Safety Report: Deer Meadows Rehabilitation and Nursing
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
11Requirements cited on more than one inspection
No citations at the “actual harm” or “immediate jeopardy” level in the last three inspection cycles.
Citations by topic
0Abuse, neglect & exploitation
3Infection control
10Medications & pharmacy
0Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (23) than in the cycle before (19).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F758) | 3 | March 14, 2025; August 6, 2024; May 2, 2019 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 3 | March 14, 2025; August 6, 2024; October 28, 2021 |
| Provide and implement an infection prevention and control program. (F880) | 3 | August 6, 2024; October 28, 2021; May 2, 2019 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | March 14, 2025; August 6, 2024 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | March 14, 2025; May 2, 2019 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | March 14, 2025; August 6, 2024 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (F655) | 2 | March 14, 2025; August 6, 2024 |
| Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. (F625) | 2 | August 6, 2024; May 2, 2019 |
| Ensure medication error rates are not 5 percent or greater. (F759) | 2 | August 6, 2024; May 2, 2019 |
| PASARR screening for Mental disorders or Intellectual Disabilities (F645) | 2 | August 6, 2024; October 28, 2021 |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (F622) | 2 | August 6, 2024; May 2, 2019 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
March 14, 2025 — 13 citations · complaint investigation
E
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F770 · complaint · corrected April 15, 2025
E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F711 · complaint · corrected April 15, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected April 15, 2025
D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F773 · complaint · corrected April 15, 2025
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected April 15, 2025
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · complaint · corrected April 15, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected April 15, 2025
D
Provide appropriate foot care.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F687 · complaint · corrected April 15, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected April 15, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected April 15, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected April 15, 2025
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · complaint · corrected April 15, 2025
D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected April 15, 2025
August 6, 2024 — 23 citations
F
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F814 · corrected September 6, 2024
F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F802 · corrected September 6, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected September 6, 2024
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected September 6, 2024
E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected September 6, 2024
E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F800 · corrected September 6, 2024
E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected September 6, 2024
E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F756 · corrected September 6, 2024
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected September 6, 2024
E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected September 6, 2024
E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F625 · corrected September 6, 2024
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected September 6, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected September 6, 2024
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected September 6, 2024
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected September 6, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected September 6, 2024
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected September 6, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected September 6, 2024
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected September 6, 2024
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected September 6, 2024
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected September 6, 2024
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected September 6, 2024
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected September 6, 2024
October 28, 2021 — 6 citations
F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected December 3, 2021
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected December 3, 2021
D
Provide or obtain dental services for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F791 · corrected December 3, 2021
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected December 3, 2021
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected December 3, 2021
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected December 3, 2021
May 2, 2019 — 11 citations
F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F868 · corrected June 13, 2019
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · corrected June 13, 2019
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected June 13, 2019
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected June 13, 2019
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected June 13, 2019
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected June 13, 2019
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected June 13, 2019
D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · corrected June 13, 2019
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected June 13, 2019
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected June 13, 2019
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected June 13, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare