Devlin Manor Nursing and Rehabilitation Center

Inspectors wroteBased on record review and interview it was determined the facility staff failed to report an allegation of abuse to the local law enforcement authorities. This was evident for 1 (#3) of 2 residents reviewed for abuse.

Inspectors wroteBased on record review and staff interviews, it was determined that facility staff failed to 1) ensure advance directives and decision-making authority were established and maintained for a resident who lacks decision making capacity and 2) document that residents were informed of their right to formulate Advance Directives upon admission. This deficient practice was evident for 4 (Resident #4, #1, #10 and #11) of 4 residents reviewed for Advance Directives during the annual survey.

Inspectors wroteBased on observation and interview, the facility failed to process and store linens in a manner to maintain infection prevention. This was evident during 1 of 1 observation of the laundry room during an annual survey.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to make sure a legal decision maker was in place for a resident in a timely manner. This deficient practice was evident for one resident (Resident #4) reviewed for decision making capacity during the annual survey.

Inspectors wroteBased on resident record review and staff interview, it was determined that the facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days of a significant change. This was evident for 1 (Resident #52) of 3 residents reviewed during the annual re-certification survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility staff failed to develop a 48-hour baseline care plan upon admission. This was evident for 1 (Resident # 106) of 20 residents reviewed for care plans during the annual re-certification survey.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility staff failed to revise the comprehensive care plan to reflect the resident's need for oxygen therapy. This deficient practice was evident for one (Resident #19) resident reviewed for care plans during the annual survey.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to ensure physician orders were obtained and implemented for oxygen therapy. This deficient practice was evident for one resident (Resident #19) reviewed for professional standard of practice during the annual survey.

Inspectors wroteBased on observations, record review and interviews, it was determined that the facility failed to ensure that a dependent resident's grooming needs were met. This was evident in 1 (Resident# 10) of 1 resident reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, record reviews, and interviews, it was determined that facility staff failed to ensure effective communication by not addressing hearing impairment for a resident identified with hearing loss. This deficient practice was evident for one (Resident #82) resident of two residents reviewed for vision and hearing during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to monitor a resident with abnormal lab findings. The failure to do so, resulted in harm to the resident since the resident had to be hospitalized for treatment. This was evident for 1 (#6) of 2 residents reviewed for quality of care.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure their residents were free from abuse. This was evident for 1 of 2 residents reviewed for abuse. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 1/23/26.

Inspectors wroteBased on record review and interview, it was determined that staff failed to recognize and report allegations of abuse to the State Agency within the required timeframe. This was evident for 1 of 4 facility reported incidents reviewed.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to that a staff member who was observed abusing a resident, no longer had access to vulnerable residents to ensure there was no further abuse. This was evident for 1 (#4) of 1 resident review for abuse.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure that a resident had the medications they needed upon admission and throughout their stay. This was evident for 1 (#6) of 2 residents reviewed for quality of care concerns.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program. This was evident during the review of the QAPI program for the revisit survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure they had an effective Quality Assurance and Performance Improvement Program to include the development and implementation of polices and procedures for the program. This was evident during the revisit survey.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to timely assess and implement interventions after a change of condition for 2 (Resident #2 and Resident #4) of 3 residents reviewed for change of condition. The failure resulted in a delay of assessment and treatment for Resident #2 and Resident #4.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of misappropriation of property timely to the state survey agency for 1 (Resident #6) of 5 facility-reported incidents for allegations of abuse, neglect, and misappropriation of property. Specifically, Resident #6 alleged to have $230 missing in January 2025, and the facility did not report the allegation to the state agency until April 2025.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to develop a care plan related to anticoagulant medication for one (Resident (R)28 residents in the sample of 28 residents. The deficient practice had the potential to cause an adverse reactions from receiving an anticoagulant medication.

Inspectors wroteBased on facility staff roster review and staff interview, it was determined that the facility has a bed capacity of 127 and did not employ a qualified social worker from December 2021 until July 2022 on a full-time basis. This deficient practice was found during an complaint survey and has the potential to affect all residents. After review of human resources records and staff interview it was determined the facility currently has employed a qualified social worker so this deficiency will be cited as past non-compliance with a correction date of July 12, 2022.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide Resident (#20 and #27) with care which promoted the highest practicable well-being. This was evident in 2 of 48 residents selected for review during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to provide adequate management of a resident's pain medication pharmacy order (Resident #27) resulting in the resident being denied scheduled pain medication when the pharmacy failed to deliver the medication to the facility. This was evident for 1 of 48 residents reviewed.

Inspectors wroteBased on observation, the facility staff failed to maintain dignity for Resident #50 while assisting the Resident with lunch. This was evident for 1 out of all Residents observed during the lunch dining service during the survey process

Inspectors wroteBased on medical records and staff interviews, it was determined that the facility staff failed to develop a Care Plan for Resident #89, related to the Resident's combativeness. This was evident for 1 out of 35 residents investigated during the survey process.