Devonshire Care Center

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

38 of 210 Colorado homes (18%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 30, 2026.

  CMS has cited this home for F0689 4 times since 2019.

• Citation F0692. Severity G: actual harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on March 22, 2026.

  CMS has cited this home for F0692 2 times since 2019.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 30, 2026.

  CMS has cited this home for F0812 2 times since 2019.

• Citation F0567. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to manage his or her financial affairs.

  CMS lists it as corrected on March 30, 2026.

• Citation F0600. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on March 30, 2026.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 30, 2026.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on March 30, 2026.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on March 30, 2026.

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CMS lists this as a standard inspection.

• Citation K0161. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Use approved construction type or materials.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on May 27, 2026.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on May 21, 2026.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on May 8, 2026.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS has cited this home for K0353 2 times since 2019.

• Citation K0363. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on May 5, 2026.

  CMS has cited this home for K0363 2 times since 2019.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on May 11, 2026.

  CMS has cited this home for K0712 3 times since 2019.

• Citation K0751. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have restrictions on the use of flammable curtains.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0751 2 times since 2024.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0914 2 times since 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS has cited this home for K0918 3 times since 2019.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0324 2 times since 2019.

• Citation K0511. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on June 17, 2026.

• Citation K0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on May 6, 2026.

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CMS fine of $7,630 on March 26, 2026.

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CMS lists this as a complaint inspection.

• Citation F0678. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on January 9, 2026.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on December 10, 2025.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Ownership

  CMS no longer lists a chain for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on April 27, 2025.

See this home on CMS Care Compare

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on April 28, 2025.

  CMS has cited this home for F0550 2 times since 2019.

• Citation F0559. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on April 28, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Fine

  CMS changed the fine from March 7, 2024 from $2,314 to $2,350.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0849. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  CMS lists it as corrected on September 30, 2024.

• Citation F0660. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.

  CMS lists it as corrected on September 30, 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on September 30, 2024.

  CMS has cited this home for F0697 2 times since 2024.

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• Fine

  CMS changed the fine from March 7, 2024 from $3,560 to $2,314.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on June 12, 2024.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Name

  CMS lists a new name for this home. It was DEVONSHIRE ACRES.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

65 of 210 Colorado homes (31%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 8, 2024.

• Citation F0565. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on March 8, 2024.

• Citation F0700. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on March 8, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 8, 2024.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on March 8, 2024.

• Citation F0574. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: The resident has the right to receive notices in a format and a language he or she understands.

  CMS lists it as corrected on March 8, 2024.

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CMS lists this as a standard inspection.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on April 15, 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 5, 2024.

• Citation K0741. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on April 5, 2024.

• Citation K0751. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have restrictions on the use of flammable curtains.

  CMS lists it as corrected on April 5, 2024.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on March 27, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on March 25, 2024.

• Citation K0923. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on April 5, 2024.

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CMS fine of $2,350 on March 7, 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

5 of 210 Colorado homes (2%) got a citation at the actual harm level in 2019.

• Citation F0692. Severity H: actual harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on November 25, 2019.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on December 2, 2019.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on December 2, 2019.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 2, 2019.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 2, 2019.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 2, 2019.

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CMS lists this as a standard inspection.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on December 23, 2019.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on December 23, 2019.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on December 23, 2019.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on December 23, 2019.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on December 23, 2019.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on December 23, 2019.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on December 23, 2019.

• Citation K0927. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

  CMS lists it as corrected on December 23, 2019.

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