Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Deerfield Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not develop care plans that clearly identified whether one or more staff were required to assist with ADLs for several residents with complex medical needs. Despite regular assessments and staff meetings, care plans lacked specific instructions, leaving CNAs without clear guidance on the level of assistance needed for each ADL.
The facility did not develop a care plan for a resident's request to discharge to the community, despite her being cognitively intact and having communicated her wishes to staff. Additionally, the facility failed to implement a physician-ordered fall mat intervention for another resident at high risk for falls, as repeated observations showed the fall mat was not in place.
A resident with diabetes and severe cognitive impairment had physician orders for insulin to be administered if blood sugar exceeded 300 mg/dL. On two occasions, blood sugar readings were above this threshold, but there was no documentation that insulin was given as ordered. The DON confirmed the insulin was not administered in accordance with the physician's instructions.
Surveyors observed that the facility did not maintain proper food storage and hygiene standards, including thawed and unsealed frozen foods, soiled storage containers, improper thawing of meat, and failure to change gloves or use tongs during meal service. The Dietary Manager confirmed these issues, and 53 residents were served meals from the affected kitchen.
The facility did not conduct or document required quarterly QAA meetings with the necessary committee members for two consecutive quarters, as confirmed by record review and staff interviews.
Staff failed to consistently implement Enhanced Barrier Precautions, including wearing gowns during high-contact care for residents with wounds or indwelling devices, and did not use required signage to indicate EBP status. PPE was not properly used during wound and catheter care, and infection control practices were not maintained, as confirmed by staff interviews and direct observation.
A resident was provided with side rails on a new bed without the facility completing the required bed rail and mattress safety assessment, bed rail use assessment form, or obtaining informed consent. Observations showed both upper and lower quarter rails were in the upright position, contrary to the physician's order, and the DON confirmed these assessments and consents were not completed prior to use.
A resident with multiple cognitive and physical impairments was provided with bed rails without the facility completing a risk assessment, reviewing risks and benefits with the resident or representative, or obtaining informed consent as required by policy. Observations confirmed the use of both upper and lower quarter rails, despite the physician's order specifying only the upper rail, and documentation for required assessments and consent was missing. The DON acknowledged these omissions during the survey.
An LPN failed to obtain vital signs for a resident with significant cardiac history after being unable to get a pulse oximetry reading due to cold and swollen fingers. The resident was given medications and became nauseated, but the LPN did not recall if vital signs were checked. Both the ADON and the resident's physician confirmed that vital signs should have been obtained in this scenario.
A resident, who was cognitively intact and independent with wheelchair use, was subjected to physical and verbal abuse by a CNA. The resident made inappropriate remarks, leading to a confrontation where the CNA pushed the resident, causing them to fall from their wheelchair, and then verbally abused them. Witnesses confirmed the incident, which violated the facility's abuse policy.
The facility failed to ensure that two residents who were unable to perform activities of daily living received necessary nail care. Both residents, with various medical conditions, were observed to have long, jagged, and dirty fingernails despite requesting assistance. The facility did not adhere to its own nail care guidelines, leading to poor grooming and personal hygiene for the residents.
The facility failed to follow physician orders for multiple residents, including not applying compression stockings, not administering oxygen at the correct rate, and not flushing a G-tube before medication administration. These deficiencies were confirmed through observations and staff interviews.
The facility failed to document the sites of subcutaneous diabetic injections for three residents, despite administering the medications as ordered. This deficiency was confirmed through interviews with the DON and ADON, highlighting a lapse in ensuring nursing staff competencies.
The pharmacist failed to identify and report irregularities in the medication administration records for two residents. Both residents had insulin orders, but the medical records for March and April 2024 lacked documentation of the injection sites. The DON and ADON confirmed the absence of this documentation and acknowledged that the pharmacist did not notify the facility of these irregularities.
The facility failed to follow prescribed diets and portion sizes for residents on pureed and mechanical soft diets. Residents did not receive the correct type of cornbread or the required 4 ounces of chicken, as specified in the menu approved by the Registered Dietician. The Dietary Manager and Administrator confirmed these deficiencies.
The facility failed to provide a pressure relieving device for a high-risk resident with multiple diagnoses, including dementia and muscle wasting, despite the care plan indicating the need for such a device. Observations over several days and staff interviews confirmed the deficiency.
A resident with multiple diagnoses was administered Alprazolam PRN for anxiety beyond the recommended 14-day period. Despite a pharmacist's recommendation to limit the use, the physician denied the dose reduction, and the medication was administered on multiple occasions past the limit, as confirmed by the DON.
Failure to Specify Staff Assistance Levels in ADL Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that clearly identified the required level of staff assistance for activities of daily living (ADLs) for five out of six sampled residents. Medical record and MDS assessment reviews showed that these residents had significant dependencies, including needs for assistance with toileting, personal hygiene, and transfers from bed to chair. However, their care plans did not specify whether one or more staff members were required to assist with each ADL. Interviews with the DON and CNAs confirmed that the care plans lacked this critical information, making it unclear for staff to determine the appropriate level of assistance needed for each resident. The residents involved had complex medical histories, including diagnoses such as dementia, psychosis, hypertensive heart disease, diabetes, pressure ulcers, Alzheimer's, osteoporosis, hypoglycemia, and schizoaffective disorder. Despite regular MDS assessments and weekly meetings to review residents' assistance needs, the facility did not incorporate this information into the care plans. Staff interviews further confirmed that there was no additional assessment tool in use to determine the specific number of staff required for each ADL, and the care plans remained incomplete in this regard.
Failure to Develop and Implement Care Plans for Discharge Planning and Fall Prevention
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to discharge planning and fall prevention. For one resident with a history of cerebral infarction, hemiplegia, and other significant medical conditions, there was no care plan focus area addressing her request to be discharged to the community, despite her being cognitively intact and having discussed her desire for independent living with staff over six months prior. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's discharge wishes, and no documentation or care plan was initiated to address her request. For another resident with multiple diagnoses, including a high risk for falls as indicated by a fall risk assessment, the facility failed to implement a physician-ordered intervention for a fall mat to be placed at the bedside. Despite the care plan and physician orders specifying the need for a fall mat, repeated observations over several days confirmed that no fall mat was present. Staff interviews corroborated that the intervention was not in place as required.
Failure to Administer Insulin as Ordered for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not administering insulin as ordered. According to the facility's policy, medications are to be administered safely, timely, and as prescribed, including following the prescriber's orders regarding timing. Review of the medical record for a resident with multiple diagnoses, including diabetes mellitus and severe cognitive impairment, showed a physician's order for Regular Insulin to be administered subcutaneously if blood sugar exceeded 300 mg/dL. Documentation revealed that on two occasions, the resident's blood sugar readings were significantly above the threshold (425 mg/dL and 381 mg/dL), but there was no evidence that insulin was administered as ordered. The DON confirmed in an interview that the insulin was not given when the resident's blood sugar was greater than 300 mg/dL, as required by the physician's order.
Failure to Maintain Food Safety and Hygiene Standards in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by multiple observations in the kitchen. Surveyors found that the freezer contained several items that were thawed instead of being kept solid, including onion rings, waffles, egg patties, cookies, and omelets, with some items left open to air. In the dry storage area, an opened bag of noodles was stored in an unsealed plastic zip bag. Storage containers for flour, corn meal, and sugar were visibly soiled with food particles and a sticky substance. Additionally, frozen chopped ham was observed thawing at room temperature in a sink, which is not an appropriate thawing method. During meal service, the Dietary Manager was observed handling serving trays and plates with gloved hands and then placing bread on residents' plates without changing gloves or using tongs, resulting in potential cross-contamination. The Dietary Manager acknowledged these lapses in hygienic practices during interviews. The facility reported that 53 residents were served meals from the kitchen during the period of observation.
Failure to Hold and Document Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required committee members present, as evidenced by the absence of documentation for the 4th quarter of 2024 and the 1st quarter of 2025. Record review showed that QAA meetings were conducted in the second and third quarters of 2024, but there was no evidence of meetings for the subsequent two quarters. During interviews, the Administrator and Director of Nursing confirmed that they could not provide documentation of QAA meetings with the required participants for the specified periods. No information regarding residents or their medical conditions was included in the report, and the deficiency centers solely on the facility's failure to document and conduct required QAA meetings with appropriate membership.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBPs) as required. Staff did not wear appropriate personal protective equipment (PPE), such as gowns, during high-contact care activities for multiple residents with wounds or indwelling medical devices. For example, during wound care for several residents, both the LPN and DON only wore gloves and did not don gowns, despite facility policy and physician orders indicating the need for EBPs. Staff interviews confirmed the lack of gown use and acknowledged the oversight. Additionally, the facility did not consistently use signage or indicators outside resident rooms to identify those requiring EBPs. The facility's policy called for an orange sticker by the resident's name outside the door to indicate EBP status, but observations revealed that several residents who required EBPs due to wounds, indwelling catheters, dialysis access, or feeding tubes did not have any such indicator. Staff interviews further confirmed that the required signage was missing for these residents, and some staff were unaware of which residents were on EBPs. The facility also failed to maintain proper infection control practices during catheter care. In one instance, a CNA performed catheter care by wiping towards the insertion site and did not change gloves after the task, subsequently touching the resident's gown, bed linens, and rails with contaminated gloves. This improper technique was confirmed by facility leadership during interviews. These failures were observed across multiple residents with significant medical histories, including vascular ulcers, pressure injuries, indwelling catheters, dialysis access, and feeding tubes.
Failure to Complete Bed Rail Safety Assessment Prior to Side Rail Use
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not conducting a required bed rail and mattress safety assessment prior to implementing the use of side rails. Multiple observations over several days showed that a resident's bed had both the top and bottom quarter rails in the upright position on one side, with the other side of the bed against the wall. The facility's policy requires an interdisciplinary evaluation of the sleeping environment, compatibility checks between bed components, and completion of a bed rail use assessment and informed consent prior to the use of side rails. However, documentation revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent were not completed before the side rails were used for this resident. Interviews with the DON confirmed that the required assessments and consent forms were not completed prior to the use of both the upper and lower quarter side rails. Additionally, the DON acknowledged that the physician's order was only for the upper quarter rail to assist the resident with positioning, and that the lower quarter rail should not have been in the upright position. The facility had recently acquired new beds with non-removable side rails, but staff failed to ensure compliance with their own policy and procedures regarding bed safety and side rail use.
Failure to Assess, Inform, and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for a resident. Specifically, staff did not review the risks and benefits of bed rail use with the resident or their representative, nor did they obtain informed consent prior to installation. Additionally, the required assessment for risk of entrapment from bed rails was not completed before the bed rails were put in use. These omissions were identified for one resident out of four reviewed for bed rail use. Observations over several days showed that the resident's bed consistently had both the top and bottom quarter rails in the upright position on the right side, with the left side of the bed against the wall. The resident was observed both in bed and in a wheelchair during these times. The resident had multiple diagnoses, including unspecified psychosis, lack of coordination, gait abnormalities, seizures, dementia, pseudobulbar affect, and intellectual disabilities. The physician's order specified the use of bilateral upper side rails for bed mobility assistance, safety, and security, but did not include the lower rail. Record review revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent documentation were not completed prior to the use of the side rails. The DON confirmed that the lower quarter side rail should not have been in the up position and that the required assessments and consent had not been completed before the side rails were utilized. The facility's policy requires these steps to be taken before bed rails are used, but they were not followed in this case.
Failure to Obtain Vital Signs After Unsuccessful Pulse Oximetry
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to obtain vital signs for a resident after being unable to obtain a pulse oximetry reading due to the resident's cold and swollen fingers. The resident, who had a medical history including acute on chronic congestive heart failure, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, fluid overload, coronary angioplasty implant/graft, and a cardiac defibrillator, was administered medications and subsequently became nauseated. The LPN did not recall if vital signs were taken following the inability to obtain a pulse oximetry reading. The Assistant Director of Nursing and the resident's physician both confirmed that vital signs should have been checked in this situation.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by staff. The incident involved a resident who was cognitively intact and independent with wheelchair use, as indicated by their Minimum Data Set assessment. On the day of the incident, the resident was found on the floor by their wheelchair on the smoking patio, with no reported injuries. Interviews revealed that the resident had been making disrespectful and sexually inappropriate remarks to staff, which led to a confrontation with a CNA. The CNA reportedly pushed the resident, causing the wheelchair to tip over and the resident to fall to the ground. The CNA then verbally abused the resident before walking away. Witnesses confirmed the resident's inappropriate behavior and the CNA's response, which included physical and verbal abuse. The facility's abuse and neglect policy defines abuse as the willful infliction of injury or intimidation, which aligns with the actions taken by the CNA. The incident was confirmed by the Administrator in Training and the Director of Nursing, highlighting a failure in the facility's duty to protect residents from abuse, as outlined in their policy.
Failure to Provide Necessary Nail Care for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents, one with diagnoses including myelopathy, COPD, and type 2 diabetes mellitus, and another with diagnoses including dementia, major depressive disorder, and type 2 diabetes mellitus, were observed to have long, jagged, and dirty fingernails. Both residents required assistance with ADLs and were unable to trim their own nails due to their medical conditions and physical limitations. Despite the facility's policy and procedure related to nail care, which mandates daily cleaning and regular trimming of nails, and specifies that diabetic nail care should be performed by a Registered Nurse, the residents' fingernails were not properly maintained. Interviews with the residents and the Director of Nursing confirmed that the residents had requested assistance with nail care but did not receive it. The observations and interviews revealed that the facility did not adhere to its own guidelines, resulting in the residents' poor grooming and personal hygiene.
Failure to Follow Physician Orders for Multiple Residents
Penalty
Summary
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 resident #23, who had diagnoses including hypertension, dementia, and edema, the facility did not apply compression stockings as ordered by the physician. Observations on multiple occasions revealed the resident's feet and ankles were edematous, and interviews with staff confirmed they were unaware of the order for compression stockings, indicating a lapse in communication and adherence to the care plan. For resident #6, who had diagnoses including paranoid schizophrenia, COPD, and diabetes mellitus, the facility did not administer oxygen as ordered by the physician. Observations showed the resident receiving oxygen at 3.5 L/min instead of the prescribed 2 L/min. Additionally, during a medication administration via G-tube, the LPN did not flush the tube with 30 cc of tap water before administering medications, as required by the physician's orders. Interviews with the DON confirmed these discrepancies. Resident #26, with diagnoses including cellulitis, type 2 diabetes mellitus, and COPD, also did not receive oxygen therapy as ordered. Observations revealed the resident receiving oxygen at varying rates (3.5 L/min and 3 L/min) instead of the prescribed 2 L/min continuously. Interviews with the ADON and DON confirmed that staff were not following the physician's orders for oxygen administration, highlighting a consistent issue with adherence to prescribed treatments across multiple residents.
Failure to Document Injection Sites for Diabetic Medications
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not document the sites of subcutaneous diabetic injections for three residents. Resident #31, who had multiple diagnoses including type 1 diabetes, received insulin injections as ordered, but the injection sites were not documented in the March and April Medication Administration Records (MARs). This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #26, with diagnoses including type 2 diabetes mellitus and unspecified dementia, received Novolog insulin injections without documentation of the injection sites in the March and April MARs. This was confirmed by both the Assistant Director of Nursing (ADON) and the DON. Additionally, Resident #40, who had diagnoses including type 2 diabetes and hypertension, received a Mounjaro injection without documentation of the injection site in the April MAR. This was also confirmed by the ADON. These lapses in documentation indicate a failure to ensure that nursing staff had the necessary competencies to provide safe and effective care for residents requiring subcutaneous injections.
Pharmacist Failed to Report Medication Administration Irregularities
Penalty
Summary
The pharmacist failed to identify and report irregularities in the medication administration records for two residents. Resident #31, who has multiple diagnoses including type 1 diabetes, was prescribed various insulin medications. However, the medical records for March and April 2024 showed no documentation of the injection sites for the insulin doses administered. The Director of Nursing (DON) confirmed that injection sites should be documented and acknowledged the lack of such documentation. Additionally, the pharmacist did not notify the facility of these irregularities. Similarly, Resident #26, who has diagnoses including type 2 diabetes and other chronic conditions, had an order for Novolog insulin with specific instructions for administration. The medication administration records for March and April 2024 also lacked documentation of the injection sites for the insulin doses. Both the Assistant Director of Nursing (ADON) and the DON confirmed the absence of this documentation and acknowledged that the pharmacist did not report these irregularities to the facility's medical team.
Failure to Follow Prescribed Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that the menus were followed for residents prescribed pureed and mechanical soft diets. Specifically, residents who were ordered pureed diets did not receive pureed cornbread, and those on mechanical soft diets did not receive moist cornbread as specified in the menu approved by the Registered Dietician. Additionally, residents who were supposed to receive 4 ounces of chicken were instead given one chicken leg, which did not meet the required portion size. These deficiencies were observed during the lunch meal on 04/08/2024. Interviews with the Dietary Manager confirmed that the prescribed diets were not followed, and the portion sizes were inadequate. The Administrator was informed of these issues, confirming that the menu approved by the Registered Dietician was not adhered to during the lunch meal. This failure affected multiple residents, compromising their nutritional needs as prescribed by their dietary plans.
Failure to Provide Pressure Relieving Device for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident #39, who had multiple diagnoses including diabetes, dementia with behavioral disturbances, and muscle wasting with atrophy, was identified as high risk for pressure ulcers. Despite this, the resident's care plan, which included an intervention to provide pressure reducing surfaces on the bed and chair, was not followed. Observations on multiple occasions revealed that the resident's wheelchair did not have a pressure relieving device, which was confirmed by both a Certified Nursing Assistant and a Licensed Practical Nurse. The Director of Nursing also confirmed that the resident should have had a pressure relieving device in her wheelchair. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, and was dependent on staff for toileting hygiene and required moderate assistance with transfers. The resident was also incontinent of bowel and bladder, further increasing the risk for pressure ulcers. Despite these risk factors and the care plan in place, the facility did not provide the necessary pressure relieving device in the resident's wheelchair, as observed over several days and confirmed through staff interviews.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, specifically for a resident with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, and chronic obstructive pulmonary disease. The physician ordered Alprazolam 0.25 mg to be given as needed for anxiety, but this order extended beyond the recommended 14-day period for PRN psychotropic medications. Despite a recommendation from the pharmaceutical consultant to limit the PRN use to 14 days, the physician denied the gradual dose reduction, citing that the dose was minimally effective. The medication was administered on multiple occasions beyond the 14-day limit, which was confirmed by the Director of Nursing during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Delhi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rayville Nursing And Rehabilitation | 13.7 mi | ★★★★★ | 9 | 0 |
| Colonial Manor Nursing & Rehabilitation Home | 15.6 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing And Rehabilitation Of Tallulah | 18.8 mi | ★★★★★ | 6 | 0 |
| Plantation Manor Nursing And Rehab Center, Llc | 24.1 mi | ★★★★★ | 0 | 0 |
| Legacy Nursing And Rehabilitation Of Winnsboro | 24.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Deerfield Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.