Devonshire Care Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 131 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- Above-median deficiencies (32 vs median 13.0)
- High staff turnover (58%)
- High RN turnover (78%)
Bottom 25% in CA · Below recommended RN staffing · Worst in GENESIS HEALTHCARE chain · $10,364 in fines
What this means for your family
This facility appears to be in a period of significant management transition, with many recent families praising the new administrators for their visibility and compassion. However, you must closely monitor clinical care, as multiple recent reports highlight dangerous lapses in medication timing and hygiene responsiveness. We recommend visiting during shift changes to personally observe how quickly staff respond to call lights.
Google Reviews
Google Reviews
131 reviews on Google“Devonshire Care Center presents a starkly divided experience, with recent reviews highlighting a significant turnaround under new management and a very kind, attentive nursing staff. However, serious allegations of neglect, including delayed medication, improper hygiene care, and inadequate response to call lights, persist in several reviews. Families should weigh the praise for the new administration against documented concerns regarding consistent clinical oversight.”
Quality Themes
Tap a score for detailsStrengths
- Kind and compassionate nursing staff
- New management and administration
- Effective physical therapy services
- Clean and recently renovated facilities
Concerns
- Delayed response to call lights and hygiene needs (mentioned by 5 reviewers)
- Inconsistent medication administration (mentioned by 3 reviewers)
- Poor communication from case managers/staff (mentioned by 2 reviewers)
- Inadequate nutritional support/food quality (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 136 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1I noticed some recent praise for the new management team; what specific changes are being implemented to improve communication between staff and families?
- 2With the recent renovations, could you show us the dining area and tell us a bit about how mealtime and nutritional support are managed?
- 3How does the nursing team ensure that call lights are answered promptly, especially during the night shifts?
- 4Can you walk us through your process for medication administration to ensure everything is handled accurately and consistently?
- 5What kind of daily activities or social programs are available to keep residents engaged and active?
- 6In the event of a medical emergency after hours, what is the protocol for contacting the physician and notifying the family?
Personalized based on this facility's data
Key Review Excerpts
“The new administrator Karsten is great and goes out of his way to help the residents and checks on us daily he also puts a smile on my face when I am down . So thank you.”
“The nurses, administrators, CNA’s, PT, OT and entire staff went above and beyond to ensure that every day was a positive and uplifting exp”
“They left her in a diaper for hours and wouldn’t change her. Had to ask multiple times for them to clean her or bathe her. Very rude and did not handle her gently.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
5
measures
6
measures
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents vaccinated for the flu
Residents needing more daily help over time
Residents whose walking got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Devonshire Care Center shows concerning patterns with 39 complaint-triggered deficiencies indicating multiple families have filed reports about care issues. The facility has recurring problems with treatment and care quality, nursing staffing adequacy, infection control, and abuse/neglect reporting that persist across surveys from 2021 to 2025. While all deficiencies show correction dates, the repeated nature of core care problems suggests ongoing quality challenges that warrant careful consideration during visits.
Apr 20, 2026Complaint2
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Apr 1, 2026Complaint1
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Jan 9, 2026Complaint1
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Aug 22, 2025Complaint1
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Jul 29, 2025Complaint1
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Jul 2, 2025Complaint4
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Federal Penalties
Fine
Jul 2, 2025
$10,364
Ownership & Operations
Who Operates This Facility
Devonshire Care Center
for profit
Chain Affiliation
Genesis Healthcare
187 facilities nationwide
Chain avg rating: 2.4/5 · Rank 132 of 188 (Worst)
Ownership & Management
Owners
Bq Operations Holdings LLC
Owner · Organization
9560 Pico LLC
Owner (parent company) · Organization
Bold Quail Holdings LLC
Owner (parent company) · Organization
Gen Bq Jv Holdings LLC
Owner (parent company) · Organization
Gen Operations I LLC
Owner (parent company) · Organization
Gen Operations II LLC
Owner (parent company) · Organization
Genesis Healthcare INC
Owner (parent company) · Organization
Genesis Healthcare LLC
Owner (parent company) · Organization
Genesis Holdings LLC
Owner (parent company) · Organization
Ghc Jv Holdings LLC
Owner (parent company) · Organization
Newgen LLC
Owner (parent company) · Organization
Pico Ar LLC
Owner (parent company) · Organization
Sun Healthcare Group INC
Owner (parent company) · Organization
Robin, Aaron
Owner (parent company)
Tress, Avrohom
Owner (parent company)
Whitman, Arnold
Owner (parent company)
Sundance Rehabilitation Holdco INC
Owner (parent company) · Organization
Welltower Op, LLC
Owner (parent company) · Organization
Zac Properties Xi LLC
Owner (parent company) · Organization
Fishman, Steven
Owner (parent company)
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
131 reviews from families & visitors
Official Website
Visit devonshirecc.com
Medicare data downloads
Original nursing home datasets
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