Devonshire Care Center

In the surveyor’s words

From the most serious findings on record at Devonshire Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 26, 2026

  Based on observations, record review and interviews, the facility failed to ensure one (#11) of four residents out of 36 sample residents remained free from accidents.Resident #11 was admitted to the facility on [DATE] with diagnoses including parkinsonism, dementia, muscle weakness, a history of falls, and dysphagia (difficulty swallowing). On 1/28/26, Resident #11 sustained an unwitnessed fall from her electronic reclining chair. The facility recommended unplugging the resident's chair to prevent her from using the remote control due to cognitive impairments. The director of nursing (DON) said on 3/26/26, at some time before the fall on 2/14/26, the resident's electric chair was plugged back in (see interview below). […]

• Actual harm, isolatedF692Mar 26, 2026

  Based on observations, record review and interviews, the facility failed to ensure two (#30 and #11) of 11 residents out of 36 sample residents received the nutritional care and services necessary to maintain their highest practicable level of well-being.Resident #30 was admitted to the facility on [DATE] with a diagnosis of dementia. Upon admission, the resident weighed 141.5 pounds (lbs) and was not identified to have nutritional concerns. On 12/10/25, the resident weighed 134.5 lbs, indicating a 7 lbs weight loss. The facility failed to address the residents' weight loss. On 12/17/25, the resident weighed 131 lbs, which indicated the resident sustained a 7.4% (10.5 lbs) weight loss in 30 days, which was considered severe. […]

• Actual harm, isolatedF689Mar 7, 2024

  Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for three (#46, #43 and #25) of six residents reviewed for falls out of 33 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living. The facility failed to provide staff education and increase residents' supervision to prevent falls when all three residents could not ask for staff assistance by using the call light due to severely impaired cognition for Residents #46, #25 and #43. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to ensure: -Food was held at the correct temperature;-Hand hygiene was conducted during meal service and dishwashing; -The kitchen was clean and sanitary; and, -Food was labeled and stored correctly in the walk-in refrigerator, freezer, reach-in refrigerator, and dry storage area. Findings include:I. Failure to hold food at the correct temperatureA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. […]

• No harm, potential for more than minimal, patternF567Mar 26, 2026

  Based on observations, record review and interviews, the facility failed to ensure residents' personal funds accounts were managed adequately for the facility and accessible to the residents for three (#7, #27 and #44) of three residents out of 36 sample residents. Specifically, the facility failed to ensure residents were educated on how to access their money on the weekends. Findings include: I. Resident interviewsResident #7 was interviewed on 3/23/26 at 2:40 p.m. He said the person who handled the money was not always at the facility. He said he was not aware of any times on the weekends when he could pull out his money. Resident #7 was interviewed a second time on 3/25/26 at 1:04 p.m. He said he normally went to the business office manager or the front desk to pull out his money. […]