Deerfield Nursing: Care Plan Deficiencies - LA
The Director of Nursing confirmed during an October 10 interview that certified nursing assistants should be able to determine staffing requirements by accessing resident care plans on hallway kiosks. But when inspectors tested this system, they found it didn't work.
One nursing assistant reviewed care plans for two residents and confirmed the documents "did not state if the resident required 1 or 2 person assist with ADL care." Another assistant said she could check the kiosk to see staffing requirements, but when she looked up one resident, she found only vague language stating the person required "1-2 persons to change."
The ambiguity left staff making judgment calls about safety protocols without clear guidance.
During a follow-up interview that same morning, the Director of Nursing reviewed the same care plans and admitted they "did not instruct staff to use 1 or 2 person assist for each specific ADLs." She acknowledged that "the care plans should have the degree of assistance required for ADLs of each resident."
The facility's assessment system compounded the problem. The Director of Nursing and MDS Nurse confirmed during an October 10 afternoon interview that "the MDS does not explicitly determine if a resident was a 1 or 2 person assist for each ADL." They reported the facility "did not have an additional assessment that was used to determine which ADLs would require assistance from 1 or 2 staff."
Federal inspectors found the pattern continued across multiple residents. On October 14, the Director of Nursing confirmed that another resident's care plan "did not include if they were a 1 or 2 person assist for any ADL."
The scope of the failure became clearer during the final interview on October 16. The Director of Nursing revealed she had "just found out the facility had weekly MDS GG meetings to review the status of the residents' assistance needs for care." These meetings generated information about what residents actually needed.
But the facility wasn't using that information effectively.
The Director of Nursing admitted "the facility failed to take that information and use it to develop a care plan that accurately reflected the residents' care needs and was clear for the CNAs for when they refer to the care plan."
The consequences affected daily operations. Nursing assistants responsible for resident safety had to rely on incomplete information when deciding whether they needed backup for potentially risky activities like transfers, bathing, or dressing changes.
Two-person assists are typically required for residents who are at risk of falling, have mobility limitations, or need additional support due to cognitive impairment or physical weakness. Using insufficient staffing can lead to resident falls, injuries to both patients and workers, and violations of safety protocols.
The Director of Nursing ultimately confirmed that the facility failed to develop adequate care plans for at least five residents. Each case represented a breakdown in the system designed to ensure staff had clear, specific instructions for providing safe care.
The inspection found that nursing assistants were left to interpret vague guidance like "1-2 persons" without understanding which activities required the higher level of support. This forced front-line staff to make safety decisions without the detailed information their supervisors acknowledged they needed.
Federal regulators cited the facility for failing to ensure care plans accurately reflected residents' needs and provided clear guidance to nursing staff. The violation affected multiple residents and represented a systemic failure in the facility's care planning process.
The weekly meetings that could have prevented these gaps were happening, but the information wasn't making it into the documents that nursing assistants used every day to make critical decisions about resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deerfield Nursing and Rehabilitation Center from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Deerfield Nursing and Rehabilitation Center in Delhi, LA was cited for violations during a health inspection on October 16, 2025.
But when inspectors tested this system, they found it didn't work.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.