Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.