Deerfield Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Deerfield Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 23, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF656Jul 22, 2026

  Based on interview and record review, the facility failed to ensure that a person-centered care plan was implemented for each resident by failing to implement the care plan for 1 (#61) of 1 resident reviewed who had a PEG tube. Findings:Review of the medical record revealed Resident #61 had an admit date of 05/07/2024 with diagnoses which included dementia, gastrostomy, schizophrenia and anxiety. Review of the July 2026 physician's orders revealed that Resident #61 had a PEG tube. The physician ordered that the dry dressing at the PEG tube site was to be changed daily and as needed. Review of Resident #61's care plan also indicated that the dry dressing at the PEG tube site was to be changed daily and as needed. […]

• No harm, potential for more than minimal, patternF677Jul 22, 2026

  Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. The facility failed to ensure: 1). a resident received feeding assistance during a meal for 1 (#7) resident reviewed for nutrition, and 2). a resident's fingernails were groomed in a timely manner for 1 (#10) resident reviewed for ADL care.Findings: Resident #10 Review of Resident #10's record revealed an admission date of 10/11/2023 with diagnoses of dementia with unspecified severity and severe intellectual disability. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 which indicated the resident was unable to complete the interview. […]

• No harm, potential for more than minimal, patternF880Jul 22, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure it maintained an infection control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to ensure: 1). biohazard trash in a resident's room was covered with a lid for 1 (#1) resident reviewed for enhanced barrier precautions, and 2). resident care equipment was stored and/or labeled properly for 2 (#27, #44) residents.Findings: Resident #27 On 07/20/2026 at 8:43 a.m., 07/21/2026 at 8:30 a.m., and 07/22/2026 at 8:30 a.m., observations of Resident #27's bathroom revealed his urinal was placed on a safety rail and the urinal was not labeled with his name or stored in a bag. […]

• No harm, potential for more than minimal, patternF921Jul 22, 2026

  Based on observations and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The deficient practice affected 1 (#51) resident and had the potential to affect all 63 residents that resided in the facility.Findings: Hall 2: On 07/20/2026 at 10:35 a.m. and 07/21/2026 at 8:56 a.m., observations of Hall 2 soiled utility room revealed the door was unlocked and there were towels soiled with a pink substance on the floor on both sides of the hopper sink. […]