Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Deer's Head Center during CMS and state inspections, most recent first.
Advance directive discussions were not documented for 3 of 6 residents reviewed. Two residents had no AD in the chart and no record of attempts to obtain prior ADs or provide AD education to the resident or representative. Another resident had a MOLST showing Full Code status, but there was no AD and no documentation of an AD discussion in the clinical record.
Failure to prevent resident-to-resident sexual abuse: A resident with severe cognitive impairment engaged in oral sexual interactions with another resident who was also severely cognitively impaired and incapable of consent. An RN witnessed the interaction during rounds, separated the residents, and reported the incident. The facility later substantiated the event based on the witness account, and the involved resident had a history of inappropriate sexual advances and comments toward staff and other residents.
Failure to monitor and document side effects of psychotropic medications was identified for two residents receiving multiple psychotropic agents, including antipsychotics, antidepressants, anticonvulsants, antihistamines, and anxiolytics. The DON stated monitoring was done by exception and not documented daily, and no records could be found showing side effect monitoring for either resident.
Food Storage Deficiency: Opened items in the freezer were found undated, unlabeled, and not properly resealed, including burger patties and frozen cookie dough. Surveyors also found numerous bread products past their best-by dates in the refrigerator and at the toaster station, and the Dietary Director acknowledged the outdated items should not have been there and that staff should have checked dates before use.
Infection control deficiencies were observed involving a resident with an indwelling urinary catheter and the clean laundry area. A resident’s urinary drainage bag was seen hanging from the bed and touching the floor, and an RN confirmed it should not have been on the floor. In the clean laundry area, a large bin contained overflowing uncovered clean items, including gowns, heel protectors, and pillows, and a laundry aide acknowledged they should have been covered.
Unsanitary Laundry Room Conditions: Surveyors observed a large amount of lint left on the floor next to a dryer, with a broom resting on top of it, after an aide said he cleaned the dryer but did not place the lint in the trash. Surveyors also found spillage on washer covers and visibly dirty bleach dispensers with thick blackened material around the edges.
Failure to post required nurse staffing information was identified in 2 of 2 units observed during the recertification survey. Staffing whiteboards did not include the facility name or resident census, and one RN confirmed the board was completed at the start of the shift without those details. In another unit, an RN stated the census was usually written beside resident names, and the DON said she expected the board to show the date, assignment, and staff-to-patient ratio.
The facility failed to protect residents from abuse, with incidents involving staff and resident interactions. A GNA physically and verbally abused a resident with dementia, and another staff member verbally abused a resident by cursing and ignoring requests for assistance. Additionally, a resident-to-resident physical abuse incident occurred, with inadequate documentation and preventive measures.
The facility failed to report abuse incidents to the state agency within the required timeframe. In one case, a GNA abused a resident, and the report was delayed by 21 hours. Another incident involved a resident feeling mistreated, with the report also delayed. A third case of resident-to-resident abuse was reported late, with insufficient documentation. These actions violated the facility's policy requiring reports within 2 hours of discovery.
A GNA verbally and physically abused a resident during transport to the shower. Despite the incident being reported, the GNA continued to work with the resident and on the unit for the rest of the day. The facility's policy requires immediate removal of staff involved in abuse allegations, but this was not followed, leading to a deficiency in protecting the resident.
A resident was transferred to the hospital without receiving the required written notice of transfer. The facility staff informed the resident's representative verbally, but there was no documentation of a written notice being provided. This deficiency was identified through a review of medical records and interviews with staff and the resident's family.
A facility failed to inform a resident and their representative of the bed hold policy during a hospital transfer. Staff interviews revealed that the policy was only discussed at admission and not provided in writing during transfers. This deficiency was identified when a resident was transferred to the hospital for a change in mental status, and the bed hold policy was not communicated.
A resident with dementia was administered Quetiapine, a psychotropic medication contraindicated for dementia patients, without proper documentation of a gradual dose reduction (GDR) or monitoring for side effects. The facility's medical staff failed to provide evidence of a GDR, and the resident's behavioral issues were not adequately monitored, leading to a deficiency finding.
The facility failed to maintain a medication error rate below 5%, with errors involving two residents and two staff members. An RN administered acetaminophen against the physician's order for a resident with a pain level of 7/10, and an LPN administered medications 1 hour and 27 minutes late. The facility's Medication Management Policy defines such discrepancies as medication errors.
A facility failed to ensure staff donned appropriate PPE when transferring a resident under Enhanced Barrier Precautions (EBP) due to a history of MRSA. Unit Manager and Geriatric Nursing Assistant were observed transferring the resident without gowns, despite EBP signage instructions. Errors in the facility matrix regarding the resident's precautions were acknowledged by the Assistant Director of Nursing.
Advance Directive Discussions Not Documented
Penalty
Summary
The facility failed to ensure that advance directives were discussed with residents and/or their responsible representatives for 3 of 6 residents reviewed during the annual survey. For Resident #5 and Resident #8, medical record review showed no advance directive in the chart, and there was no documentation that the facility attempted to obtain any previously completed advance directive or provided education to the resident or the resident's representative about advance directives. During interview, the Nursing Home Administrator confirmed that advance directive information was typically included in the admission packet, but there was no documentation showing that it had been provided or that any prior advance directive had been sought for either resident. For Resident #7, the clinical record contained a Maryland MOLST form dated [DATE] indicating the resident was Full Code after discussion with the resident. However, there was no advance directive and no documentation of any discussion about advance directives in the clinical record. Staff stated that the Social Worker was responsible for advance directives and had resigned, and the Administrator, who was covering that role temporarily, later confirmed that there was no advance directive and no documentation of a discussion on advance directives in Resident #7's record.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving Resident #16 and Resident #20. The facility’s investigation for Facility Reported Incident #340863 was reviewed by the surveyor and substantiated, based on a witness statement from RN Staff #11, that Resident #16 engaged in oral sexual interactions with Resident #20 on the Sun Porch while the residents were being observed during rounds. RN Staff #11 immediately separated the residents and reported the incident to her supervisor. Both residents were assessed and no injuries were identified. Resident #16 was admitted to the Dementia Unit with diagnoses including dementia and had a BIMS score of 4 on the admission MDS, indicating severe cognitive impairment. By the end of January 2025, the resident had demonstrated numerous inappropriate sexual advances and comments toward staff and other residents. Resident #20 was admitted to the Dementia Unit with diagnoses including Alzheimer’s disease and had a BIMS score of 1 on the annual MDS, indicating severe cognitive impairment and inability to give consent. The DON stated the facility investigated the incident and substantiated it because a witness observed the interaction.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to provide adequate side effect monitoring for residents receiving psychotropic medications, affecting 2 of 5 residents reviewed for unnecessary medications. Resident #7 was admitted with diagnoses including Major Depressive Disorder, Anxiety Disorder, Borderline Personality Disorder, and End Stage Renal Disease, and had active orders for Abilify, Hydroxyzine HCL, and two Sertraline orders. Resident #20 was admitted with diagnoses including Alzheimer's Disease, Epilepsy, and Anxiety Disorder, and had active orders for Divalproex Sodium and Risperidone. Review of both residents' clinical records did not reveal a process for monitoring side effects of psychotropic drugs, including the frequency of monitoring or the tools used. The facility's psychotropic medication policy stated that nursing staff shall monitor for and report side effects and adverse consequences of antipsychotic medications to the LP, and identified antipsychotics, antidepressants, antianxiety medications, anticonvulsants, antihistamines, and hypnotics as psychological medications. During interview, the DON stated that side effects were monitored but not documented daily and were documented only by exception when an event occurred, with nurses relying on familiarity with the medications and morning huddles. When asked to provide records showing monitoring for the two residents, the DON later stated that no documentation could be found for either resident.
Food Stored Open, Undated, and Past Best-By Dates
Penalty
Summary
The facility failed to store food in a manner that maintained professional standards of food service safety. During an initial tour of the kitchen with the Dietary Manager, surveyors found foods in the walk-in freezer that had been opened but were undated and unlabeled, including a clear bag of burger patties removed from the box and a box of oatmeal raisin frozen cookie dough left open to air and not resealed. The Dietary Director stated that opened items should have been covered and labeled with an expiration date and agreed the burger patties and cookie dough should have been dated after opening, and that the cookie dough should have been resealed. In the walk-in refrigerator and at the kitchen toasting station, surveyors found numerous bread products past their best-by dates, including English muffins, Texas toast, whole wheat bread, enriched bread, hamburger rolls, deli split top rolls, rye bread, Italian hoagie rolls, and cinnamon swirl bread. The Dietary Director stated the bread at the toaster station should have been thrown away and that staff should have checked dates before using the loaves of bread, and also stated the outdated bread in the refrigerator should not have been there. The facility's Dietary-Sanitation: Dating Potentially Hazardous Food policy stated potentially hazardous ready-to-eat food will be labeled and dated to ensure rotation and prevent or reduce food borne illness, and the Food Storage Chart stated bread expiration is the best by/sell by date.
Infection Control Deficiencies with Urinary Catheter Care and Clean Laundry Storage
Penalty
Summary
An indwelling urinary catheter care deficiency was identified for Resident #6. On 12/08/25 at 12:37 PM, the surveyor observed the resident lying in bed with the urinary drainage bag hanging from the side of the bed and touching the floor. During an interview at 12:40 PM, Charge RN #1 confirmed she was the assigned nurse for Resident #6 and acknowledged that the drainage bag was touching the floor after she had lowered the bed. On 12/09/25 at 9:42 AM, the DON confirmed that urinary drainage bags are expected to remain off the floor. A separate infection control deficiency was identified in the laundry room. On 12/09/25 at 11:00 AM, the surveyor observed a large blue bin in the clean area of the laundry room with contents overflowing and exposed. The bin contained folded green hospital gowns, heel protectors, and pillows, and none of the items were covered. Laundry Aide #6 stated the items were clean and acknowledged they should have protective coverings as an infection control measure. The Environmental Services Supervisor was informed of the concern during an interview at 11:18 AM, and the Administrator was made aware at 12:17 PM.
Unsanitary Laundry Room Conditions
Penalty
Summary
The facility failed to keep a sanitary environment in the laundry room during the annual survey. During a walkthrough of the laundry room with Laundry Aide #6, the surveyor observed a large amount of white lint heaped on the floor next to a white dryer, with a broom resting on top of the lint heap. Laundry Aide #6 stated that he had cleaned the dryer at 7:00 AM and left the lint on the floor, saying he should have put it in the trash but did not. Additional observation of the laundry room found three small washing machines with spillage of a blue substance on their covers, and inside two of the washing machines were visibly dirty bleach dispensers with thick blackened material around the edges. The concerns were then brought to the attention of the Environmental Services Supervisor, and later the Administrator was made aware of the observations.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post all required nurse staffing information on a daily basis in 2 of 2 units observed during the recertification survey. On 12/10/25, the staffing whiteboard in the Magnolia Manor unit did not include the facility name or the resident census, and on 12/11/25, the whiteboard in the Whispering unit also did not include the facility name or the resident census. On 12/15/25, the Magnolia Manor board showed the date, shift, and staffing schedule with the ratio, but still did not identify the facility name or specify the resident census. RN #3 confirmed the board was completed at the beginning of the shift but did not include the facility name or resident census. In the Whispering unit, RN #1 confirmed the resident census was not specified and stated that the total number of residents was usually written beside their names; after surveyor intervention, RN #1 posted census 14 and MLOA-2. The DON stated she expected the board to show the date, assignment, and staff-to-patient ratio.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving both staff and resident interactions. In one case, a Geriatric Nursing Assistant (GNA) physically and verbally abused a resident with severe cognitive impairment during a transport to the shower. The resident, who was unable to communicate effectively due to vascular dementia, was yelled at and physically manipulated by the GNA after an incident of incontinence. This abuse was witnessed by other staff members, and the GNA was eventually terminated. However, the facility did not document any immediate assessment or follow-up on the resident's condition after the incident. Another incident involved a staff member verbally abusing a resident by turning off the call light and cursing at the resident without providing the requested assistance. The resident, who had previously experienced another verbal altercation with a different staff member, reported the incident, and the staff member was placed on administrative leave. Despite the resident's denial of current abuse, the facility's handling of the situation was inadequate, as there was a lack of immediate removal of the staff member from the unit. Additionally, the facility failed to prevent a resident-to-resident physical abuse incident. A resident with a history of dementia entered another resident's room and physically assaulted them with a call bell cord, resulting in minor injuries. The facility's documentation was insufficient, lacking staff witness statements and progressive notes on the victim's condition. The facility's response to the incident was inadequate, as there was no evidence of measures taken to prevent such occurrences in the future.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to report instances of abuse to the state agency within the required timeframe. In the first incident, a Geriatric Nursing Assistant (GNA) verbally and physically abused a resident after the resident defecated on the floor. This incident was witnessed by multiple staff members, including another GNA and two registered nurses. Despite the immediate awareness of the incident by the Assistant Director of Nursing (ADON), the self-report to the state agency was not filed until 21 hours later, contrary to the facility's policy that requires a report within 2 hours of discovery. In the second incident, a resident reported feeling like they were treated as 'a sack of potatoes' by staff, which they considered 'assault and battery.' The Nursing Home Administrator (NHA) was informed of this allegation, but the report to the state agency was delayed beyond the 2-hour requirement. The facility's policy clearly states that any allegation of abuse should be reported within 2 hours, yet this was not adhered to. The third incident involved resident-to-resident physical abuse, where one resident hit another with a call bell cord, resulting in minor injuries. The initial report to the state agency was submitted the following day, but the final report exceeded the 5-day submission timeframe. Additionally, there was a lack of documentation regarding the incident, including statements from staff or other residents, and no progressive notes or change of condition documentation related to the injuries sustained by the victim.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect residents from an alleged perpetrator during an abuse investigation. On 5/30/23, a Geriatric Nursing Assistant (GNA) was involved in an incident with a resident during which the resident defecated on the floor. The GNA responded by yelling at the resident and physically turning the resident's head to the floor, which was witnessed by other staff members. The investigation confirmed verbal and physical abuse by the GNA, who was eventually terminated and reported to the board of nursing. However, the GNA continued to work with the resident and on the unit for the rest of the day, despite the incident being reported to the Assistant Director of Nursing (ADON) shortly after it occurred. The facility's abuse prevention policy states that an employee involved in a staff-to-patient abuse allegation should be removed from patient care immediately. However, the ADON did not remove the GNA from the unit, citing that only Human Resources could relieve an employee from duty. The Chief Nursing Officer later indicated that the GNA should have been placed on administrative leave pending investigation. The GNA was placed on administrative leave the following day, but no evidence was found that the GNA's assignment or work hours changed on the day of the incident, indicating a failure to adhere to the facility's policy and protect the resident from further potential harm.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of transfer to a resident or their representative, as required by regulations. This deficiency was identified during a review of medical records and interviews with facility staff and the resident's family. Specifically, the issue was noted for a resident who was transferred to the hospital due to a change in mental status. A nursing progress note indicated that the resident's representative was informed verbally, but there was no documentation of a written notice being provided at the time of transfer. Interviews with facility staff revealed that the protocol for hospital transfers involved verbal communication with the resident's family, typically via phone calls, and documentation in the electronic record. However, there was no evidence of a written notice being given to the resident or their representative. The resident's representative confirmed that they were only informed verbally about the transfer and had never received written notification, which was consistent with past hospitalizations. This lack of written notification constitutes a failure to comply with regulatory requirements for resident transfers.
Failure to Communicate Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to implement a process to ensure that residents and their representatives were informed of the bed hold policy upon transfer to a hospital. This deficiency was identified during a review of medical records and interviews with facility staff, specifically concerning a resident who was transferred to the hospital due to a change in mental status. The nursing progress note documented by a registered nurse indicated that the resident's representative was informed of the transfer, but there was no mention of the bed hold policy being communicated. Interviews with various staff members, including a registered nurse, the Assistant Director of Nursing, and a licensed social worker, revealed that the bed hold policy was not provided to residents or their families at the time of hospital transfer. The Assistant Director of Nursing confirmed that the policy was only given at the time of admission and followed upon the resident's return from the hospital. The social worker also confirmed that while the policy was discussed during admission, it was not provided in writing during hospital transfers.
Deficient Psychotropic Medication Management in Dementia Patient
Penalty
Summary
The facility was found to have administered a psychotropic medication, Quetiapine, to a resident with dementia, despite it being contraindicated for such patients. The resident, who did not have a history of schizophrenia, was observed to be excessively sedated during surveyor rounds. The medical record review revealed that the resident was prescribed Quetiapine in varying doses since April 2022, but there was no documentation of a gradual dose reduction (GDR) being attempted, as required. The facility's Medical Director and Certified Registered Nurse Practitioner (CRNP) were unable to provide sufficient documentation to verify that a GDR had been conducted, despite claims that it was attempted. Additionally, the facility failed to monitor the resident for extrapyramidal side effects associated with the psychotropic medication. The resident's behavioral report indicated episodes of resistance to care and physical aggression, yet there was no evidence of appropriate monitoring or intervention. The CRNP acknowledged the resident's behavioral issues but deferred the responsibility of behavioral monitoring to nursing staff. The lack of proper documentation and monitoring highlights the facility's failure to adhere to regulatory requirements for the use of psychotropic medications in residents with dementia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by a 31.25% error rate observed during a survey. This deficiency involved two residents and two staff members. One incident involved a Registered Nurse (RN) administering acetaminophen to a resident who reported a pain level of 7/10, despite the medication order specifying administration for pain levels between 1-6/10. The RN acknowledged the error during an interview, admitting that the medication should not have been administered as per the physician's order. Another incident involved a Licensed Practical Nurse (LPN) administering multiple medications to a resident 1 hour and 27 minutes after the scheduled time, exceeding the standard practice of administering medications within 1 hour before or after the scheduled time. The LPN confirmed the delay and noted that a note could be written in the Medication Administration Record (MAR) to explain the lateness. The facility's Medication Management Policy was reviewed, which defines a medication error as any discrepancy between the physician's order and what was administered.
Failure to Don Appropriate PPE During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was donned by staff when transferring a resident under Enhanced Barrier Precautions (EBP). This deficiency was identified during a survey when Unit Manager (UM) #28 and Geriatric Nursing Assistant (GNA) #35 were observed transferring Resident #4 without wearing the required gown, despite the resident's EBP order due to a history of methicillin-resistant staphylococcus aureus (MRSA). The EBP signage clearly instructed staff to wear gowns and gloves during high-contact activities, including transferring residents. During interviews, UM #28 acknowledged the oversight, admitting that she did not wear a gown and that she had informed GNA #35 of the EBP requirements. GNA #35, however, was unaware of the EBP meaning and did not don a gown during the transfer. The facility matrix provided to the survey team contained errors, including incorrect transmission-based precautions (TBP) status for Resident #4, which was later clarified as EBP. The Assistant Director of Nursing (ADON) admitted to errors in the matrix and promised to provide an updated copy.
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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.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wicomico Nursing Home | 1.1 mi | ★★★★★ | 13 | 0 |
| Anchorage Rehabilitation And Wellness Center | 1.3 mi | ★★★★★ | 28 | 0 |
| Bay Harbor Post Acute Healthcare Center | 1.5 mi | ★★★★★ | 15 | 2 |
| Delmar Nursing & Rehabilitation Center | 5.3 mi | ★★★★★ | 4 | 0 |
| Manokin Nursing And Rehab | 13.2 mi | ★★★★★ | 44 | 2 |
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