Inspection Reports for
Deerfield Nursing and Rehabilitation Center
522 MAIN STREET, DELHI, LA, 71232
Back to Facility Profile6 Reports
Inspection Report — Oct 16, 2025
Annual Inspection CMS
Date: Oct 16, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning requirements for residents, specifically evaluating whether care plans accurately reflected the assistance needs for activities of daily living (ADLs).
Findings
The facility failed to develop comprehensive, person-centered care plans that identified the required assistance of one or more staff for each ADL for 5 of 6 sampled residents. Interviews with staff confirmed care plans did not specify whether residents required one or two person assistance for ADLs.
Deficiencies (1)
F 0656: The facility failed to develop and implement complete care plans that meet all residents' needs with measurable timetables and actions. Care plans for Residents #1, #2, #3, #4, and #5 did not specify the required assistance of one or more staff for each ADL.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed care plans should specify degree of assistance required for ADLs and acknowledged facility failed to develop such plans. | |
| MDS Nurse | Confirmed MDS does not explicitly determine if a resident requires one or two person assist for ADLs and no additional assessment was used. | |
| Certified Nursing Assistant | Reported care plans for Residents #2 and #3 did not state if one or two person assist was required. |
Inspection Report — Sep 23, 2025
Complaint Investigation CMS
Date: Sep 23, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident falls, elopement, and staff competency in a nursing home.
Complaint Details
The complaint investigation was substantiated. The facility was found deficient in fall care plan implementation, environmental safety leading to elopement, and staff competency in responding to falls. Immediate jeopardy was identified due to the elopement incident.
Findings
The facility failed to implement a comprehensive care plan for a resident at high risk for falls, failed to prevent elopement due to unlocked kitchen doors, and failed to ensure nursing staff had appropriate competencies to respond to an unwitnessed fall. Immediate jeopardy was identified due to elopement risk.
Deficiencies (3)
F 0656: The facility failed to implement Resident #7's fall care plan intervention, resulting in an unwitnessed fall with minor bruising but no injury.
F 0689: The facility failed to secure the kitchen door, allowing Resident #1 to elope from the facility, resulting in immediate jeopardy to resident health or safety.
F 0726: The facility failed to ensure nursing staff had appropriate competencies; a nurse did not send Resident #7 to the hospital after an unwitnessed fall as required by policy.
Report Facts
Fall risk assessment score: 11
Incident date: 2025
Elopement date: 2025
BIMS score: 1
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (S8LPN) | Assessed Resident #7 after fall and failed to send to hospital as required. | |
| Certified Nursing Assistant (S9CNA) | Reported Resident #7 fall and assisted in care. | |
| Administrator (S1Administrator) | Confirmed deficiencies and oversaw corrective actions. | |
| Registered Nurse (S4RN) | Responded to elopement incident and coordinated with police. | |
| Licensed Practical Nurse (S5LPN) | Conducted head count during elopement incident. | |
| Cook (S13Cook) | Failed to lock kitchen door leading to elopement. |
Inspection Report — May 14, 2025
Routine CMS
Date: May 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, infection control, and facility operations at Deerfield Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to develop and implement complete care plans, improper use and assessment of bed rails, failure to administer medications as ordered, food safety violations, lack of proper infection control practices including failure to use appropriate personal protective equipment and signage for Enhanced Barrier Precautions, inadequate catheter care technique, and failure to hold required Quality Assessment and Assurance meetings.
Deficiencies (8)
F 0656: The facility failed to develop a discharge planning care plan for resident #28 and failed to implement a fall mat intervention for resident #46 as ordered.
F 0689: The facility failed to conduct a bed rail/mattress safety assessment prior to using side rails for resident #36 and improperly used the lower quarter side rail.
F 0700: The facility failed to review risks and benefits with resident or representative and obtain informed consent prior to bed rail use for resident #36, and failed to assess risk of entrapment prior to installation.
F 0726: Licensed Practical Nurse failed to obtain vital signs after being unable to obtain pulse oximetry reading for resident #53.
F 0757: The facility failed to administer insulin as ordered for resident #32 when blood sugar readings were above 300 mg/dL.
F 0812: The facility failed to maintain food safety standards including improper freezer temperatures, open food packaging, soiled storage containers, improper thawing, and poor hygienic practices during food service.
F 0868: The facility failed to hold quarterly Quality Assessment and Assurance meetings with required members for 4th quarter 2024 and 1st quarter 2025.
F 0880: The facility failed to implement infection prevention and control program requirements including failure to wear appropriate PPE during Enhanced Barrier Precautions for residents #7, #8, #11, and #46, lack of signage for residents on EBPs, and improper catheter care technique for resident #16.
Report Facts
Residents served meals: 53
Blood sugar reading: 425
Blood sugar reading: 381
Fall risk assessment score: 20
Pulse oximetry reading failure: 1
Bed rails used: 4
Residents reviewed for unnecessary medications: 5
Residents affected by deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S12 LPN | Licensed Practical Nurse | Failed to obtain vital signs after pulse oximetry failure and failed to administer insulin as ordered |
| S2 DON | Director of Nursing | Confirmed multiple deficiencies including lack of care plans, improper bed rail assessments, medication errors, and infection control failures |
| S3 LPN | Licensed Practical Nurse | Failed to wear gown during wound care for multiple residents requiring Enhanced Barrier Precautions |
| S4 DM | Dietary Manager | Observed violating food safety and hygiene practices |
| S5 ADON | Assistant Director of Nursing | Confirmed absence of fall mat for resident #46 |
| S13 CNA | Certified Nursing Assistant | Failed to use proper technique during catheter care for resident #16 |
Inspection Report — Jun 26, 2024
Complaint Investigation CMS
Date: Jun 26, 2024
Visit Reason
The investigation was conducted due to a complaint alleging physical and verbal abuse of a resident by staff at the nursing facility.
Complaint Details
The complaint investigation substantiated that resident #1 was physically and verbally abused by staff on 06/05/2024. Multiple staff interviews and resident statements confirmed the incident and inappropriate staff conduct.
Findings
The facility failed to protect resident #1 from physical and verbal abuse by staff, resulting in the resident being pushed from his wheelchair to the ground. Interviews and record reviews confirmed the incident and inappropriate staff behavior.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse by staff. Resident #1 was pushed from his wheelchair to the ground by a staff member after making inappropriate remarks.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Inspection Report — Apr 11, 2024
Routine CMS
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, medication administration, pressure ulcer prevention, nursing competencies, medication regimen review, psychotropic medication use, and nutritional services.
Findings
The facility was found deficient in multiple areas including failure to provide adequate nail care for residents unable to perform activities of daily living, failure to follow physician orders for compression stockings, oxygen therapy, and medication administration, failure to provide pressure relieving devices for residents at risk of pressure ulcers, inadequate documentation of insulin injection sites, failure to limit psychotropic medication use as required, and failure to follow approved menus for residents on special diets.
Deficiencies (7)
F 0677: The facility failed to provide nail care for residents #12 and #38 who were unable to trim their own nails, resulting in long, jagged fingernails.
F 0684: The facility failed to apply compression stockings as ordered for resident #23, administer oxygen as ordered for residents #6 and #26, and flush the gastrostomy tube with 30 cc of water prior to medication administration for resident #6.
F 0686: The facility failed to provide a pressure relieving device for resident #39, who was at high risk for pressure ulcers while in a wheelchair.
F 0726: Nurses failed to document the injection sites for subcutaneous diabetic injections for residents #26, #31, and #40.
F 0756: The pharmacist failed to identify and report irregularities related to undocumented injection sites for insulin administration for residents #26 and #31.
F 0758: The facility failed to ensure psychotropic medication Alprazolam was not administered as needed for longer than 14 days for resident #26.
F 0803: The facility failed to follow the approved menu by not providing pureed or moist cornbread to residents on pureed and mechanical soft diets and failed to provide 4 ounces of chicken during the 04/08/2024 lunch meal for several residents.
Report Facts
Deficiencies cited: 7
Medication dose: 30
Oxygen flow rate: 2
Oxygen flow rate observed: 3.5
Insulin doses: 10
Chicken portion: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed failures in nail care, oxygen administration, medication flushing, pressure ulcer prevention, insulin injection documentation, and psychotropic medication use. |
| S5 Certified Nursing Assistant | Certified Nursing Assistant | Interviewed regarding lack of awareness of compression stocking requirement and pressure relieving device absence. |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed resident #23 was not wearing compression stockings and wheelchair lacked pressure relieving device. |
| S7 Assistant Director of Nursing | Assistant Director of Nursing | Confirmed lack of documentation of insulin injection sites and failure of pharmacy consultant to notify facility. |
| S6 Dietary Manager | Dietary Manager | Confirmed menus were not followed and chicken portions were insufficient. |
Inspection Report — May 10, 2023
Annual Inspection CMS
Date: May 10, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, assistance with activities of daily living, accident hazard prevention, drug regimen management, and dietary services. Deficiencies involved environmental sanitation, resident grooming and dressing, fall prevention interventions, lab work omissions, and failure to serve prescribed pureed diet desserts.
Deficiencies (5)
F 0584: The facility failed to maintain a sanitary and orderly environment in the laundry room, evidenced by a hole in the wall behind the dryer, a cotton blanket covering the dryer vent duct, and heavy lint buildup behind dryers.
F 0677: The facility failed to provide nail care for residents #1 and #50 and failed to ensure resident #1 was appropriately dressed, including wearing mismatched socks and having long, dirty fingernails.
F 0689: The facility failed to ensure the resident's environment was free from accident hazards and did not provide adequate supervision or appropriate fall prevention interventions for resident #15 who sustained multiple falls.
F 0757: The facility failed to ensure lab work was obtained as ordered for resident #27, missing labs due in March 2023 including lipid panel, TSH, Vitamin D, CBC, CMP, and Hemoglobin A1C.
F 0803: The facility failed to follow the menu for residents on a pureed diet, serving prepackaged pudding cups instead of the prescribed pureed bread pudding for residents #24, #34, and #35.
Report Facts
Residents investigated for ADL care: 2
Residents reviewed for accidents: 6
Residents whose drug regimens were reviewed: 5
Residents on pureed diet: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Confirmed laundry room deficiencies and notified about pureed diet dessert issue | |
| S2 Director of Nursing | Confirmed resident #1's grooming issues, notified about fall interventions and pureed diet dessert issue | |
| S4 Certified Nursing Assistant | Confirmed resident #1's need for assistance and grooming issues | |
| S5 Assistant Director of Nursing | Confirmed missing lab work for resident #27 and notified about fall interventions and pureed diet dessert issue | |
| S6 Dietary Manager | Confirmed residents on pureed diet received incorrect dessert |
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