Diamond Ridge Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident mental disorder for 5 of 6 resident reviewed (Residents #1, #12, #14, #87, and #139). Findings include: 1) Review of Resident #12's Preadmission Screening and Resident Review (PASRR) dated 10/4/2023 revealed anxiety disorder was checked under mental illness. No other diagnosis was checked. Review of Resident #12's admission record revealed the resident was admitted on [DATE] and was subsequently diagnosed with recurrent mild major depressive disorder with onset date of 12/12/2023 and Post Traumatic Stress Disorder (PTSD) with onset date of 10/5/2023. Review of Resident #12's clinical records failed to reveal documentation that Resident #12 was later identified with a newly evident or possible serious mental disorder and was referred to the appropriate state designated authority for evaluation. 2) Review of Resident #14's Level I PASRR dated 8/19/2024 revealed anxiety disorder was checked under…

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, interview, and record review, the facility failed to implement a person-centered comprehensive care plan for 1 of 3 residents reviewed for falls (Resident #15). Findings include: During an observation on 7/20/2025 at 11:22 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed (Photographic evidence obtained). During an observation on 7/21/2025 at 9:46 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed. During an observation on 7/21/2025 at 3:50 PM, Staff A, Certified Nursing Assistant (CNA), stated, There is no mat on the right side of the bed because she only gets up on the left side of the bed. Review of Resident #15's physician order dated 4/9/2025 read, Floormats at bedside while Res. [Resident] in bed every shift for monitoring. Review of Resident #15's care plan initiated…

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 record review and interview, the facility failed to ensure physician-ordered parameters for administering hypertension medications were followed for 2 of 7 residents reviewed for medication administration (Residents #39, #139). Findings include: 1) Review of Resident #139’s physician order dated 6/20/2025 read, “Olmesartan Medoxomil Tablet 20 MG [milligram], Give 1 tablet by mouth one time a day for hypertension, hold for SBP [Systolic Blood Pressure] less than 130.” Review of Resident #139’s Medication Administration Record (MAR) for July 2025 for administration of Olmesartan Medoxomil showed the medication was administered outside the ordered parameters on 7/2/2025 for blood pressure of 121/63, on 7/3/2025 for blood pressure of 121/66, on 7/12/2025 for blood pressure of 114/63, on 7/16/2025 for blood pressure of 129/62, and on 7/18/2025 for blood pressure of 124/62. During an interview on 7/23/2025 at 7:45 AM, the Director of Nursing (DON) stated that the documentation indicated that the medication was administered outside parameters for the above referenced dates. 2)…

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, interview, and record review, the facility failed to ensure residents received respiratory services as per physician order for 1 of 3 residents reviewed for respiratory services (Resident #39). Findings include: During an observation on 7/20/2025 at 10:05 AM, Resident #39's nebulizer mask was lying on the bedside table not covered and dated 7/19/2025. Resident #39 was receiving oxygen via nasal cannula (NC) at 4 liters per minute. There was no padding or ear cushions noted on the NC tubing for skin protection (Photographic evidence obtained). During an interview on 7/20/2025 at 10:05 AM, Resident #39 stated, I receive my nebulizer treatments randomly. I received my treatments last week. My oxygen varies from 2 liter to 4 liters. I do not touch the regulator. Sometime the cushion is on the tubing and other times when the tubing is changed, the cushion is not there. During an observation on 7/21/2025 at 9:36 AM, Resident #39's nebulizer mask was lying on the bedside table not covered and dated 7/19/2025. Resident #39 was receiving oxygen via nasal cannula (NC) at…

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 and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include: During an observation on 7/20/2025 at 9:00 AM, the posted nurse staffing information was dated 7/18/2025 (Photographic evidence obtained). During an interview on 7/21/2025 at 9:00 AM, the Administrator stated, Upon my arrival to the facility, I noticed the posting was not updated. The expectation is for the staffing to be posted daily. The Staffing Coordinator is responsible on Friday before leaving to print the reports for the weekend to include Monday.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care to the residents on enhanced barrier precautions (EBP) for 1 of 2 residents reviewed for intravenous medication administration (Resident #159) to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 7/22/2025 at 9:00 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #159's room, which had a signage for enhanced barrier precaution (EBP) on the door indicating the providers and staff must wear gloves and a gown for the high-contact resident care activities such as devise care or use including central line. Staff C donned gloves. Staff C did not wear a gown. Staff C primed the peripherally inserted catheter central catheter (PICC) line on the resident's upper right arm and set the intravenous (IV) pump. Staff C proceeded to connect the PICC line to the IV medication and began to administer Vancomycin. During an interview on 7/22/2025 at…

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 record review and interview, the facility failed to ensure the resident's physician was immediately informed of an accident that resulted in injury for 1 of 3 residents reviewed, Resident #1. Findings include: Review of Resident #1's health record documented an appointment to see the cardiologist on 7/15/2024. Review of Resident #1's Emergency Department documentation dated 7/15/2024 showed the resident was in a wheelchair in a transfer vehicle and struck the left side of her face. CT (Computed Tomography) of head demonstrated a zygoma (cheekbone) fracture. The resident was anticoagulated but had no intracranial hemorrhage. Minimal blood in the sinus was noted and the resident had no signs of entrapment. During an interview on 12/6/2024 at 11:07 AM, the Administrator stated, I completed a thorough investigation of this incident on 7/16/2024 after the transport van incident, with [Resident #1's name] on 7/15/2024. I interviewed her twice on 7/16/2024 and [Resident #1's name] stated that the van driver…

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, record review, and interview, the facility failed to ensure staff performed hand hygiene during medication administration between residents and failed to ensure resident care reusable items were cleaned and disinfected to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 4/2/2024 at 8:33 AM, Staff A, Licensed Practical nurse (LPN) started preparing medications for Resident #8 without performing hand hygiene. During obtaining medication from the medication cart for Resident #8, Staff A stopped and locked the medication cart and entered the common room to assist Resident #36 with pencils and a coloring book. Staff A, then, returned to the locked medication cart and retrieved additional 8:00 AM medications for Resident #8. Staff A proceeded to Resident #8's room and administered the medications. Staff A did not perform hand hygiene. Staff A proceeded to the medication cart and started preparing medications for Resident #107. Staff A administered the medications for Resident #107 and did not perform hand…

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 record review and interview, the facility failed to ensure residents received as needed narcotic pain medication as per physician order for 2 of 5 reviewed residents, Residents #9 and #15. Findings include: Review of Resident #9's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included chronic kidney disease, fracture of neck of left femur, osteoarthritis, dementia, and type 2 diabetes mellitus. Review of Resident #9's physician order dated 3/21/2024 read, Oxycodone HCl [hydrochloride] oral tablet 5 mg [milligram] (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for pain 6-10. Review of Resident #9's Medication Administration Record (MAR) for March and April 2024 showed the resident received Oxycodone 5 mg on 3/21/2024 (pain level 5), 3/22/2024 (pain level 5), 3/23/2024 (pain level 5), 3/26/2024 (pain level 5), 3/30/2024 (pain level 5), 4/1/2024 (pain level 5), 4/3/2024 (pain level 5). Review of Resident #9's care plan dated 2/1/2024 read,…

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, record review, and interview, the facility failed to ensure resident records were complete and accurate for 2 of 4 residents reviewed for intravenous infusion, Residents #103 and# 176. Findings include: 1. Review of Resident #103's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the nervous system, Methicillin susceptible staphylococcus aureus infection, unspecified dementia, and bilateral primary osteoarthritis of hip. During an observation on 4/1/2024 at 9:57 AM, Resident #103 had a transparent dressing on his left upper arm, covering Peripherally Inserted Central Catheter (PICC) line, which was dated 3/22/2024. Review of Resident #103's physician order dated 3/18/2024 read, IV [Intravenous]: Central Line- PICC Line: Change transparent dressing every day shift every Wed [Wednesday] for preventative care. Review of Resident #103's Treatment Administration Record for March 2024…

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 record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge review, Resident #115. Findings include: Review of Resident #115's Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing Home Discharge (BD) Item Set dated 9/15/2022, reads, Section A. Identification Information. A0310. Type of Assessment . F. Entry/discharge reporting: 10. Discharge assessment- return not anticipated. A1800. Entered From: 03. Acute hospital. A1900. admission Date (Date this episode of care in this facility began): 08/30/2022. A2000. discharge date : [DATE]. A2100. Discharge Status: 03. Acute Hospital. Review of Resident #115's Discharge Planning Review dated 9/15/2022 reads, 7. Where resident discharged to at time of discharge: a. Private residence. Revie of Social Service Note dated 9/13/22 reads, [Family Member's name and Resident #115's name] want to discharge to VA hospital to treat his cancer. requested for…

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 ensure residents received wound care services consistent with professional standards of practice for 1 of 4 sampled residents with pressure ulcers, Resident #8. Findings include: Review of Resident #8's medical records revealed the resident wat admitted on [DATE] with diagnoses including pneumonia, acute respiratory failure with hypoxia, chronic diastolic heart failure, dehydration, chronic obstructive pulmonary disease, interstitial pulmonary disease, muscle weakness, paroxysmal atrial fibrillation, anemia, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, essential hypertension, morbid obesity due to excess calories, stage 3 chronic kidney disease, unspecified severe protein-calorie malnutrition, restless leg syndrome, generalized edema, cystocele, and myocardial infraction type 2. Review of physician orders dated 11/30/2022 for Resident #8 reads, Wound Care: Coccyx shear, apply calmaceptine and cover with…

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 ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 6 medication carts reviewed. Findings include: During an observation of medication cart #2 on [DATE] at 9:58 AM with Staff B, Licensed Practical Nurse (LPN), there was a bottle of Alphagan P Solution 0.15% expired on [DATE] and a Levemir insulin pen with expiration date of [DATE]. During an interview on [DATE] at 9:59 AM, Staff B, LPN, stated, Alphagan Solution 0.15% is expired and Levemir insulin pen not sure if it has been labeled incorrectly. During an observation of medication cart #3 on [DATE] at 10:09 AM with Staff C, LPN, there was a Humalog insulin with no opened or expiration dates. During an interview on [DATE] at 10:10 AM, Staff C, LPN, stated, Not sure why it is not labeled. During an interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) stated, Medication in…

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.