Deerfield Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews the facility failed to develop comprehensive person centered care plans for each resident that met each residents' nursing needs for activities of daily living (ADLs) for 5 (#1, #2, #3, #4, #5) of 6 sampled residents.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible by not locking the door to the kitchen giving residents direct and full access to the kitchen and the ability to elope from the facility through an exterior door at the back of the kitchen for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) for Resident #1 on 08/29/2025 at 11:35 p.m. when Resident #1 exited out of the facility. Resident #1 was able to access the kitchen through an unlocked kitchen door, walk through the kitchen and leave through an exterior door at the back of the kitchen. Resident #1 was located by the police two blocks away from the facility on a two-lane road. Resident #1 was returned to the facility on [DATE] at 12:20 a.m. without injury. [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. The facility failed to implement Resident #7's fall care plan intervention.

Inspectors wroteBased on record review and interviews the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide care for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. A nurse failed to send Resident #7 to the hospital after an unwitnessed fall. Review of the facility's policy and procedure related to Accidents and Incidents - Investigating and Reporting policy with a revised date of 06/9/2025 revealed in-part: Policy Interpretation and Implementation1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on the Report of Incident/Accident form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);c. [...]

Inspectors wroteBased on observations, record reviews and interviews the facility failed to develop a plan of care for 1 (#28) of 1 (#28) residents for discharge planning and failed to implement the plan of care for 1 (#46) of 1 (#46) residents by failing to place a fall mat on the floor at the bedside.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to administer insulin as ordered for 1 (#32) of 5 (#3, #4, #8, #32, and #36) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: 1) freezer temperatures were maintained at a level to keep frozen food solid; 2) frozen foods and noodles were properly sealed and not left open to air; 3) storage containers for flour, corn meal, and sugar were free from spills and splatters; 4) frozen chopped meat was thawed appropriately, and 5) hygienic practices were followed during food service. S4Dietary Manager (DM) reported that 53 residents were served meals from the kitchen.

Inspectors wroteBased on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of 4th quarter of 2024 and 1st quarter of 2025 QAA meetings.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1) implement policies and procedures for Enhanced Barrier Precautions (EBPs) by not wearing the appropriate personal protective equipment during care for 4 (#7, #8, #11, and #46) of 4 residents, 2) have signage or an indicator outside of rooms to determine residents that should be on EBPs for 6 (#2, #7, #8, #11, #46, and #50) of 6 residents that required EBPs, and 3) ensure infection control practices were maintained during catheter care for 1 (#16) of 1 residents observed for catheter care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the resident's environment remained free from accident hazards by not conducting a bed rail/mattress safety assessment prior to implementing the use of side rails for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for the use of side rails.

Inspectors wroteBased on observations, record reviews and interview, the facility failed to 1.) review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and 2.) assess the resident for risk of entrapment from bed rails prior to installation for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for bed rails.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the licensed nurses have the competencies and skill sets necessary to care for residents' needs for 1 (#53) of 1 closed record review. S12Licensed Practical Nurse (LPN) failed to obtain vital signs after she was unable to obtain a pulse oximetry reading.

Inspectors wroteBased on record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical and verbal abuse by staff.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#12 and #38) of 4 (#12, #26, #38, and #59) sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#23) of 1 resident reviewed for edema, 2 (#6 & #26) of 3 (#6, #26, #50) residents reviewed for Oxygen, and 1 (#6) of 1 resident observed during a Percutaneous Endoscopic Gastrostomy (PEG) tube medication administation. The facility failed to: 1. Apply compression stockings as ordered by the physician for resident #23, 2. Administer Oxygen as ordered by the physician for resident #6 and resident #26, and 3. Administer a 30 cubic centimeters (cc) water flush prior to the administration of resident #6's medications as ordered by the physician.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses documented the site of subcutaneous diabetic injections for 3 (#26, #31, and #40) of 5 (# 23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 2 (#26, #31) of 5 (#23,#26,#31,#40,#48) sampled residents reviewed for unnecessary medications and insulin administration.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the menus were followed for 4 (#25, #36, #55 and #113) of 4 residents who were prescribed pureed diets and 11 (#16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363) of 11 residents who were prescribed mechanical soft diets. The facility failed to ensure the menus were followed for 8 (#14, #17, #23, #28, #39, #53, #54, and #58) of 8 residents by not providing 4 ounces of chicken during the 04/08/2024 lunch meal.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#39) of 3 (#12, #16, #39) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device while in the wheelchair for resident #39.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from unnecessary medication use for 1 (#26) of 5 (#23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Alprazolam) was not ordered to be given as needed for a time period greater than 14 days for resident #26.

Inspectors wroteBased on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment for the interior of the building. The failed practice was evidenced by a blanket over the dryer vent duct, a hole in the wall behind the dryer, and heavy lint buildup behind dryers.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure lab work was obtained as ordered by the physician for 1 (#27) of 5 (#5, 19, 27, 37, 50) residents whose drug regimens were reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide assistance for residents who were unable to carry out activities of daily living and received the necessary services to maintain good grooming and personal hygiene for 2 (#1, #50) of 2 (#1, #50 ) residents investigated for ADL (activities of daily living) care. 1) The facility failed to ensure nail care was provided for resident #1 and #50; and, 2) The facility failed to ensure resident #1 was appropriately dressed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible. The facility failed to attempt appropriate interventions after a resident sustained falls for 1 (#15) of 6 (#7, 15, 25, 27, 29 and 41) residents reviewed for accidents.

Inspectors wroteBased on observation, review of the menus, and interviews the facility failed to ensure the menus were followed for 3 (#24, #34 and #35) of 3 (#24, #34 and #35) residents that had an order for a pureed diet. The facility failed to serve the correct dessert listed on the menu for the residents that had an order for a pureed diet.