ElderGrade

Inspection citations at Devonshire Care Center

73 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 4 0
2025 38 1
2024 12 0
2023 3 0
2021 16 0
E April 20, 2026 Tag F0921 Complaint investigation Corrected Apr 2026

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

E April 20, 2026 Tag F0880 Complaint investigation Corrected Apr 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 1, 2026 Tag F0697 Complaint investigation Corrected Apr 2026

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D January 9, 2026 Tag F0805 Complaint investigation Corrected Feb 2026

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0697 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D July 29, 2025 Tag F0921 Complaint investigation Corrected Jul 2025

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

E July 2, 2025 Tag F0881 Complaint investigation Corrected Jul 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

E July 2, 2025 Tag F0865 Complaint investigation Corrected Jul 2025

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

No actual harm, potential for more than minimal harm

E July 2, 2025 Tag F0726 Complaint investigation Corrected Jul 2025

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

J July 2, 2025 Tag F0684 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Immediate jeopardy to resident health or safety

D June 4, 2025 Tag F0684 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 4, 2025 Tag F0658 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E June 4, 2025 Tag F0725 Complaint investigation Corrected Jun 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

D May 21, 2025 Tag F0609 Complaint investigation Corrected May 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0921 Corrected Apr 2025

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0761 Corrected Apr 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0730 Corrected Apr 2025

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0692 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0690 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0685 Corrected Apr 2025

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0684 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0641 Corrected Apr 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0584 Corrected Apr 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 14, 2025 Tag F0558 Corrected Apr 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0880 Corrected Apr 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0812 Corrected Apr 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0804 Corrected Apr 2025

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0725 Complaint investigation Corrected Apr 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0677 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0657 Complaint investigation Corrected Apr 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E April 14, 2025 Tag F0578 Corrected Apr 2025

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D April 1, 2025 Tag F0698 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D March 26, 2025 Tag F0697 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

E March 26, 2025 Tag F0684 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D March 12, 2025 Tag F0609 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D February 10, 2025 Tag F0602 Complaint investigation Corrected Feb 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

No actual harm, potential for more than minimal harm

E February 10, 2025 Tag F0656 Complaint investigation Corrected Feb 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D February 4, 2025 Tag F0686 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D February 4, 2025 Tag F0684 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D February 4, 2025 Tag F0610 Complaint investigation Corrected Feb 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.