Diamondback Healthcare Center

Based on observations, staff interviews, and policy review, the facility failed to ensure that food is labeled and dated after opening in accordance with professional food safety standards. The deficient practice may result in practices of food storage that may not be in accordance with professional food safety standards. Findings include:An observation of the kitchen was conducted on January 4, 2026, at 8:40 AM with the facility's Dietary Manager (DM/Staff #152). The following food items were discovered without labels indicating what date they had been opened: Two liquid egg cartons did not have an opened date label.One bag of chicken tenders in the freezer without opened date label.One bag of tilapia in the freezer had no opened date label. One bag of hot dog buns had no opened date label.The dietary manager proceeded to remove these items from the refrigerator and freezer and disposed of the food with no open date labels.An interview was conducted on January 5, 2026, at 10:40 AM with the DM/Staff #152, who stated that the food should be labeled with the date that it is opened,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and review of policy and procedures, the facility failed to ensure proper infection prevention and control practices were implemented related to contact precautions for one resident of 5 residents (#117) and the facility failed to ensure that community infection control surveillance mapping was documented. The deficient practice could result in transmission of infection in the facility.Findings include: -Regarding Contact Precautions: Resident #117 was admitted to the facility on [DATE] with diagnoses that include enterocolitis due to clostridium difficile (C. Difficile), not specified as recurrent, urinary tract infection, site not specified, and other psychoactive substance abuse.Review of the comprehensive care plan dated February 3, 2026 revealed a focus for C. Difficile with interventions that included to use contact precautions such as: gowns and gloves during high-contact care activities, wear gowns and masks when changing contaminated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, staff interviews, review of facility process and policy, and the State Operations Manual the facility failed to ensure that all transfer/discharge notifications were made for two residents (#17 and #22). The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.Findings include:Regarding Resident #17 -Resident #17 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, fracture of the left femur, pulmonary hypertension, heart failure, and pneumonia. Review of the Ombudsman notification provided by the facility revealed no corresponding notification pertaining to the hospital transfer on September 5, 2024. The notification information provided was dated August 29, 2024 which was for a planned discharge. Review of the resident's face sheet revealed that the husband was listed as the responsible party while the daughter was listed as the emergency contact. The face sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document that a medication was discontinued and rationale thereof for one (#28) of three sampled residents. The deficient practice could result in negatively impacting continuity of care documentation. Findings include:Review of Resident #28's hospital records prior to admission revealed that she was admitted to the hospital on [DATE]. Upon discharge from the hospital, the medication list indicated no medication changes, and included olanzapine 2.5 mg by mouth once daily.Resident #28 was admitted to the facility on [DATE], with diagnoses including: urinary tract infection, resistance to multiple antibiotics, noninfective gastroenteritis and colitis, cerebral palsy, muscle weakness, abnormalities of gait and mobility, and depression.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews and review of facility policy and procedure, the facility failed to ensure medications were administered within the physician ordered parameters for Resident #09. The deficient practice may result in medications being administered outside physician ordered parameters.Findings Include:Resident # 09 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, hypotension, dependence on respirator (ventilator) status, and bradycardia. A review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Staff Assessment for Mental Status (SAMS) score of 3, indicated the resident cognition was severely impaired.Review of the medical records revealed medication orders with start date of May 07, 2024:Carvedilol Oral Tablet 3.125 milligram; Give 2 tablet enterally two times a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, observations, staff interviews and the facility policy and procedures, the facility failed to report an injury of unknown origin and complete a 5-day written investigation in accordance to their Abuse Policy's required timeframe for one resident (#2). The sample size was three. The deficient practice may result in residents being abused or receiving the appropriate treatment and care untimely. Findings include: Resident #2 was admitted on [DATE] with diagnoses of anoxic brain damage, respiratory failure, pleural effusion, epilepsy, gangrene and necrosis of lung. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which meant the resident did not have the BIMS assessment completed. The MDS assessment revealed that the resident was always incontinent of bladder and bowel. A review of the care plan revealed that the resident had a communication problem: rarely/never understood and rarely/never understands related to severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, observations, staff interviews and the facility policy and procedures, the facility failed to report an injury of unknown origin within required timeframe for one resident (#2). The sample size was three. The deficient practice may result in residents being abused or receiving the appropriate treatment and care untimely. Findings include: Resident #2 was admitted on [DATE] with diagnoses of anoxic brain damage, respiratory failure, pleural effusion, epilepsy, gangrene and necrosis of lung. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which meant the resident did not have the BIMS assessment completed. The MDS assessment revealed that the resident was always incontinent of bladder and bowel. A review of the care plan revealed that the resident had a communication problem: rarely/never understood and rarely/never understands related to severe cognitive loss due to anoxic brain damage history, with an intervention to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of facility documentation, and review of facility policy, the facility failed to ensure that care and services were provided according to professional standards for one of one sampled resident (#42). The deficient practice could result in care not being provided to accepted standards of practice, leading to harm to a resident. -Findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included traumatic hemorrhage of cerebrum, Alzheimer's disease, dysphagia, and protein-calorie malnutrition. The admission minimum data set (MDS) assessment dated [DATE] revealed that the resident's brief interview for mental status (BIMS) score was 03, which indicated resident was severely cognitively impaired. Moreover, revealed the resident required substantial assistance for bed mobility and was totally dependent on staff for transfers from bed to chair. The assessment also indicated the resident had one unstageable unhealed pressure wound. An admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel record reviews, facility documentation, staff interviews and policy review, the facility failed to ensure staffs had competencies or skills needed to provide care for 8 residents on ventilator and tracheostomy. The facility census was 75. The deficient practice could result in patients with ventilator and tracheostomy (Vent/ Trach) not receiving care that they need. Findings include: Review of the Vent/Trach Census revealed eight (8) residents identified with a tracheotomy, ventilator or both a tracheotomy and ventilator. Review of the facility staff schedule dated August 11, 2024 revealed the following staff scheduled for the 6:00pm to 6:00 am shift for the facility: - For A Wing (Ventilator/ Tracheostomy unit) : LPN (Licensed Practical Nurse)/Staff #201 LPN/Staff #38 LPN/Staff #157 (requested off) - For C Wing: LPN/Staff #116 LPN/Staff #34 - 2nd Floor Nurse: LPN/Staff #67 The staff schedule did not reveal that a Respiratory Therapist (RT) was scheduled for 6pm to 6am schedule. One RT staff (#68) was only scheduled for 6:00a.m-6:30p.m. Review of the personnel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and review of policy and procedure, the facility failed to ensure that controlled medications were secured in a separately locked, permanently affixed compartment. This deficient practice could result in controlled medication accessible to unauthorized personnel. Findings include: On April 4, 2023 at 9:25 a.m., an observation of the medication storage room A was conducted with a licensed practical nurse (LPN/staff #70). A refrigerator was inside the medication room was not locked and had no locking mechanism visible. Inside the refrigerator was a locked box/container which the LPN said was a container for storage of controlled medications. Also, inside the refrigerator was a box of medication that contained a bottle of unopened lorazepam (antianxiety) oral concentrate belonging to a resident. The bottle of lorazepam was not inside the locked box/container found in the refrigerator. On April 4, 2023 at 10:00 a.m., the survey team was provided with access cards that allowed access to the use of the elevators. This access card was also allowed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.