Deerfield Health Care Center

In the surveyor’s words

From the most serious findings on record at Deerfield Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF757Dec 15, 2022

  Based on observation, clinical record review, hospital record review, facility record review, staff interview, the facility failed to respond appropriately to an INR level below the target range for treatment for one resident reviewed and failed to appropriately monitor another resident's PT/INR as directed by the physician as a means to assure individual therapeutic levels. (Resident #1 and Resident #4) The facility identified a census of 22 residents. Findings include: 1. A Significant Change Minimum Data Set (MDS) assessment form dated 10/10/22 for Resident #1 documented diagnoses that included: systolic and diastolic heart failure (HF), abnormal anti-coagulant profile, atrial fibrillation (AF), respiratory failure with hypoxia and a duodenal ulcer with perforation and hemorrhage. […]

• Actual harm, isolatedF689Mar 14, 2022

  Based on observations, record review, interviews and facility policy review the facility failed to complete a safety and skin assessments and failed to provide adequate supervision to prevent a burn for 1 of 3 residents reviewed for supervision (Resident #1). Resident #1 required assistance of one staff for eating. Staff left Resident #1 unsupervised with a hot cup of coffee and Resident #1 sustained second degree [CONDITION(S)] on her thighs. The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating in intact cognitive ability. […]

• No harm, potential for more than minimal, widespreadF880Oct 7, 2021

  Based on observations, facility record review, review of guidance from the Center for Disease Control (CDC), and staff interviews, staff failed to follow CDC guidelines for appropriate personal protective equipment in a medical facility by not wearing goggles while performing resident cares when county is considered high risk. The facility also failed to screen visitors for COVID-19 immediately upon entrance to the facility. The facility reported a census of 23 residents. Findings Include: 1. On 10/4/21 at 10:27 AM, the survey team entered the facility by the skilled nursing entrance. Upon entrance, staff took the team through the skilled nursing unit, to a room to place belongings and then to the front entrance to complete screening for COVID-19. […]

• No harm, potential for more than minimal, patternF678Oct 7, 2021

  Based on personnel file reviews, facility record review and staff interview, the facility failed to ensure staff trained in cardiopulmonary resuscitation (CPR) on duty at all times for six of 23 residents who requested CPR in a life threatening emergency (Residents #16, #73, #74, #76, #77, and #125). The facility reported a census of 23. Findings include: The documents entitled Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Schedules from [DATE] to [DATE] and staff CPR Certification records revealed the facility failed to have CPR certified staff on duty on the following dates and shifts: a. [DATE] - 10 PM to 6 AM shift; b. [DATE] - 10 PM to 6 AM shift; c. [DATE] - 6 AM to 2 PM shift; d. [DATE] - 10 PM to 6 AM shift; e. [DATE] - 10 PM to 6 AM shift; f. […]

• No harm, potential for more than minimal, isolatedF684Jul 2, 2026

  Based on clinical record review, hospital record review, internal incident investigation documentation, family and staff interviews, the facility failed to adapt safety interventions in response to cognitive changes for 1 of 3 residents reviewed for falls (Res #1). The facility reported a census of 23 residents. Findings include:The Minimum Data Set (MDS) of Res #1 dated 9/11/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment (possible score of 0-15).The MDS of Res #1 dated 12/10/25 identified a BIMS score of 11/15.The MDS of Res #1 dated 3/10/26 identified a BIMS score of 10/15, a continued trend of lower scoring, indicating worsening cognitive impairment.The Comprehensive Care Plan of Res #1 identified a Focus Area of Impaired… […]