Deer's Head Center

In the surveyor’s words

From the most serious findings on record at Deer's Head Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 12, 2024

  Based 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). The Findings include: 1) On 7/10/24 at 10:14 AM, the surveyor reviewed the facility's investigation of an incident that took place between Geriatric Nursing Assistant (GNA) #36 and Resident #27. The review revealed that, on 5/30/23 at about 10:00 AM, GNA #36 was working with Resident #27 and was transporting him/her to the shower. During transport, the resident defecated onto the floor. […]

• No harm, potential for more than minimal, isolatedF578Dec 16, 2025

  Based 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.The findings include: 1. An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. During a review of medical records for Resident #5 on [DATE] at 4:05 PM it was revealed that there was no advance directive in the medical records for Resident #5. […]

• No harm, potential for more than minimal, isolatedF600Dec 16, 2025

  Based 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. […]

• No harm, potential for more than minimal, isolatedF757Dec 16, 2025

  Based 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.The findings include:Psychotropic medications are drugs that affect the brain and central nervous system, altering mood, thoughts, perceptions, and behaviors. They are primarily used to treat mental health conditions, such as anxiety, depression, schizophrenia, and bipolar disorder.1) On 12/09/2025 at 6:00 PM a review of Resident #7's medical record revealed that he/she was admitted to the facility in March 2021 with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Borderline Personality Disorder and… […]

• No harm, potential for more than minimal, isolatedF812Dec 16, 2025

  Based 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. The findings include:During the initial tour of the Kitchen with the Dietary Manager on 12/08/25 at 9:11 AM there were foods found opened, unlabeled and foods kept past the best by dates. The following foods were identified: In the Walk-in Freezer the following items were found: 1. A clear bag of burger patties that had been opened and removed from the box was undated and unlabeled.2. A box of Oatmeal Raisin Frozen Cookie Dough had been opened with the bag left open to air and was not resealed. […]