Deerfield Nursing and Rehab: Elopement Immediate Jeopardy - LA
Federal inspectors who visited the 522 Main Street facility on September 23, 2025, found conditions serious enough to warrant an immediate jeopardy citation, the most severe level of deficiency CMS issues, reserved for situations where inspectors determine that residents face a risk of serious injury, harm, or death.
The deficiency centered on elopement prevention, the systems nursing homes use to keep vulnerable residents, often those with dementia or other cognitive impairments, from wandering out of the building undetected.
When inspectors reviewed the facility's documentation of daily exit door checks and wander guard system tests, they found no record that those checks had been completed and verified. The systems existed on paper. Whether they were working, on any given day, was another question.
The administrator, identified in the inspection report as S1Administrator, told inspectors on September 11, 2025, that the facility's quality assurance team had already reviewed its wandering and elopement policy by that point. She described what the new process would look like going forward: the director of nursing, herself, and the weekend registered nurse would be responsible for verifying that exit door alarms were checked daily, with ward clerks handling those checks Monday through Friday and the weekend RN covering Saturday and Sunday.
She also described a plan for elopement drills, random weekly drills for the first month, then monthly for three months after that, with her and the director of nursing conducting them. Findings, she said, would be reported at daily QA meetings held Monday through Friday.
The kitchen doors were a specific concern. The administrator said she and the director of nursing would personally monitor a new sign-in sheet verifying that kitchen doors were being locked daily, a process she described as newly implemented at the time of the interview.
That word, newly, does a lot of work in an inspection report. It means the process wasn't in place before. It means the gap inspectors identified was real, not a documentation error or a miscommunication. The kitchen doors, the exit alarms, the wander guard checks: the corrective measures were new because the prior practices had failed.
Immediate jeopardy citations require a facility to demonstrate that the threat has been corrected before inspectors leave or shortly after, and the inspection report reflects that Deerfield was in the process of doing that. But the citation itself stands as a matter of public record, a federal finding that residents at this facility faced a situation serious enough that CMS considered their health or safety in immediate danger.
Elopement is not a theoretical risk in nursing homes. Residents who wander out of facilities, particularly those with dementia, can become disoriented within minutes. They can wander into traffic. In winter months they can die from exposure. The reason facilities run wander guard systems and check exit alarms daily is that the window between a door opening and a resident in danger can be very short.
At Deerfield, for some period before September 2025, nobody had documented that the alarms were working. Nobody had verified the kitchen doors were locked. The checks that were supposed to happen every single day, the ones designed to catch a failure before a resident walked out, were not being confirmed.
The administrator's plan, as she described it to inspectors, put those responsibilities on named people: herself, the director of nursing, the weekend RN. It created a paper trail, the sign-in sheet, to show the work was being done. Whether that accountability holds past the inspection period is something no inspection report can answer.
What the report does answer is what was happening before anyone came to check.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deerfield Nursing and Rehabilitation Center from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Deerfield Nursing and Rehabilitation Center in Delhi, LA was cited for immediate jeopardy violations during a health inspection on September 23, 2025.
Whether they were working, on any given day, was another question.
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.