Devlin Manor Nursing And Rehabilitation Center
DEVLIN MANOR NURSING AND REHABILITATION CENTER in CUMBERLAND, MD — inspection on September 12, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
money missing on 01/15/2025, but staff could never confirm the resident ever had the money.
Following the allegation, the facility provided the resident with a lock box for valuables, but the resident never locked the drawer.
The SW further stated they disregarded the allegation in January 2025 because no staff saw the resident with a large amount of money.
Per the SW, the allegation related to missing money came up again in April 2025, so the facility chose to report the allegation to the state agency.
During an interview on 09/09/2025 at 2:11 PM, Unit Manager (UM) #15 stated Resident #6 alleged to have money missing in January 2025 and staff checked the resident's room thoroughly without finding the money.
Staff then placed a lock box in Resident #6's bedside table, but the resident never locked up their valuables. UM #15 further stated staff were not aware of Resident #6 having the amount of money they claimed was missing.
Per UM #15, when Resident #6 expired, staff cleaned out their belongings and did find money in their lock box.
Staff inventoried the resident's belongings and passed them on to their power of attorney (POA).During an interview on 09/09/2025 at 2:45 PM, UM #17 stated she did the state reportable related to Resident #6's missing money.
Per UM #17, she received a call from compliance notifying her of Resident #6's missing money not being addressed, so she called her nursing consultant, who instructed her to report the allegation to the state agency. UM #17 further stated that after Resident #6 expired, staff found around $300 throughout their room.
Staff inventoried the resident's belongings and gave them to the SW, who then gave them to the resident's family.
During an interview on 09/10/2025 at 11:25 AM, the DON stated that in January 2025, Resident #6 alleged they were missing money, but staff were unable to determine if the resident ever had the amount of money they alleged was missing.
The DON further stated Resident #6's concern related to their missing money came up again in April 2025, so they made the decision to report the allegation of misappropriation to the state agency at that time.
During an interview on 09/10/2025 at 12:14 PM, the Administrator stated that as the abuse coordinator, they reported any allegation of abuse, neglect, or misappropriation to the state agency within two hours of the allegation being made.
The Administrator further stated Resident #6 alleged to have a large amount of money missing at one time, but facility staff treated it more as a grievance as opposed to an allegation of misappropriation because staff could not verify the resident ever had the amount of money alleged to be missing.
The Administrator further stated the decision was made to make the reportable in April 2025 because Resident #6 again brought up the large amount of missing money, but facility staff had to again unsubstantiate it because they could not verify the resident ever had the money.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Devlin Manor Nursing and Rehabilitation Center
10301 North East Christie Road Cumberland, MD 21502
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/10/2025 at 11:25 AM, the Director of Nursing (DON) stated she received a call from UM #15 on 05/24/2025 that RN #18 observed bruising around Resident #4's eyes.
Per the DON, she instructed UM #15 to interview the staff that worked with Resident #4 to determine what happened and found out the bruising was reported to LPN #4 and RN #10 the previous day.
During the follow-up investigation, there was some confusion. LPN #4 thought the bruising was reported to LPN #9 and that LPN #9 assessed the resident and did the required reporting prior to LPN #4 taking over LPN #9's hall on 05/23/2025.
Per the DON, Resident #4 denied falling on 05/23/2025 when initially asked.
The DON further stated RN #18 was on duty 05/24/2025 and asked Resident #4 how they obtained the facial bruising and the resident stated, I fell yesterday, but could not give any details.
Per the DON, Resident #4 was independently ambulatory and could get up on their own if they did have a fall.
The DON further stated the incident should have been identified and reported on 05/23/2025.
Following the incident, the DON provided re-education to all nurses on identifying changes in condition and communication between the nurses to ensure any medical needs were addressed timely.
During an interview on 09/10/2025 at 12:14 PM, the Administrator stated he expected nursing staff to notify the provider in a timely manner when they identified a resident's change in condition.
During an interview on 09/11/2025 at 1:10 PM, LPN #4 stated she worked as a GNA when Resident #4's bruising was initially reported on 05/23/2025, and LPN #9 was present during that time. LPN #4 further stated LPN #9 looked at the resident at that time, and LPN #4 thought LPN #9 would have called the provider and done an assessment. LPN #4 further stated nothing related to Resident #4 was passed on in report on 05/23/2025 because she thought LPN #9 would have taken care of that during her shift, so she took no further actions during her shift as a nurse on 05/23/2025.
During an interview on 09/11/2025 at 3:54 PM, GNA #20 stated staff did not know what happened to Resident #4's face on 05/23/2025, but they first noticed yellow and black bruising around the resident's eyes around dinner time that day. GNA #20 further stated LPN #4 monitored the resident that shift, with no further concerns noted.
During an interview on 09/12/2025 at 9:09 AM, the MD stated he expected nursing staff to report to a provider of a possible head injury right away.
The MD further stated his medical group should have been notified of Resident #4's facial bruising on 05/23/2025 instead of the next morning.
Per the MD, Resident #4 should have been sent to the emergency room right away to rule out any further injury beyond bruising.
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