Devlin Manor Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
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Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Devlin Manor Nursing and Rehabilitation Center
10301 North East Christie Road Cumberland, MD 21502
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)
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
the MD on 05/23/2025 when the bruising was first identified. Per UM #17, LPN #9 stated to her that she did not remember seeing or hearing anything about Resident #4's facial bruising on 05/23/2025. UM #17 further stated RN #18 notified everyone of the bruising the next day on 05/24/2025 and then started neuro checks.During an interview on 09/09/2025 at 4:05 PM, UM #17 stated if an injury of unknown origin was brought to either nurse on duty's attention, one of them should have assessed the resident and notified the MD. Per UM #17, the nurses usually took care of only the residents on their assigned hall, but one of the nurses should have done something on 05/23/2025 when the bruising was first identified. 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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DEVLIN MANOR NURSING AND REHABILITATION CENTER in CUMBERLAND, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CUMBERLAND, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DEVLIN MANOR NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.