Cycle 1
Health 2024-03-07 · Fire 2024-03-07
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Sterling, CO
Devonshire Care Center
2-star overall rating with 2-star inspections with $2,350 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1330 Sidney Ave, Sterling, CO
(970) 522-4888
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-03-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,862
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 36.71% · Performance 63.44% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.09
Baseline 4.69 hours · Performance 4.53 hours · Measure score 5.09 · Achievement 5.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.79% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 0% · Lower 95% interval 5.62% |
| Discharge to community | 55.96% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 58.18% · Lower 95% interval 44.39% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 75 · Denominator 76 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 64.81% |
53.69%
11.1 pts better
|
Numerator 35 · Denominator 54 |
| Discharge mobility score | 74.07% |
50.94%
23.1 pts better
|
Numerator 40 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.67% |
2.29%
0.4 pts worse
|
Numerator 2 · Denominator 75 · Adjusted rate 2.44% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 94.89% |
42%
52.9 pts better
|
Numerator 130 · Denominator 137 |
| Discharge function score | 74.07% |
56.45%
17.6 pts better
|
Numerator 40 · Denominator 54 |
| Transfer of health information to provider | 65.52% |
95.95%
30.4 pts worse
|
Numerator 19 · Denominator 29 |
| Transfer of health information to patient | 87.5% |
96.28%
8.8 pts worse
|
Numerator 21 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 11.9% |
25.2%
13.3 pts worse
|
Numerator 5 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
93.5%
11.6 pts worse
|
93.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.5% · Q2 83.6% · Q3 97.9% · Q4 98.1% · 4Q avg 81.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.7%
3.7 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.4%
0.3 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.8% · Q3 4.2% · Q4 5.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
7.4%
3.9 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 2.0% · Q3 4.3% · Q4 1.9% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 18.9% |
5.0%
13.9 pts worse
|
5.4%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 13.2% · Q3 18.2% · Q4 25.0% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
11.2%
4.6 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 5.7% · Q3 2.1% · Q4 9.3% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
20.6%
10.2 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.5% · Q3 8.8% · Q4 11.9% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.9% |
15.2%
0.3 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 22.3% · Q4 14.1% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
14.6%
3.8 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 14.3% · Q3 7.0% · Q4 12.0% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
22.4%
5.1 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 26.9% · Q3 29.7% · Q4 22.1% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
3.7%
3.1 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
76.4%
3.1 pts better
|
81.7%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.9% · Q2 72.7% · Q3 89.6% · Q4 82.2% · 4Q avg 79.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
12.8%
5.5 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 16.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.7% · Q3 4.2% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.9% |
75.6%
6.7 pts worse
|
79.7%
10.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
20.3%
2.9 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 23.6% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-18 · Fire 2019-11-18
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-10-18 · Fire 2018-10-18
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-03-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-05
D · Potential for more than minimal harm
2019-11-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-11-18
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2019-12-23
D · Potential for more than minimal harm
2018-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-08
D · Potential for more than minimal harm
2018-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-12-03
D · Potential for more than minimal harm
2018-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-12-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-05-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-20
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-04-28
E · Potential for more than minimal harm
2024-09-17
F849 · Administration Deficiencies
Health
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.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-17
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-05-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-12
G · Actual harm
2024-03-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-03-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-03-07
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-03-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-08
C · Minimal harm
2024-03-07
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-03-08
H · Actual harm
2019-11-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-11-25
E · Potential for more than minimal harm
2019-11-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-11-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-11-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-11-18
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-12-02
E · Potential for more than minimal harm
2018-10-18
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-11-13
E · Potential for more than minimal harm
2018-10-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-11-13
D · Potential for more than minimal harm
2018-10-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-11-13
Penalties and ownership
What sits behind the stars
$2,350
2024-03-07
Fine
Fine · fine $2,350
Fine
Ownership
Nearby options
Other facilities in reach
#1
Sterling Rehabilitation And Nursing, LLC
Sterling, CO
1-star overall rating with 2-star inspections with $117,325 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Eben Ezer Lutheran Care Center
Brush, CO
2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
South Platte Rehabilitation And Nursing LLC
Brush, CO
1-star overall rating with 2-star inspections with $49,843 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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