Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Devlin Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Advance directive documentation was incomplete for multiple residents. A resident who lacked decision-making capacity had no record of an authorized decision-maker or advance directive, even though a family member had been making decisions without legal documentation. In addition, records for three other residents showed MOLST completion but no documentation that advance directives were discussed with the resident and/or responsible representative.
Laundry and linen handling was not maintained in a manner to support infection prevention. Surveyors observed uncovered clothing racks full of resident linen in the hallway, an uncovered rack labeled for unlabeled clothing, and a basket of rags/cloths on the floor in the room used to wash, dry, and sort resident clothing. Staff confirmed that resident clothing was processed in that room, while bed linens, towels, and other items were handled in separate laundry rooms, and that clean resident clothing racks were placed in the hallway because there was no room inside.
Failure to establish a legal healthcare decision maker for a resident with dementia and documented lack of decision-making capacity. The resident had no advance directives in the chart, and the record did not show evidence of a court-appointed healthcare decision maker. The DSS stated the facility was unsure whether the required documentation had been obtained and had no documentation of prior attempts to secure an appointed decision maker since admission.
Delayed MDS Assessment After Significant Change: A resident was observed with a contracted left hand, and records showed OT had documented the contracture while later MDS assessments still recorded no upper-extremity impairment. The DON acknowledged the left hand contracture was a significant change and should have been documented timely.
A resident’s 48-hour baseline care plan was not completed after admission. The care plan could not be found in the EHR, and the DON and CDON confirmed it had not been done, despite acknowledging it should have been completed within 48 hours.
Failure to update a resident’s care plan for oxygen therapy. Surveyors observed a resident receiving O2 at 2 L via NC, but the comprehensive care plan did not include oxygen use, respiratory monitoring, or related interventions. The DON acknowledged the plan should have been updated after prior hospitalizations, and discharge summaries confirmed ongoing O2 needs that were not reflected in the care plan.
A resident was observed receiving oxygen via NC, but the medical record did not contain an order for oxygen. RN confirmed the resident was on oxygen and acknowledged the missing order, while the DON stated the admitting nurse was responsible for entering hospital discharge orders into the facility system after the resident returned from the hospital on oxygen with a hx of hypoxia.
A resident with severe cognitive impairment was observed with a disheveled appearance and unshaven facial hair on multiple occasions. The record did not show refusal of grooming or shaving, and a GNA stated the resident did not refuse grooming when care was provided. The DON later stated the resident sometimes refused care, but this was not documented on the care plan.
A resident with documented hearing loss reported difficulty hearing and said hearing was better in the left ear, but did not have hearing aids. The care plan included communication interventions, and the MDS showed worsening hearing difficulty, yet the record lacked evidence of an audiology screening or evaluation. The DON confirmed the resident had not been assessed for hearing loss and could not explain the lack of referral or evaluation.
A resident with pancreatic cancer and cirrhosis, including ascites and esophageal varices, had labs ordered that showed a significantly elevated ammonia level. The PA reviewed the abnormal result, documented "no new orders," and did not enter any treatment, monitoring parameters, or the intended order to recheck the ammonia level, nor a progress note explaining the assessment. Days later, the resident developed altered mental status and abdominal pain, and was sent to the ED at the family’s insistence, where an even higher ammonia level was found and hepatic encephalopathy was diagnosed, requiring treatment with lactulose and a multi-day hospitalization.
A cognitively impaired resident who depended on staff for most ADLs was being transferred with a mechanical lift when a GNA reported being hit by the resident and responded by cursing at and verbally degrading the resident, including making offensive remarks and threatening to withhold treats. Another staff member nearby overheard the GNA loudly say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at another staff member rather than the resident, resulting in unreported verbal abuse.
Staff failed to timely report a witnessed allegation of verbal abuse to the State Agency. A GNA verbally abused a resident during an evening shift, and on‑duty staff who observed the incident did not report it when it occurred. The DON later learned of the allegation the following morning and submitted the report to the State Agency several hours after that notification, rather than within 2 hours of the actual incident. The DON reported she believed the reporting timeframe began when she was informed of the allegation, leading to noncompliance with required abuse reporting timelines.
Staff failed to immediately remove a GNA from resident care after verbally abusing a cognitively impaired resident with dementia. During an evening shift, the GNA used profane language toward the resident while providing care, but other staff present did not recognize or report the incident as abuse at the time. The DON was not informed until the following morning, and staffing records confirmed that the GNA continued working for about 10 hours with vulnerable residents after the incident occurred.
Facility staff failed to ensure that a resident with pancreatic cancer and a prior Whipple procedure consistently received prescribed Creon with meals, resulting in multiple missed doses when the medication was not available. The MAR documented missed administrations due to the drug not being in stock or on order, and pharmacy records showed that refills were sent only after the supply had already run out. The DON knew the resident required Creon and that it was a special‑order medication but had no process to secure it before admission or to reorder in time, and staff instead contacted the family to bring medication from home. The facility’s medication ordering policy lacked provisions for special‑order drugs and there was no documentation that the hospital had instructed the family to supply the medication.
The facility failed to develop and implement a QAPI program because it did not have a written QAPI plan to guide performance improvement activities. The QA coordinator, DON, and NHA were unaware of the regulatory requirement, and the QA coordinator reported she had no established plan to guide QAA committee meetings or oversight duties.
Incomplete QAPI Program and Physician Visit Review Deficiency: The facility failed to maintain an effective QAPI program with clear policies, procedures, benchmarks, and communication methods, and it remained out of compliance with physician visit requirements. For a resident with duodenal ulcers, NPO status, and TPN, discharge medications including a PPI and GI protectant were not ordered, and the physician note did not reflect awareness that the medications were missing or that the resident had no bowel sounds on admission. Interviews showed confusion about the discharge summary, no auditing of physician notes by the DON, and a mismatch between the written QAPI policy and how the committee actually operated.
Two residents experienced delays in assessment and treatment after changes in condition were not promptly addressed by nursing staff. In one case, a resident sustained a hand laceration during care, which was not immediately assessed or documented by the LPN after being reported by aides, and was only discovered by family later. In another case, a resident developed facial bruising and a hematoma that was reported to nurses but not assessed or reported to a provider until the following day, resulting in delayed medical evaluation. Both incidents involved lapses in communication and failure to follow facility policy for timely intervention and documentation.
A resident with intact cognition and multiple medical conditions reported missing money to staff, who searched the room and provided a lock box but could not confirm the resident ever had the funds. The incident was initially treated as a grievance and not reported to the state agency as required. The allegation was only reported months later after being raised again, resulting in a late submission of the required investigation report.
A facility failed to include anticoagulant medication in a resident's care plan. The resident, with moderate decision-making impairment and conditions like paroxysmal atrial fibrillation, was prescribed Eliquis. However, the care plan lacked focus, goals, or interventions for the medication. Interviews with the MDS Coordinator and DON confirmed the omission, despite facility policy requiring comprehensive care plans.
Advance Directive Documentation Not Established or Recorded
Penalty
Summary
Facility staff failed to ensure advance directives and decision-making authority were established and maintained for a resident who lacked decision-making capacity at the time of admission in March 2024. The resident’s medical record did not show evidence that the facility obtained documentation of an authorized decision-maker or an advance directive. The Director of Social Services stated that a family member had been making decisions since 2024, but no legal documentation was present to support that person’s authority, and no documentation existed showing attempts by the facility to establish an authorized decision-maker or complete advance directive documents from admission through 03/23/2026. Facility staff also failed to document that residents were informed of their right to formulate advance directives upon admission. Electronic records for three residents showed MOLST forms were completed, but the records did not reveal that advance directives were discussed with the residents and/or responsible representatives. During interview, the Director of Social Services reviewed the clinical records and reported that she could not find documentation indicating that information on advance directives was discussed with the residents and/or responsible representatives.
Laundry and Linen Handling Not Maintained
Penalty
Summary
The facility failed to process and store linens in a manner to maintain infection prevention. During an observation of the hallway by the clean and dirty laundry rooms, two uncovered clothing racks that appeared to be full of resident linen were seen in the hallway. In the same area, a room with a singular washer and dryer was observed, along with an uncovered clothing rack labeled for unlabeled clothing and a medium-sized basket on the floor containing various rags and cloths. During interview, the Housekeeping Aide stated that resident linen was washed, dried, and sorted in the room with the singular washer and dryer, while separate clean and dirty laundry rooms were used for bed linen, towels, and other items other than resident clothing. She also stated that the rags and cloths in the basket were from the kitchen and were cleaned in the same room used for resident clothing and linen. The Housekeeping Director confirmed that resident clothing was processed in the resident clothing-only room, that bed linens, towels, and other items were processed in the clean and dirty laundry rooms, and that clean resident clothing was sorted on racks placed outside in the hallway because the facility had no room for the racks. The Nursing Home Administrator later acknowledged that the exposed clean resident clothing rack had been moved after surveyor intervention.
Failure to Establish Legal Healthcare Decision Maker
Penalty
Summary
Facility staff failed to ensure that a legal healthcare decision maker was in place in a timely manner for Resident #4, who was admitted on 03/06/2024 with multiple diagnoses including dementia. The medical record showed no advance directives documented for the resident, and the attending physician certified on 05/31/2024 and the nurse practitioner certified on 06/03/2024 that the resident lacked decision-making capacity. The record did not show evidence of a court-appointed legal healthcare decision maker. During interview on 03/25/2026, the Director of Social Services stated that when a resident is admitted without decision-making capacity, the facility contacts the resident's family and advises them to seek legal guidance to establish a decision maker. When asked about Resident #4's appointed decision maker, the DSS stated she was unsure whether the required documentation had been obtained and reported that the facility was currently in the process of obtaining guardianship. A progress note dated 03/23/2026 indicated that certification for guardianship had been submitted to the physician and provider for completion, and the DSS stated the facility did not have documentation of any prior attempts to obtain an appointed healthcare decision maker since the resident's admission in 2024.
Delayed MDS Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive MDS assessment within 14 days of a significant change for Resident #52. During survey observation, the resident was lying in bed with the left hand contracted. Record review showed PT had identified contractures of the right and left ankle on the admission assessment, and OT documented a contracture of the left hand muscle. However, MDS assessments completed later documented no impairment in the upper extremities in section GG on multiple assessments, even though the resident had been receiving OT for the left hand contracture since April 2024. The DON reviewed the OT notes and MDS assessments and acknowledged that the documentation of the resident’s left hand contracture was a significant change and should have been documented timely.
Missing 48-Hour Baseline Care Plan
Penalty
Summary
The facility failed to develop a 48-hour baseline care plan upon admission for Resident #106, who was admitted to the facility on [DATE]. During review of the medical record on 03/24/26, the baseline care plan could not be found in the Matrix electronic health record. When Staff #5, the Regional Clinical Director of Nursing, was asked to provide a copy of the resident’s 48-hour baseline care plan, none was produced. Staff #2, the DON, and Staff #5 were later interviewed and stated that the 48-hour care plan had not been completed for Resident #106, and both acknowledged that the baseline care plan should have been completed within 48 hours of admission.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to revise Resident #19’s comprehensive care plan to reflect the resident’s need for oxygen therapy. During survey observations on 03/23/2026 and 03/24/2026, Resident #19 was observed in bed receiving oxygen at 2 liters via nasal cannula. Review of the resident’s comprehensive care plan showed that it did not include oxygen therapy, respiratory monitoring, or related interventions. During an interview on 03/24/2026, the DON acknowledged that the care plan should have been updated after the resident’s hospitalizations in October 2025 and November 2025. Hospital discharge summaries from those hospitalizations confirmed ongoing oxygen therapy needs, but the care plan was not revised to reflect the change in condition.
Missing Oxygen Order for Resident Receiving Oxygen
Penalty
Summary
The facility failed to ensure physician orders were obtained and implemented for oxygen therapy for Resident #19. On 03/23/2026 and 03/24/2026, the resident was observed in bed receiving oxygen at 2 liters via nasal cannula. During an interview on 03/24/2026, RN #12 confirmed the resident was receiving oxygen, and review of the medical record showed no order for oxygen. The RN acknowledged the missing order and stated the resident should have had an oxygen order. Hospital discharge documents from October 2025 indicated the resident was to be weaned to 1 liter of oxygen, and discharge documents from November 2025 noted a history of hypoxia requiring 3 liters of oxygen via nasal cannula. The DON stated that admitting nurses are responsible for copying hospital discharge orders into the facility system and acknowledged that the resident returned from hospitalization on oxygen, but the admitting nurse failed to enter an oxygen order upon readmission.
Failure to Meet a Dependent Resident’s Grooming Needs
Penalty
Summary
The facility failed to ensure that a dependent resident’s grooming needs were met. Resident #10 had a BIMS score of 6 on the most recent MDS, indicating severe cognitive impairment, and the clinical record and care plans did not show that the resident refused care, including shaving and grooming. During observations, the resident was seen sitting at the side of the bed with a disheveled appearance and facial hair about a quarter of an inch long, and was later observed again with unshaven facial hair. A GNA stated that the resident did not refuse grooming when care was provided, and the Unit Manager confirmed the observations. The DON stated that the resident sometimes refused care, but that refusal was not documented on the care plan.
Failure to Address Resident Hearing Loss
Penalty
Summary
Facility staff failed to ensure effective communication by not addressing a resident’s hearing impairment and not obtaining an audiology screening or evaluation for the resident. During an interview, the resident reported difficulty hearing, stated hearing was better in the left ear, and said they did not have hearing aids. The care plan identified hearing loss and included interventions such as facing the resident and speaking clearly, and the MDS showed a progression from minimal hearing difficulty to moderate hearing difficulty. However, review of the medical record did not show evidence of an audiology screening or evaluation, and the DON confirmed the resident had not been assessed for hearing loss and could not explain why no referral or evaluation had been made.
Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. Record review showed that the resident had severe cognitive impairment, unclear speech, intermittent understanding, and dependence on staff for most ADLs. During an evening shift, a GNA was assisting another GNA with transferring the resident using a mechanical lift when the resident reportedly hit the GNA. Witness accounts documented that the GNA responded by cursing, including statements such as “don’t fucking hit me,” and later, in reference to the resident, “fucked [his/her] ass straight up and [his/her] is a fucking retarded gimp,” and that the resident “won’t be getting any more ice cream” from her. Another staff member heard the raised voice and profanity but could not see into the room because the door was closed. The facility’s investigation file and interviews further showed that the GNA admitted to holding the resident’s arm down after being hit and later admitted to cursing at the resident. A CMA who was near the room at the time heard the GNA say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at the other GNA rather than the resident. The DON’s interviews with involved staff confirmed that the GNA’s voice was raised during the incident and that abusive language was used toward the resident, establishing that the resident was subjected to verbal abuse and that at least one staff member failed to recognize and report the allegation of abuse at the time it occurred.
Failure to Timely Report Witnessed Verbal Abuse Allegation to State Agency
Penalty
Summary
Staff failed to recognize and report an allegation of verbal abuse to the State Agency within the required timeframe. Record review showed that a Geriatric Nursing Assistant (GNA) verbally abused Resident #6 on 1/20/26 during the evening shift, between approximately 8:00 PM and 8:30 PM, and that this abuse was witnessed by facility staff who did not report the incident at the time it occurred. The facility’s investigation file for facility reported incident #2726923 documented that the DON became aware of the allegation of abuse on 1/21/26 at 9:32 AM, and an email confirmation showed the report was sent to the State Agency on 1/21/26 at 12:42 PM. During interview, Certified Medicine Aide (CMA) #5 confirmed she was present when the verbal abuse occurred on the evening of 1/20/26. The DON stated she believed the 2‑hour reporting timeframe began when she was notified of the allegation, rather than from the time the abuse occurred, resulting in the allegation not being reported within the required timeframe. This deficiency was identified for 1 of 4 facility‑reported incidents reviewed and is cross‑referenced to F600 and F610.
Failure to Remove Alleged Abusive Staff Member From Resident Care
Penalty
Summary
Facility staff failed to ensure that a staff member observed verbally abusing a resident was immediately removed from access to vulnerable residents. Record review showed that Resident #6 had dementia and was severely cognitively impaired per an MDS with an assessment reference date of 12/18/25. The facility’s investigation file for a reported incident indicated that on 1/20/26 during the evening shift, GNA #3 verbally abused Resident #6 while GNA #3 and GNA #4 were putting the resident back to bed, stating, “Do not fucking hit me.” Staff did not recognize this as abuse at the time, and it was not reported to the DON until 1/21/26 at 9:32 AM. Staff assignment sheets and time punches confirmed that GNA #3 worked the evening shift starting at 2:30 PM on 1/20/26 and continued working until 6:30 AM on 1/21/26, resulting in approximately 10 hours of continued work with vulnerable residents after the verbal abuse occurred. A CMA who was present confirmed the time frame of the incident as between 8:00 PM and 8:30 PM on 1/20/26. These findings show that the facility did not promptly remove the alleged perpetrator from resident care or immediately report the abuse to appropriate leadership after it occurred.
Failure to Ensure Availability of Essential Pancreatic Enzyme Medication
Penalty
Summary
Facility staff failed to ensure that a resident with pancreatic cancer who had undergone a Whipple procedure consistently received the prescribed pancreatic enzyme medication, Creon, upon admission and throughout the stay. The hospital discharge summary documented the need for Creon with meals to assist with digestion and nutrient absorption, and the resident’s orders specified Creon capsules three times daily. Review of the MAR showed multiple missed doses on specific dates when the medication was not administered because it was not available, with nurses documenting that the drug was not available from the pharmacy, was on order, or was pending physician evaluation. On the day of admission, the assigned RN did not administer Creon because it had not been ordered from the pharmacy and documented the missed dose accordingly. Pharmacy dispensing records showed that Creon was shipped in 100‑capsule quantities on three separate dates, which coincided with documented missed doses when the facility allowed the supply to run out before refills arrived. The DON acknowledged awareness prior to admission that the resident required Creon and its importance with each meal, yet there was no process in place to ensure the medication was available at admission or to prevent running out between refills. The DON reported that staff asked the family to provide the medication from home and that special‑order medications took longer to obtain because they required her signature and were not stocked at the pharmacy. The facility’s policy on ordering and receiving medications lacked an implementation date and did not include provisions for special‑order medications, and there was no documentation that the hospital case manager had instructed the family to bring the medication at admission.
Missing Written QAPI Plan
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program because it did not have a written QAPI plan to guide its efforts in maintaining acceptable levels of performance and continual improvement. During review of the QAPI program information provided by the QA coordinator, surveyors did not find a QAPI plan. The DON and QA coordinator stated they were unaware of the regulatory requirements for a QAPI plan and were unsure whether the facility had one. The DON said she would need to contact corporate consultants to determine whether a plan existed, and the QA coordinator reported she was responsible for overseeing the program and conducting QAA committee meetings but had no established QAPI plan to guide those duties. In a later interview, the DON stated that a corporate consultant told her a QAPI plan was not required to be written out, then acknowledged after review of the regulation that the facility had no QAPI plan in writing. The NHA also stated he was unaware of the required QAPI plan.
Incomplete QAPI Program and Physician Visit Review Deficiency
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program, including the development and implementation of policies and procedures for the program. During the revisit survey, the facility was found to still be out of compliance with CMS regulation 483.30(b) related to physician visits, and the deficiency was associated with harm to a resident. The survey also identified that the facility’s QAPI policies and procedures were incomplete, lacking dates of completion, implementation, and last review, and did not clearly define the committee’s feedback mechanisms, benchmarks, responsible role for data collection and analysis, or communication methods for QAPI indicators, initiatives, strategies, and results. For Resident #1, a hospital discharge summary documented multiple duodenal ulcers, NPO status, TPN, and discharge medications that included a proton pump inhibitor and a gastrointestinal protectant. A review of the resident’s physician orders showed those medications had not been ordered. There were no notes explaining why the medications were not continued by the admitting RN, and no orders or notes entered by the PA who reviewed the discharge with the RN. The resident’s history and physical by Physician #6 later stated the full plan of care, including medication orders, had been reviewed and indicated the resident was to continue the proton pump inhibitor and gastrointestinal protectant, but the note did not show awareness that the resident had no bowel sounds on admission, had reported not being on oral medications in the hospital, or that the discharge medications had not been ordered. Interviews confirmed confusion about the discharge summary and that the resident was supposed to remain NPO until examined by the physician the next day, but this information was made part of the medical record. Physician #6 stated he thought the resident was on the medications as listed on the discharge summary and acknowledged it would have been his mistake if the medications were not entered or handwritten. The DON stated the facility was not auditing physician notes to ensure the full plan of care and medications were reviewed at each visit. The QA coordinator stated there were no established QAPI policies and procedures and that she relied on procedures from other facilities, while the NHA stated he participated in meetings but could not explain his role beyond monitoring the meeting and quality improvement. The facility’s written policy identified the NHA as chair of the committee, but the QA coordinator actually ran the meetings, and the policy did not match the facility’s practice.
Failure to Timely Assess and Intervene After Resident Change of Condition
Penalty
Summary
The facility failed to timely assess and implement interventions after a change of condition for two residents, resulting in delays in assessment and treatment. In the first case, a resident with severe cognitive impairment and dependence for activities of daily living sustained a deep laceration to the right hand during care when the resident grabbed a side rail while being turned. The incident was initially reported by the geriatric nursing assistants to an LPN, but there was no immediate nursing assessment or documentation. The injury was ultimately discovered by the resident's family, prompting a registered nurse to assess the wound and arrange for emergency care. Witness statements revealed that the LPN did not recall being informed of the injury, and there was a lack of timely follow-up and documentation as required by facility policy. In the second case, another resident with moderate cognitive impairment and a history of falls was observed with facial bruising and a hematoma by staff. The discoloration was reported to nurses at the station, but there was confusion among staff regarding who was responsible for assessing and reporting the injury. The assigned nurse did not document or report the injury, and no immediate assessment or notification to the medical provider occurred. The following day, the resident was found with more extensive bruising and swelling, at which point a full assessment was completed, and the resident was sent to the emergency room. Interviews with staff indicated that the initial report of the injury was not acted upon in a timely manner, and the required procedures for injuries of unknown origin were not followed. Both incidents demonstrate a failure to follow facility policy regarding timely assessment, documentation, and communication of changes in resident condition. Staff interviews revealed lapses in communication and uncertainty about responsibilities, resulting in delays in care and treatment for the affected residents. The deficiencies were identified through interviews, record reviews, and facility document reviews, which confirmed that the required interventions and notifications were not completed as specified in the facility's policies.
Failure to Timely Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of property to the state survey agency, as required by policy. A resident, who had a history of congestive heart failure, type II diabetes mellitus, and acute respiratory failure with hypoxia, reported missing money in January. The resident, who was cognitively intact, informed the social worker that $225 was missing from their belongings. Staff searched the resident's room and provided a lock box for valuables, but could not locate the money or confirm if the resident ever possessed the amount claimed. Despite the allegation being reported to multiple staff members, including a Geriatric Nursing Assistant and the Director of Nursing, the incident was not reported to the state agency at that time. The facility's policy required immediate reporting of any alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property. However, the staff treated the incident as a grievance rather than a reportable allegation because they could not verify the resident had the missing money. The allegation resurfaced in April, at which point the facility reported it to the state agency, several months after the initial report by the resident. The required 5-day investigation report was also submitted late, outside of the mandated timeframe. Interviews with staff revealed that the decision not to report the incident in January was based on the inability to substantiate the resident's claim. Staff, including the social worker and unit managers, stated that they did not observe the resident with the alleged sum and only reported the incident after it was brought up again months later. The administrator confirmed that the facility typically reported such allegations within two hours but, in this case, delayed reporting due to doubts about the validity of the claim.
Failure to Include Anticoagulant in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving anticoagulant medication, specifically Eliquis. The resident, who was admitted with diagnoses including unspecified disorders of the brain and paroxysmal atrial fibrillation, was noted to have a moderately impaired decision-making ability. Despite the resident's condition and the physician's order for Eliquis, the care plan did not include any focus, measurable goals, or interventions related to the use of anticoagulant medication. Interviews with the MDS Coordinator and the Director of Nurses confirmed that the care plan should have included information about the anticoagulant medication. The MDS Coordinator stated that care plans are typically updated during each quarterly assessment, and acknowledged that the anticoagulant should have been included. The Director of Nurses also confirmed that the resident was receiving Eliquis and that this information should have been part of the care plan. The facility's policy requires the development of a comprehensive care plan that meets professional standards of quality care, which was not adhered to in this case.
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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 Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lions Rehab Center | 0.8 mi | ★★★★★ | 34 | 0 |
| Allegany Health Nursing And Rehab | 1.5 mi | ★★★★★ | 19 | 0 |
| Cumberland Healthcare Center | 2.1 mi | ★★★★★ | 27 | 1 |
| Frostburg Rehab Center | 6.7 mi | ★★★★★ | 54 | 0 |
| Mountain City Rehab Center | 7.7 mi | ★★★★★ | 33 | 0 |
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