Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Devonshire Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and severe cognitive impairment had conflicting documentation regarding resuscitation status, with the MOST form indicating CPR should be performed while the physician's order specified DNR. Inconsistent staff training and review processes led to the resident receiving CPR in the emergency room, contrary to the documented DNR order.
Two residents with wounds did not have complete or accurate wound assessments documented in their medical records. Required details such as wound measurements, progression, and treatment effectiveness were missing, with documentation limited to wound locations. Staff interviews confirmed that wound assessments should be more detailed, and the DON and medical director were unaware of the incomplete documentation until the survey.
A resident with severe cognitive impairment and a known risk for elopement was left unsupervised in an unsecured area after being taken to a church service in the AL section, which lacked wanderguard protection. The resident exited the facility through an unalarmed door and was found several blocks away after staff realized the resident was missing and initiated a search. Required 15-minute checks and supervision were not maintained, leading to the resident's elopement.
The facility failed to respond to call lights promptly, affecting four residents' dignity and well-being. Residents reported waiting 20 to 45 minutes, leading to anxiety and accidents. Staff interviews revealed inconsistent understanding of response times, and data showed significant delays. The administration acknowledged the issue, with plans to address it.
The facility failed to provide timely written notification of room and roommate changes for three residents, violating their policy. Residents were moved without documentation or notification of their rights to refuse the changes. Interviews confirmed the lack of documentation and notification.
The facility failed to meet professional standards for hospice care for four residents. Two residents lacked complete physician's orders for hospice care, and hospice agency notes were not consistently accessible or documented. Additionally, a hospice care plan was not initiated timely for one resident. Interviews revealed unclear processes for obtaining hospice services and documentation.
A resident with severe cognitive impairment and aggressive behaviors was not provided with an effective discharge plan. The facility failed to document the discharge process in the EMR and did not keep the resident's representative informed. Miscommunication and lack of documentation regarding referrals to secure units, including a facility in Nebraska, contributed to the deficiency.
The facility failed to provide adequate pain management for two residents. One resident received morphine sulfate without documented pain levels, often at the family's request, despite having a pain level of 0. Another resident, who was severely cognitively impaired, was not assessed using the PAINAD scale as ordered, with staff using an inappropriate numerical pain scale instead. The DON confirmed that the nursing staff did not follow physician orders or facility policy, leading to inadequate pain management.
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. One resident experienced ineffective pain relief and inconsistent administration of prescribed medications, while another resident faced delays in receiving new pain medication and inappropriate pain assessment methods. Staff interviews revealed gaps in medication availability and pain management processes.
The facility failed to provide adequate supervision and implement necessary interventions to prevent falls for residents with cognitive impairments and mobility issues. One resident with a history of falls and cognitive impairment was not properly assessed for call light use and did not have updated fall prevention measures after a major fall resulting in hospitalization and surgery. Another resident with Parkinson's disease and requiring substantial assistance experienced falls due to inconsistent inclusion of new interventions in the fall care plan and lack of necessary assistance during transfers. These deficiencies highlight the need for consistent monitoring and proactive measures to address fall risks.
The facility failed to address and document follow-up actions for grievances raised by residents during council meetings. Concerns about insufficient sit-to-stand devices causing long wait times were not resolved, and meetings were held in open spaces with staff present, preventing residents from speaking freely.
The facility failed to properly assess and document the use of bed rails for ten residents, including not obtaining informed consent or conducting necessary evaluations. This deficiency was observed in multiple residents' records, where there was a lack of proper assessment, physician consultation, and documentation before the installation of bed rails.
The facility failed to ensure staff wore PPE correctly during an RSV outbreak, with multiple staff members observed wearing facemasks improperly. Despite facility-wide education on proper mask usage, LPNs and office employees were seen with their noses uncovered or masks not fitted properly, indicating a lapse in infection control practices.
The facility failed to provide trauma-informed care for a veteran resident with multiple health issues, leading to inadequate management of his anxiety and nightmares. Staff interviews revealed a lack of awareness and understanding of the resident's trauma history and triggers, resulting in a deficiency in care.
The facility failed to post a sign with information on how to file a complaint to the State Survey Agency. During interviews, residents were unaware of their ability to file a complaint, and observations confirmed the absence of such signs in the lobby and units. Staff were also unaware of the sign's location.
Failure to Accurately Document and Align Resuscitation Preferences
Penalty
Summary
The facility failed to accurately document and align a resident's resuscitation preferences in the medical record, resulting in a discrepancy between the Medical Orders for Scope of Treatment (MOST) form and the physician's order. The resident, who had multiple diagnoses including dementia, diabetes, atrial fibrillation, hypertension, heart disease, dysphagia, and osteoporosis, was severely cognitively impaired and required varying levels of assistance with daily activities. The physician's order clearly indicated a Do Not Resuscitate (DNR) status, reflecting the wishes of the resident or their representative. Upon review, the resident's MOST form, completed at admission, was marked 'Yes' for CPR, indicating a desire for resuscitation, while the physician's order and other documentation, such as psychosocial assessments and care conference notes, consistently indicated DNR status. Additionally, the MOST form's Section B was marked for comfort-focused treatment, which conflicted with the requirement that a 'Yes' for CPR should be paired with full treatment to prolong life. The care plan did not specify the resident's CPR wishes, and the hospital transfer form referred to the MOST form, which was inaccurately completed. Staff interviews revealed a lack of consistent training and understanding regarding the completion and review of MOST forms. Nurses responsible for completing the forms reported minimal training and uncertainty about review frequency. The DON acknowledged the confusion caused by the incorrectly completed MOST form and confirmed that the nurse who completed it was new and no longer employed at the facility. As a result of the documentation error, the resident received CPR in the emergency room, contrary to the physician's DNR order, due to the conflicting information presented on the MOST form.
Failure to Accurately Document Wound Assessments in Medical Records
Penalty
Summary
The facility failed to maintain accurately documented medical records for two of three residents reviewed, specifically regarding wound assessments. For both residents, the facility did not ensure that wound assessments included required details such as measurements, wound progression, and treatment effectiveness. The documentation only noted the location of the wounds without providing comprehensive assessment data, which is contrary to the facility's own policy that requires detailed wound care documentation, including wound bed color, size, drainage, and any changes in condition. One resident, who had diagnoses including pulmonary embolism, type 2 diabetes, and muscle weakness, had multiple wound care orders for the lower extremities. However, the skin/wound notes for this resident lacked detailed assessments and did not include measurements or descriptions of wound progression. Similarly, another resident with cellulitis, sepsis, and mobility difficulties had wound care orders for the left leg, heel, and foot, but the documentation again failed to provide detailed wound assessments, only noting the wound's location. Interviews with staff, including an LPN certified in wound care and the DON, confirmed that wound assessments should include measurements and detailed descriptions, and that such documentation was lacking. The DON acknowledged the deficiency and noted that accurate wound documentation is necessary for evaluating treatment effectiveness. The facility's medical director also stated that he relied on nursing staff for wound assessment details and was unaware that the required documentation was not being completed.
Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement was left unsupervised and unattended in an unsecured area of the facility. The resident, who had diagnoses including dementia with behavioral disturbances, Wernicke's encephalopathy, and amnesia, required 15-minute checks due to his elopement risk. On the day of the incident, the resident was taken by a CNA to a church service held in the assisted living (AL) side of the facility, which did not have a wanderguard system on its exterior doors. The CNA left the resident in the AL dining room and returned to her assigned area, assuming the activities aide would assist the resident back. The activities aide, however, was not aware of the resident's presence or his need for supervision at that time. The facility's layout allowed residents from the long-term care (LTC) side, which was equipped with wanderguard systems, to access the AL side, where such systems were absent. Once the resident was on the AL side, there were no electronic safeguards to prevent him from exiting the building. Staff interviews confirmed that the last wanderguard alarm was turned off to allow the resident into the AL area, and after that point, there was no further monitoring or alarm system in place. Documentation revealed that 15-minute checks were not completed for the resident from 10:15 a.m. to 1:00 p.m., and staff did not notice the resident was missing until after the church service had ended and a search was initiated. The resident was able to exit the facility through an unsecured door on the AL side and was found approximately three blocks away by staff after an extended search involving facility staff, family, and local police. At the time of the incident, the resident's care plan included interventions such as monitoring his location every 15 minutes, use of a wanderguard, and documentation of wandering behavior, but these interventions were not followed during the period in question. The failure to provide adequate supervision and maintain a secure environment directly led to the resident's elopement.
Delayed Call Light Responses Affect Resident Dignity
Penalty
Summary
The facility failed to ensure residents' rights to a dignified existence by not responding to call lights in a timely manner for four residents. The facility's policy required immediate response to call lights, with tasks completed within five minutes if possible. However, residents reported waiting times ranging from 20 to 45 minutes, leading to anxiety, insecurity, and in some cases, physical harm or accidents. Resident #7, for instance, sustained a cut on her forearm and had to walk to the nurses' station for assistance after waiting 30 minutes for a response. Resident council meeting minutes and call light system data corroborated the residents' complaints. The minutes from meetings held between October 2024 and February 2025 consistently highlighted concerns about slow call light responses, although there was a noted improvement in February 2025. The call light data showed that response times exceeded 20 minutes in a significant percentage of calls for the affected residents, indicating a pattern of delayed responses. Interviews with staff revealed inconsistencies in understanding the expected response times, with estimates ranging from two to 15 minutes. Staff acknowledged the delays and their impact on residents, including instances of soiling themselves due to prolonged waits. The assistant director of nursing and the nursing home administrator were aware of the issue and acknowledged the need for improvement, as residents had complained about the long waiting times and the associated risks.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to provide timely written and/or verbal notification of room and/or roommate changes for three residents, which is a violation of their policy and procedure. The policy requires that residents and their representatives receive at least a five-day advance written notice of any room or roommate changes, including the reasons for the change and information to help the new roommates become acquainted. However, for Residents #7, #8, and #13, there was no documentation in their electronic medical records (EMR) indicating that they or their representatives were informed of the room changes or their rights to refuse such changes. Resident #7, who was cognitively intact and independent in certain activities of daily living, was moved from one hall to another because the initial hall was being converted to private pay rooms. Similarly, Resident #8, who required varying levels of staff assistance and was also cognitively intact, was moved for the same reason. In both cases, there was no documentation in their EMRs to indicate that they were informed of the room changes or their rights to refuse the move. Resident #13, who was also cognitively intact and independent in certain activities, was moved from a private room to a semi-private room without receiving written notice. The resident was unaware of the reasons for the move and had not been introduced to the new roommate prior to the change. Interviews with the nursing home administrator, assistant director of nursing, and regional director of operations confirmed the lack of documentation and notification for all three residents, acknowledging that there should have been progress notes and documentation of the room/roommate change forms.
Deficiencies in Hospice Care Documentation and Coordination
Penalty
Summary
The facility failed to ensure that hospice services provided met professional standards for four residents receiving hospice care. For two residents, the facility did not obtain complete physician's orders for hospice care. Specifically, one resident's electronic medical record lacked a physician's order for hospice care, despite the resident's passing being reported to hospice. Another resident's physician's order did not include a diagnosis for the need for hospice care. Additionally, the facility did not ensure that hospice agency notes were easily accessible to staff and consistently documented hospice care visits and updates. For one resident, the last hospice notes uploaded into the facility's electronic medical record were dated over a month prior to the resident's discharge from hospice services. Another resident's electronic medical record lacked hospice progress notes for two consecutive months. Furthermore, the facility did not initiate a hospice care plan in a timely manner for one resident, with the care plan being initiated 26 days after the resident was admitted to hospice services. Interviews with facility staff revealed a lack of clarity regarding the process and timeline for obtaining hospice services and documentation, contributing to the deficiencies observed.
Deficiency in Discharge Planning for a Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident, leading to a deficiency in discharge planning. The resident, an 89-year-old with severe cognitive impairment and multiple health conditions, including Alzheimer's disease and diabetes, was identified as having physically aggressive behaviors and a tendency to wander, posing a risk to herself and others. Despite these concerns, the facility did not document a discharge plan in the resident's electronic medical record (EMR), nor did they ensure that the resident's representative was adequately informed about the discharge planning process. The resident's representative expressed dissatisfaction with the facility's communication, stating that she was not kept informed about the discharge process or the status of referrals to other facilities. Although the facility had initiated referrals to secure units, there was a lack of documentation indicating the representative's agreement to these referrals or any facility-initiated discharge notice. Additionally, there was confusion regarding a referral to a facility in Nebraska, which the representative had requested, but was not sent due to a misunderstanding about the facility's capabilities. Interviews with facility staff revealed inconsistencies in the discharge planning process. The Social Service Director admitted to not documenting all actions in the EMR and was unclear about the status of certain referrals. The Nursing Home Administrator and the Regional Clinical Resource provided conflicting information about the availability of a secured unit at the Nebraska facility. These communication and documentation failures contributed to the deficiency in the discharge planning process for the resident.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, as required by professional standards and the residents' care plans. For one resident, the facility did not establish parameters for administering as-needed (PRN) pain medications, leading to the administration of morphine sulfate without documented pain levels. This resident, who had multiple health conditions including diabetes, osteoarthritis, and mild vascular dementia, was given morphine sulfate several times despite having a pain level of 0 out of 10, often at the request of the family for comfort care. Another resident, who was severely cognitively impaired and on hospice care, was not assessed for pain using the appropriate PAINAD scale as ordered by the physician. Instead, the nursing staff used a numerical pain scale, which was not suitable for the resident's condition. This inconsistency in pain assessment occurred on 24 out of 30 days, indicating a failure to follow the physician's orders and the facility's pain management policy. Interviews with the Director of Nursing (DON) revealed that the facility's policy required the use of the PAINAD scale for residents with cognitive impairments. The DON acknowledged that the nursing staff did not adhere to the physician's orders or the facility's policy, resulting in inadequate pain management for the residents involved.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #2, who had undergone recent back surgery, reported significant pain that was not effectively managed. Despite having multiple pain medications prescribed, including Norco, Tylenol, and a Lidocaine patch, the resident experienced instances where the medications were either not administered as ordered or were ineffective. The facility did not consistently offer or document non-pharmacological interventions, such as baths, which the resident found helpful. Additionally, there were lapses in medication availability, with the Lidocaine patch not being administered on several occasions due to stock issues, and no follow-up actions were documented. Resident #1, who had severe cognitive impairment and chronic pain, also experienced deficiencies in pain management. The resident's pain medication was changed from Fentanyl patches to Methadone pills, but there were delays in receiving the new medication, resulting in missed doses. The facility did not consistently use the appropriate PAINAD scale for assessing pain in this cognitively impaired resident, instead relying on a numerical scale that was not suitable. This inconsistency in pain assessment and the lack of timely medication administration contributed to inadequate pain management for the resident. Interviews with facility staff revealed gaps in the processes for ensuring medication availability and effective pain management. LPNs and RNs described procedures for handling unavailable medications and assessing pain, but these were not consistently followed. The facility's policies and procedures for pain management, including the use of non-pharmacological interventions and proper documentation, were not adhered to, leading to the deficiencies identified in the care of Residents #1 and #2.
Inadequate Supervision and Fall Prevention Interventions
Penalty
Summary
The report highlights multiple instances where the facility failed to provide adequate supervision and implement necessary interventions to prevent falls for residents #46, #25, and #43. For Resident #46, who had a history of falls and cognitive impairment, the facility did not appropriately assess his call light use ability and failed to update the care plan with new fall prevention interventions after a major fall resulting in hospitalization and surgery for a right hip fracture. The resident's repeated falls were not adequately addressed, indicating a lack of proactive measures to prevent future incidents. Similarly, for Resident #25, who had Parkinson's disease and required substantial assistance with daily activities, the facility did not consistently include new interventions in the fall care plan after each fall incident. The report highlighted instances where staff members did not provide necessary assistance or supervision, leading to falls when the resident attempted to transfer himself between his wheelchair and reclining chair. The lack of consistent monitoring and failure to identify root causes of falls contributed to the ongoing risk of accidents for this resident.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to provide a response, action, and rationale to residents involved in group grievances, specifically failing to follow up with residents' concerns brought up by the resident council during regular meetings. Resident #27 reported that there were not enough sit-to-stand devices, causing long wait times to use the bathroom. This concern was raised during resident council meetings, but no resolution was documented or communicated back to the residents. Additionally, the meetings were held in open spaces where staff were present, preventing residents from speaking freely without staff oversight. A frequent visitor confirmed that the sit-to-stand lift concern was not resolved and that meetings were held in open areas with staff present. The nursing home administrator acknowledged that the concerns discussed in the resident council were considered grievances and that solutions were worked on between meetings. However, the grievance regarding the sit-to-stand lifts remained unresolved, and the facility failed to document or communicate any follow-up actions. Resident council notes from January and February 2024 also lacked documentation of any resolution to the concerns raised, leaving the old business section of the minutes blank.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach when determining the use of bed rails for ten residents. Specifically, the facility did not assess the residents for the risk of entrapment prior to installing bed rails, did not obtain consent from the residents or their responsible parties, and did not follow guidelines for maintaining bed rails. This deficiency was observed in residents who had bed rails installed without proper evaluation and documentation in their electronic medical records (EMR). For instance, Resident #2's EMR revealed no evidence of an interdisciplinary team (IDT) evaluation, bed rail risk assessment, or informed consent for the use of bed rails. Similar deficiencies were found in the records of Residents #22, #26, #36, #43, #58, #59, #62, #68, and #71, where there was a lack of proper assessment, physician consultation, and documentation of tried and failed alternatives before the installation of bed rails. The facility's policy and procedure on bed safety and bed rails, revised in August 2022, required an interdisciplinary evaluation, resident assessment, and informed consent before the use of bed rails. However, the facility did not adhere to these guidelines. For example, Resident #22's care plan did not include a focus of care, goals, and interventions for bed rails, and there was no evidence of a current physician order or consultation for the use of bed rails. Similarly, Resident #26's care plan indicated the use of a helper rail for positioning, but there was no documentation of an IDT evaluation or informed consent. Interviews with staff members, including a registered nurse (RN) and the director of nursing (DON), revealed that bed rails were often left attached to bed frames received from vendors, and residents were not consistently evaluated for their use. The DON acknowledged that an audit was completed for residents needing bed rails, but the necessary evaluations and consents were obtained only after the survey began. The facility's failure to follow its own policies and procedures for bed rail use resulted in the installation of bed rails without proper assessment, documentation, and informed consent for multiple residents.
Failure to Maintain Proper PPE Usage During RSV Outbreak
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infections on two of three units. Specifically, the facility did not ensure that staff wore personal protective equipment (PPE) correctly during an outbreak of respiratory syncytial virus (RSV). Observations revealed that multiple staff members, including licensed practical nurses (LPNs) and office employees, were seen wearing their facemasks improperly, with their noses uncovered, even after facility-wide education on proper mask usage was conducted. On several occasions, LPNs and office employees were observed in hallways, common areas, and resident rooms with their facemasks worn incorrectly. Despite the facility being in outbreak status for RSV, staff members continued to wear their masks below their noses or not fitted properly around their mouths. Interviews with the assistant director of nursing (ADON), the infection preventionist (IP), and the director of nursing (DON) confirmed that staff were aware of the outbreak and the importance of wearing PPE correctly, yet compliance was not consistently observed. The facility's infection prevention and control program policy, which was revised in October 2018, emphasized the importance of educating staff on proper techniques and procedures and following established guidelines from the Centers for Disease Control (CDC). However, the failure to ensure staff adherence to these guidelines during the RSV outbreak indicates a lapse in the facility's infection control practices. The report highlights specific instances where staff did not follow PPE protocols, contributing to the potential spread of infection within the facility.
Failure to Provide Trauma-Informed Care for Veteran Resident
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who was a veteran and had served during wartime. The resident, who was moderately cognitively impaired and had multiple health issues including Parkinson's disease, transient ischemic attack, scoliosis, and depression, experienced anxiety and nightmares related to his military service and past surgeries. Despite the facility's policy requiring the identification of trauma triggers and the development of individualized care plans, the resident's care plan did not identify specific triggers for his trauma, leading to inadequate management of his anxiety and nightmares. Interviews with staff revealed a lack of awareness and understanding of the resident's trauma history and triggers. A CNA was unaware that the resident was a trauma survivor, and an RN relied on her intuition rather than documented information to identify trauma triggers. The social services director acknowledged that the initial life event questionnaire did not capture detailed information about the resident's triggers or the impact of trauma on his mental health. This lack of detailed assessment and communication among staff contributed to the deficiency in providing appropriate trauma-informed care. The resident's trauma interview, conducted after the deficiency was identified, revealed specific triggers such as anxiety related to medical transports, fear of falling, and concerns about his surgical incision. The care plan was subsequently updated to include these details, but the initial failure to identify and address these triggers resulted in inadequate care for the resident's trauma-related symptoms. The facility's failure to adhere to its own policy and procedures for trauma-informed care led to the deficiency noted in the report.
Failure to Post State Agency Complaint Information
Penalty
Summary
The facility failed to ensure residents received notices in a written description of their legal rights, specifically by not posting a sign with information on how to file a complaint to the State Survey Agency. During a group interview with three residents, all stated they were unaware of their ability to file a complaint with the State Agency and did not know where to find pertinent contact information. Observations conducted throughout the facility confirmed the absence of such signs in the front lobby and in each of the four units. The corporate nurse consultant was unaware of the sign's location, and the nursing home administrator acknowledged that a sign used to be in the lobby but was unsure of its current whereabouts. A sign was later posted in the lobby entrance next to information on how to contact the ombudsman.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Sterling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Rehabilitation And Nursing, Llc | 2.1 mi | — | 10 | 0 |
| Eben Ezer Lutheran Care Center | 35.4 mi | — | 1 | 0 |
| South Platte Rehabilitation And Nursing Llc | 35.7 mi | — | 3 | 1 |
| Srmc Long Term Care, Llc Dba Pole Creek Estates | 36.6 mi | — | 0 | 0 |
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