Devlin Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Devlin Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF711Mar 20, 2026

  Based 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. The findings include:Cirrhosis of the liver is a condition in which the liver becomes scarred and unable to work properly. Ascites is a complication in which the liver does not produce protein in the blood causing fluid to build up in the abdominal cavity and if left untreated it can cause the resident to have trouble breathing. […]

• No harm, potential for more than minimal, widespreadF850Sep 20, 2023

  Based 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. The findings include: Interview with the Director of Nursing (DON) and the Administrator on 9/20/23 at 1:00 PM revealed the facility failed to employ a qualified Social Worker from December 2021 to July 2022. […]

• No harm, potential for more than minimal, patternF578Mar 27, 2026

  Based 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. The findings include: 1) On 03/25/26 at 9:40 AM, a review of Resident #4's medical record indicated the resident lacked decision making capacity at the time of admission in March 2024. […]

• No harm, potential for more than minimal, patternF880Mar 27, 2026

  Based 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.The findings include:On 03/24/26 at 9:02 AM, an observation of the hallway by the clean and dirty laundry rooms revealed two uncovered clothing racks which appeared to be full of resident linen.At the same time, further observation of the hallway revealed a room which had a singular washer and dryer next to one another. […]

• No harm, potential for more than minimal, patternF684Sep 12, 2025

  Based 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. Findings included: A facility policy titled, Physician and Other Communication/Change in Condition, revised 05/05/2023, specified To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the… […]