Deer's Head Center

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives. This was found to be evident for 3 (Resident #5, #8 and #7) out of 6 residents reviewed for advance directives during the annual survey.

Inspectors wroteBased on facility investigation, medical record review and interviews, it was determined that the facility failed to prevent an incident of resident-to-resident sexual abuse. This was evident for 1 (Resident #20) of 1 resident reviewed for abuse. The findings Include:Brief Interview for Mental Status (BIMS) is a quick, standardized screening tool used primarily in healthcare, especially long-term care facilities, to assess cognitive function. Scores range from 0-15, with higher scores (13-15) indicating intact cognition, while lower scores suggest moderate (8-12) or severe (0-7) impairment. The facility's investigation related to Facility Reported Incident # 340863 was reviewed by the surveyor on 12/09/25 at 6:45 PM. [...]

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to provide adequate side effects monitoring for residents on psychotropic medications. This was evident for 2 (Resident #7 and #20) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to 1) maintain appropriate infection control practices for a resident with an indwelling urinary catheter and 2) store clean laundry in a manner that minimized the potential for the spread of infection. This was evident for 1 (Resident #6) out of 1 resident reviewed for urinary catheters and 1 random observation of the laundry room during the annual survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to keep a sanitary environment in the laundry. This was evident during 1 random observation of the laundry room during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to post all required staffing information on a daily basis. This was evident in 2 of 2 units observed during the recertification survey.

Inspectors wroteBased on a review of medical records and interview with facility staff and interview with resident's family, it was determined that the facility failed to provide written notice with the reason for transfer to a resident or resident representative. This was evident for one resident (Resident #13) out of one resident reviewed for hospitalization.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to implement a process to ensure that residents and resident representatives were made aware of the facilities bed hold policy upon transfer to the hospital. This was evident for one resident (Resident #13) out of one resident reviewed for hospitalization.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff administered a psychotropic medication that was contraindicated for Dementia, failed to monitor a resident for extrapyramidal side effects, and failed to complete a gradual dose reduction in the past year. This deficient practice was evidenced in 1 (#21) of 1 resident record reviewed for unnecessary psychotropic medications during the survey.

Inspectors wroteBased on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure the medication error rate was less than 5 percent. This was evident for 2 (#28, #42) of 4 residents observed with 32 medication administration opportunities which resulted in an error rate of 31.25% by 2 (#55, #58) of 4 staff observed.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to don appropriate personal protective equipment (PPE) when transferring a resident. This was evident for 1 (#4) of 21 residents reviewed during the survey.

Inspectors wroteBased on review of records, observation, and interview, it was determined that the facility failed to keep residents safe from physical and verbal abuse. This was evident for 4 (Residents #27, #2, #11, and #28) of 10 residents reviewed for abuse, one of which was determined to have sustained actual harm (Resident #27).

Inspectors wroteBased on review of records and interview with facility staff, it was determined that the facility failed to report instances of abuse to the state agency (SA) within 2 hours of it being identified or reported and the final report within 5 working days. This was evident for 3 of 11 facility reported incidents reviewed during the survey.

Inspectors wroteBased on review of resident records and interview with facility staff, it was determined that the facility failed to keep residents protected from an alleged perpetrator during an abuse investigation. This was evident 1 of 11 facility reported incidents during the survey.

Inspectors wroteBased on observation, staff interview and medical record review, it was determined the facility failed to provide a dignified dining experience for two residents that needed assistance with eating lunch. This was evident for 2 residents (Residents #18, #26) observed during the lunch meal on the initial tour of the facility.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to promote Resident (#8's) self-determination. This was evident for 1 of 27 residents selected for review of self-determination during the survey process.

Inspectors wroteBased on surveyor observation, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect residents.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to ensure a pressure sensory alarm was functioning for a resident with a history of falls. This was evident for 1 (Resident's #26) of 2 residents reviewed for accidents during an annual recertification survey.