Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Devonshire Oaks Nursing Center during CMS and state inspections, most recent first.
The facility failed to offer snacks to all residents without contraindications, provided unpasteurized eggs for breakfast, and maintained insufficient water temperature for handwashing in the kitchen. The Dietary Manager acknowledged these issues, noting that snacks were only given upon request to avoid waste, pasteurized eggs were unavailable, and the water temperature was lower than usual.
The facility failed to implement baseline care plans within 48 hours for two new residents, as required. One resident lacked a care plan for pain management, mobility, and anticoagulant therapy, while another had no plan for ADLs and mobility. The MDS Coordinator confirmed these omissions, potentially affecting care continuity and resident safety.
A facility failed to complete a comprehensive care plan for a resident with a foley catheter, who had a history of hemiplegia and hemiparesis. The absence of a care plan was confirmed by the DON, and an IDT meeting had not been conducted due to time constraints. An observation revealed a CNA searching for the urinary bag, indicating inadequate documentation and planning for the resident's catheter care.
A resident with multiple health conditions experienced a change of condition, including a seizure and decreased oxygen saturation. The facility failed to create a care plan or document an interdisciplinary team meeting to address the change. The DON and MDS Nurse acknowledged the lack of documentation and care planning, which could impact the resident's care.
The facility failed to document and witness the destruction of controlled medications for two residents, as required by policy. The Polaris Rx Narcotic Destruction Log lacked necessary signatures and dates for lorazepam, morphine sulfate, and oxycodone. The DON and LNHA acknowledged the oversight, and the Consulting Pharmacist confirmed the absence of records for these instances.
The facility failed to develop a coordinated care plan and communication process with the hospice agency for two residents receiving hospice services. For one resident, there was no care plan addressing hospice services, and documentation of family and interdisciplinary meetings was lacking. Another resident's care plan was missing, and there was no communication about a skin issue noted by a hospice nurse. The facility's policy requires a coordinated plan of care, which was not developed, leading to a deficiency.
Deficiencies in Snack Provision, Egg Safety, and Handwashing Facilities
Penalty
Summary
The facility failed to offer snacks to all residents who did not have contraindications, as required by their nourishment policy. The Dietary Manager stated that residents had to ask for snacks to avoid wastage, and those unable to ask needed a recommendation from a dietician, nurse, or doctor. This practice was contrary to the facility's policy, which mandated that bedtime snacks of nourishing quality be routinely offered to all residents unless contraindicated. The responsibility for ensuring that each resident received the ordered nourishments was assigned to the nursing department. Additionally, the facility provided unpasteurized eggs to residents who requested fried eggs for breakfast, despite the Dietary Manager's acknowledgment that pasteurized eggs were not available. The facility's menu indicated that fried eggs were part of the breakfast offering, and the Dietary Manager's invoices showed that pasteurized shell eggs were not ordered, although pasteurized liquid eggs were. Furthermore, the water temperature at the kitchen handwashing sink was consistently below the required level for effective handwashing, with the highest recorded temperature being 96.6 degrees Fahrenheit, which felt cold to the touch. The Dietary Manager confirmed that the water temperature was usually around 100 degrees Fahrenheit but agreed that it felt cold during the survey.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two new residents, which is a requirement to ensure immediate care needs are met. During a review, it was found that Resident 18, who was admitted on an unspecified date, did not have a baseline care plan in place for pain management, position/mobility, and anticoagulant therapy. The MDS Coordinator confirmed the absence of such a plan. Similarly, Resident 36's care plan lacked documentation for Activities of Daily Living (ADL) and position/mobility, which was acknowledged by the MDS Coordinator. This deficiency in care planning could potentially affect the continuity of care and communication among nursing staff, thereby decreasing resident safety and the ability to monitor residents' progress based on their changing needs and preferences.
Lack of Comprehensive Care Plan for Resident's Catheter
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident who was readmitted with a foley catheter. The resident, who had a history of hemiplegia and hemiparesis following a cerebrovascular disease, was observed without a documented care plan addressing the management of their urinary catheter. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a comprehensive care plan for the resident's catheter care. The deficiency was further highlighted during an interview with Social Services, who admitted that an Interdisciplinary Team meeting had not yet been conducted for the resident due to time constraints, although the family had been informed. An observation of the resident's room revealed that a Certified Nursing Assistant was searching for the urinary bag, which was found beside the resident's left hip, indicating a lack of proper documentation and planning for the resident's catheter care needs.
Failure to Document and Monitor Change of Condition
Penalty
Summary
The facility failed to adequately assess and document a resident's change of condition, which occurred on January 5, 2025. The resident, who has a medical history including dementia, seizures, diabetes mellitus, and Down syndrome, experienced a seizure and a decrease in oxygen saturation. Despite these significant changes, there was no care plan or interdisciplinary documentation and monitoring of the resident's status. The Director of Nursing acknowledged the absence of a care plan for the resident's urinary tract infection and dehydration, despite the resident being on IV antibiotics and hydration. Additionally, the MDS Nurse confirmed that there should have been a care plan and an interdisciplinary team meeting following the resident's change of condition. However, no such documentation or meetings were recorded. The lack of a care plan and interdisciplinary review after the resident's change of condition indicates a failure to meet the resident's needs and ensure appropriate care and monitoring.
Failure to Document Controlled Medication Destruction
Penalty
Summary
The facility failed to ensure proper documentation and witnessing of the destruction of controlled medications for two residents, which could lead to potential drug abuse or diversion. During an interview and record review, it was found that the Polaris Rx Narcotic Destruction Log lacked signatures and dates of destruction for several controlled substances prescribed to two residents. These included lorazepam and morphine sulfate for one resident, and oxycodone for another. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged the requirement for two signatures by a registered pharmacist and a licensed nurse for controlled substances, which was not adhered to in this instance. The Consulting Pharmacist confirmed that he had signed the destruction log for other medications but did not recall the specific instances involving the two residents in question. The facility's policy and procedure for the disposal of medications clearly outlined the need for documentation, including the date of destruction, resident's name, medication details, and signatures of witnesses. However, these procedures were not followed, as evidenced by the missing signatures and dates on the destruction log for the controlled substances involved.
Lack of Coordinated Care Plan for Hospice Residents
Penalty
Summary
The facility failed to develop a coordinated plan of care and communication process with the hospice agency for two residents receiving hospice services. For Resident 28, there was no care plan addressing the services hospice would provide, and there was a lack of documentation regarding family and interdisciplinary team meetings. The Director of Nursing (DON) acknowledged the absence of a baseline care plan and directives for managing pain and other comfort measures. Additionally, the Registered Nurse (RN1) could not find a physician's order for hospice admission, and there was no clear communication about the hospice schedule. Similarly, for Resident 4, there was no care plan that included communication between the facility and the hospice agency. The DON admitted that the care plan was missing, and RN1 was unaware of a hospice nurse's note indicating a skin issue, as there was no communication from the hospice nurse. The facility's policy requires a coordinated plan of care between the facility, hospice agency, and resident/family, which was not developed, leading to a deficiency in care coordination.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redwood City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atherton Park Post-acute | 3.4 mi | ★★★★★ | 3 | 0 |
| Belmont Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Vi At Palo Alto | 4.2 mi | ★★★★★ | 7 | 0 |
| Webster House | 5 mi | ★★★★★ | 0 | 0 |
| Palo Alto Post-acute | 5.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.