The reviews for Devonshire Care Center are strongly polarized: many families report exceptional, compassionate care from specific nurses, CNAs, therapists, and administrators, while an almost equal number of reviews describe neglectful, unsafe, or unprofessional care. Across the dataset two clear themes emerge — a consistently praised physical therapy/rehab program and a highly variable nursing and personal care experience. Numerous reviewers credit the therapy team with successful recoveries and improved outcomes; multiple accounts describe seamless transitions home following coordinated discharge planning. Admissions and front-desk staff are frequently described as welcoming and helpful, and several administrators and case managers receive explicit praise for responsiveness, clear communication, and hands-on problem solving. Some areas of the building have been renovated and families report clean, well-maintained rooms and a warm atmosphere under newer management.
However, the negative reports raise substantial safety and quality concerns. The most recurrent clinical issues are medication delays and missed doses (including insulin and pain medications), delayed wound care with exposed drainage or bloody bandages left unattended, unattended IVs, rare or absent physician visits, and patients left without needed equipment (walkers, bed rails) or basic repositioning leading to pressure injuries. Hygiene and personal care problems are frequent in multiple reviews: soiled diapers left for hours, infrequent bathing, feces on potty equipment, and family members stepping in to perform laundry and personal care. These reports are often tied to chronic understaffing, especially nights and weekends, with CNAs described as overwhelmed and unable to respond promptly to call lights. Families report slow or no response to call buttons, which compounds risks for bedbound, incontinent, or high-fall-risk patients.
Facility- and environment-related complaints are also common and serious. Several reviewers note overcrowded rooms (three-bed rooms and shared bathrooms used by multiple residents of different genders), lack of privacy, noise (loud televisions, noisy fans), and heating or air conditioning issues. Cleanliness is inconsistent across reports: while some families describe a fresh-smelling, well-kept facility, others report strong odors, trash in bathrooms, and soiled bedding. Safety concerns include suspected theft of personal items or money, reports of an unscreened person sleeping in the lobby, lack of cameras, and inconsistent infection control practices. These issues, together with accounts of unprofessional or allegedly intoxicated staff and at least one report of verbal or physical abuse from a caregiver, point to significant variability in staff training, supervision, and oversight.
Dining and nutrition are another area of mixed feedback but with repeated negative notes: many reviewers describe poor-quality meals, lack of dietitian presence or oversight, and specific dietary mismanagement for diabetic residents (e.g., inappropriate carbohydrates or sugary items served). Some families link this to clinical deterioration or weight loss. Activities and social programming receive fewer strong endorsements; some reviewers praise the activities director while others note limited engagement opportunities.
Management and organizational themes are split. Several reviewers praise particular administrators (named individuals) for being compassionate, responsive, and personally involved in resolving problems, and some families note tangible improvements after management changes and remodeling. Conversely, other reviewers describe a “profit-first” impression, reports of a “fake busy” administration, slow responses to serious medical issues, and calls for regulatory intervention. This split suggests recent turnover and that quality may be improving in places but remains inconsistent across shifts and departments.
Patterns and overall judgment: the most frequent and consequential pattern is inconsistency — many families experienced excellent, attentive care and praise specific employees and departments, while an equally large group experienced neglect, medication errors, wound-care failures, and hygiene lapses. Because the negative reports involve safety, medication administration, wound care, and potential abuse, they are particularly important for prospective residents with high medical needs, complex wounds, insulin dependence, or mobility/continence issues. Conversely, for patients primarily needing short-term rehab and strong physical therapy, many accounts indicate positive outcomes.
If considering Devonshire Care Center, families should (1) verify current staffing levels on the unit and at night/weekends, (2) ask for specific information about wound care and on-call physician coverage and weekend services, (3) inquire how medications and insulin are administered and audited, (4) request details on room configurations and privacy (single vs. multi-bed rooms and bathroom arrangements), (5) tour recently renovated areas and inspect cleanliness and odor, (6) ask management about recent incidents, theft prevention, cameras, and infection-control policies, and (7) confirm whether named strong staff or therapy personnel will be involved in the incoming resident’s care. The reviews indicate there are pockets of excellent care and effective leadership, but also persistent, serious lapses that should be addressed or monitored closely before choosing this facility for long-term or high-acuity care.
