Deficiency Records for Devlin Manor Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Devlin Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-20 | 2023-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-20 | 2023-09-30 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-09-20 | 2023-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-08 | 2019-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-04 | 2019-12-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-15 | 2018-07-15 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-06-15 | 2018-07-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-15 | 2018-07-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-06-15 | 2018-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-15 | 2018-07-15 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-15 | 2018-07-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-15 | 2018-07-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-15 | 2018-07-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-15 | 2018-07-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-06-15 | 2018-07-15 | N |
| Provide activities to meet all resident's needs. | Health | 2018-06-15 | 2018-07-15 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-06-15 | 2018-07-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-06-15 | 2018-07-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-06-15 | 2018-07-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-15 | 2018-07-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-15 | 2018-07-15 | N |
| Keep all essential equipment working safely. | Health | 2018-06-15 | 2018-07-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-06-15 | 2018-07-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-06-13 | 2018-07-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-06-13 | 2018-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-13 | 2018-07-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-06-13 | 2018-07-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-23 | 2017-05-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-03-23 | 2017-05-19 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-23 | 2017-05-19 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-23 | 2017-05-19 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-03-23 | 2017-05-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-23 | 2017-05-19 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-23 | 2017-05-19 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-23 | 2017-05-19 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-23 | 2017-05-19 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-23 | 2017-05-19 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-23 | 2017-05-19 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-23 | 2017-05-19 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2017-03-23 | 2017-05-19 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-03-23 | 2017-05-19 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-23 | 2017-05-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-23 | 2017-05-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-03-30 | 2017-04-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-30 | 2017-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-30 | 2017-04-24 | N |
