Health inspection·January 9, 2026

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident A) of three residents sampled, was receiving food and drink prepared in a form to meet the resident's needs.This failure had the potential to result in coughing and choking for Resident A. Findings:On December 5, 2024, at 4:15 p.m., an unannounced visit was conducted at the facility to investigate quality care issues. On December 8, 2025, at 12:00 p.m., a review of Resident A's, admission Record, was conducted, which indicated Resident A was admitted to the facility on [DATE], with diagnoses which included oropharyngeal dysphagia (difficulty swallowing) and Alzheimer's (progressive brain disorder) disease.A review of Resident A's Minimum Data Set (MDS-a standardized health assessment tool) indicated the following:- September 15, 2025, .Section GG- Functional Abilities.eating.supervision/touch assistance.; and - September 17, 2025, .Section K-Swallowing.Yes-cough/choke during meal.when swallowing medications.yes-pain when swallowing.mechanical altered diet.regular with change in texture of food/liquids.A review of Resident A's Order Recap Report, effective from October 1 to December 31, 2025, indicated, Regular diet Regular texture, Mildly Thick consistency, fortified food . Further review indicated the diet was ordered on November 6, 2025. A review of Resident A's Speech Therapy Treatment Encounter Notes indicated the following-December 03, 2025, .due to limitations in insight, safety awareness, new learning, oral motor strength and oral motor control.supervised the pt (patient) during PO (oral) intake. Pt (patient) presented with decreased safety awareness and coughs post swallow x (times) 5 (five) for the entire duration of the meal.; and -December 5, 2025, .precautions.confused.patient was also observed taking 4 (four) sips of nectar thick liquid via straw with congested coughing heard 7 (seven) times .mildly thick drinks MT2 (mildly thick level two) .Resident A's care plans reviewed and indicated:-Resident requires Speech Therapy (rehabilitation to help with swallowing) related to Dysphagia, initiated on September 14, 2025; and -Resident is at nutritional risk due to dementia, Bronchitis, Alzheimer's, hypertension, dysphagia, therapeutic diet and altered texture and consistency, initiated on November 6, 2025. The care plan further indicated interventions which included: Provide 1:1 assistance when needed, encourage 100% consumption of all fluids provided, and provide diet, as ordered.On December 8, 2025, at 12:30 p.m., an observation and interview were conducted with Resident A. Resident A was observed receiving his meal tray, drinking water that had been thickened. The nurse brought him (Resident A) another glass of water with thickener. However, when the resident took the drink, the thickener was observed to have settled at the bottom of the glass, leaving the water on top thinner. Resident A began coughing and choking. The resident was then assisted to sit up at a 90-degree angle and leaned forward. The nurse was called for assistance.On December 8, 2025, at 1:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing staff is permitted to add thickener to the liquids for the residents. However, the process requires a few minutes for the water to achieve the desired consistency. If only a minute (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056095 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Care Center 1350 East Devonshire Avenue Hemet, CA 92544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)