematoma.

-Resident #150 was admitted on February 20, 2020 with diagnoses of dementia, depressive disorder, and chronic obstructive pulmonary disease (COPD). Resident #150 was discharged on July 14, 2020.

Review of the admission MDS dated February 28, 2020 revealed resident #150 had a BIMS score of 12, indicating moderate cognitive impairment and required limited assistance or supervision with transfers and ambulation.

Review of the care plan for resident #150 revealed no behavioral care plans prior to the incident on April 14, 2020.

A nursing progress note dated April 14, 2020 included the resident got up to go to the bathroom and his roommate was standing beside his own bed when this resident stated "get the hell out of my way" and pushed his roommate to the floor. Per the documentation, the resident was moved to a different room.

Regarding resident #151 and #152

-Resident #151 was admitted on September 11, 2020 with diagnoses of depressive disorder, dementia, diabetes, and schizoaffective disorder. Resident #151 was discharged from the facility on April 5, 2022.

The quarterly Minimum Data Set (MDS) assessment dated December 16, 2020 revealed the resident had a BIMS score of 08, indicating moderate cognitive impairment. The assessment also included that the resident was dependent on staff for transfers and limited assistance for locomotion using a wheelchair.

The nursing progress note dated January 9, 2021 included that the resident was grabbed by her arm and was struck several times by another resident (#152) with closed fist.

-Resident #152 was admitted to the facility on December 30, 2020 with diagnoses including diabetes, dementia, and schizoaffective disorder. Resident #152 was discharged from the facility on May 1,2021.

The admission MDS assessment dated January 6, 2021 revealed a BIMS score of 0 indicating the resident had severe cognitive impairment. The assessment also included that the resident required limited assistance for transfers and locomotion using a wheelchair.

A nursing progress note dated January 9, 2021 included the resident exhibited physical aggressive behaviors with female peer (#151); and that, the resident had a firm hold of peer's (#151) arm and with the other hand had strike the peer (#151) repeatedly with closed fist. Per the documentation, the resident refused to stop the aggression and stated that she did not want to and that the other resident (#151) deserved it.

Regarding resident #153 and #154

-Resident #154 was admitted on January 16, 2020 with diagnoses of bipolar disorder, dementia, chronic kidney disease, and pain. Resident #154 was discharged April 25, 2021.

Review of the quarterly MDS assessment dated February 24, 2021 revealed the resident had severely impaired decision making ability, fluctuating inattention and continuous disorganized thinking; and, had not exhibited behavioral symptoms during the 7-day lookback period. The assessment also included that the resident required limited assistance for transfers and was ambulatory without assistive devices and supervision.

A behavioral care plan dated March 9, 2021 included the resident had verbal aggression, intrusive with peers, and physical behavioral symptoms. The goal was that the resident would maintain functional status and acceptable behaviors. Interventions included to avoid over-stimulation with noise, crowding, and other residents who may be verbally/physically aggressive.

The monthly summary dated April 17, 2024 included the resident had exh

Based on observation the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on July 19, 2023, revealed the following;

1) the Central Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 43 lbf.
2) the West II Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 50+ lbf.

During the exit conference on July 19, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.2.1 "Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems, unless otherwise permitted by 19.3.3.2.2 through 19.3.4.2.4." Chapter 9, Section 9.6.2.7, "Each manual fire alarm box on a system shall be accessible, unobstructed, and visible."

Findings include:

Observation made while tour on July 19, 2023, revealed power scooter was parked directly in front of a manual fire alarm pull station in the north hall, near the nurses station.

During the exit conference on July 19, 2023 the above finding was again acknowledged by management staff.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on July 19, 2023, revealed the following;

1) room 39 the door stop on the lower handle side was wore down leaving a 1/2 inch gap
2) room 30 the door stop on the upper handle side, leaving a 1/2 inch gap
3) room 42 the door stop on the lower handle side was wore down leaving a 1/2 inch gap
4) in West II going to the dining area was 1 hour rated door and the upper hinge area was damaged and the door wood was split.

During the exit conference conducted on July 19, 2023, the above findings were again acknowledged by the management team.