Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diamond Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not update or coordinate PASRR assessments for several residents who developed new or previously unrecognized mental health conditions after admission. Despite new diagnoses such as major depressive disorder, PTSD, bipolar disorder, and anxiety, there was no documentation of referral to the state authority for further evaluation, and the DON confirmed that PASRRs were not properly updated.
A resident with multiple fall risk factors, including visual impairment and a history of falls, did not have floor mats placed on both sides of the bed as required by the care plan and physician order. Staff only placed a mat on one side, contrary to documented interventions, and the DON confirmed that both mats should have been in place.
Two residents received antihypertensive medications despite physician orders to hold the medications for systolic blood pressure (SBP) less than 130. In one case, a resident was given Olmesartan Medoxomil multiple times when SBP was below the ordered threshold. In another case, an LPN prepared to administer Losartan to a resident with an SBP of 128, not recognizing the specific hold parameter. The DON confirmed that medications were administered outside of the prescribed parameters.
A resident did not receive respiratory care in accordance with physician orders, as their nebulizer mask was left uncovered at the bedside and oxygen was administered via nasal cannula without the required ear cushions or padding. Staff and the DON confirmed that facility policy and physician orders for equipment storage and skin protection were not followed.
Nurse staffing information was not updated daily as required, with posted data found to be outdated by two days. The Administrator confirmed the lapse and identified the Staffing Coordinator as responsible for ensuring daily postings.
A LPN failed to wear a gown, as required by enhanced barrier precautions, while administering IV medication via a PICC line to a resident. The LPN wore gloves but did not don a gown during this high-contact care activity, despite clear signage and facility policy requiring both gloves and a gown for such procedures. The DON confirmed that a gown should have been used.
A resident was injured during transport to a cardiologist appointment when her wheelchair tipped over, causing a facial fracture. The transport driver, a CNA, did not call 911 immediately, despite the resident's visible injuries and pain. Instead, the driver continued to the appointment, where the resident was later sent to the ER. The facility's policy to report and seek immediate medical assistance for such incidents was not followed.
The facility failed to ensure staff performed hand hygiene during medication administration and did not clean and disinfect reusable resident care items, leading to potential infection risks. An LPN was observed preparing and administering medications to multiple residents without hand hygiene, and contaminated pill cutters were found in multiple medication carts. Staff interviews confirmed the lack of adherence to hand hygiene and cleaning protocols.
The facility failed to administer narcotic pain medication according to physician orders for two residents, resulting in the administration of Oxycodone for pain levels below the prescribed range. Staff interviews revealed a misunderstanding of the pain medication parameters, and the facility's pain management policy was not followed.
The facility failed to ensure complete and accurate documentation for two residents receiving IV care. One resident's PICC line dressing changes were inconsistently documented, and another resident's saline flushes and IV site monitoring were not recorded after a certain date, despite staff confirming continued care.
Failure to Coordinate PASRR Assessments for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for residents who developed newly evident or possible serious mental disorders after admission. Specifically, for five out of six residents reviewed, there was no documentation that the facility referred these residents to the appropriate state-designated authority for evaluation after new mental health diagnoses were identified. For example, one resident was initially screened for anxiety disorder only, but was later diagnosed with recurrent mild major depressive disorder and PTSD, with no evidence of referral for further PASRR evaluation. Another resident was initially screened for anxiety disorder, but was subsequently diagnosed with bipolar disorder, again without documentation of referral for a Level II PASRR screening. Additionally, three other residents were admitted without any mental illness indicated on their initial PASRR screenings, but were later diagnosed with major depressive disorder, adjustment disorder with depressed mood, and anxiety. Clinical records and psychiatric evaluation notes confirmed these new diagnoses and histories of psychiatric illness, yet there was no evidence that the PASRR assessments were updated or that referrals were made as required. During interviews, the Director of Nursing acknowledged that the PASRRs for these residents were not correct and should have been updated to reflect the new diagnoses and initiate appropriate screenings.
Failure to Implement Bilateral Fall Mat Intervention per Care Plan and Physician Order
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for a resident at risk for falls. Observations on multiple occasions showed that the resident, who was visually impaired, had poor safety awareness, gait and balance problems, used psychotropic medications, had a history of falls, and was weak, did not have bilateral floor mats placed on both sides of the bed as required. Instead, only one floor mat was placed on the left side of the bed, while the mat for the right side was folded and stored under the bed. The resident's physician order and care plan both specified that floor mats should be present on both sides of the bed while the resident was in bed. Staff confirmed that the mat was not placed on the right side because the resident only got up on the left side, despite the care plan and physician order requirements. The DON acknowledged that physician orders must be followed and that mats should be on both sides.
Failure to Follow Physician-Ordered Blood Pressure Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for administering hypertension medications were followed for two residents. For one resident, the physician's order specified that Olmesartan Medoxomil should be held if the systolic blood pressure (SBP) was less than 130. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's SBP was below the ordered threshold, with documented readings of 121/63, 121/66, 114/63, 129/62, and 124/62. The Director of Nursing confirmed that the medication was given outside the prescribed parameters on these dates. In another instance, an LPN prepared to administer Losartan to a resident after obtaining a manual blood pressure reading of 128/78, despite a physician order to hold the medication for SBP less than 130. The LPN stated she was accustomed to looking for lower SBP parameters and did not notice the specific threshold of 130 in this order. The facility's policy requires medications to be administered as prescribed and for staff to follow the five rights of medication administration, but these protocols were not followed in these cases.
Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident as per physician orders. Observations revealed that the resident's nebulizer mask was left uncovered on the bedside table for multiple days, despite facility policy requiring respiratory therapy equipment to be bagged when not in use. Additionally, the resident was observed receiving oxygen via nasal cannula at 4 liters per minute without the required ear cushions or padding for skin protection, as ordered by the physician. These deficiencies were confirmed through interviews with the resident, who reported inconsistent use of nasal cannula cushions and irregular administration of nebulizer treatments, and with staff, who acknowledged the equipment was not properly stored and the required padding was not in place. Record review showed physician orders for Ipratropium-Albuterol nebulizer treatments every six hours as needed for shortness of breath, and for nasal cannula ear cushions or padding every shift to reduce pressure. Despite these orders, the resident's care did not consistently follow the prescribed protocols. The Director of Nursing confirmed that the facility's policy mandates bagging of respiratory equipment and adherence to physician orders for nasal cannula padding, but these procedures were not followed in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted accurately on a daily basis. During an observation, the posted nurse staffing information was found to be dated two days prior to the current date. Photographic evidence was obtained to document this finding. In an interview, the Administrator confirmed that the staffing information had not been updated as expected and stated that the Staffing Coordinator is responsible for printing and posting the reports for the weekend and the following Monday before leaving on Friday. No information about residents or their medical conditions was included in the report.
Failure to Use Required PPE During High-Contact Care on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to use appropriate personal protective equipment (PPE) while providing high-contact care to a resident on enhanced barrier precautions (EBP). During an observation, the LPN entered the resident's room, which was clearly marked with EBP signage requiring the use of gloves and a gown for high-contact activities such as device care involving a central line. The LPN donned gloves but did not wear a gown while priming and connecting a peripherally inserted central catheter (PICC) line and administering intravenous (IV) Vancomycin to the resident. When questioned, the LPN stated a belief that a gown was only necessary for direct contact, interpreting the EBP requirements as not applying to IV administration since the IV was "contained." The Director of Nursing (DON) later confirmed that a gown should have been worn during this procedure. Review of the facility's EBP policy indicated that gown and glove use is required for high-contact resident care activities, including device care or use such as central lines.
Failure to Inform Physician and Seek Immediate Medical Assistance After Resident Injury
Penalty
Summary
The facility failed to ensure that a resident's physician was immediately informed of an accident resulting in injury. The incident involved a resident who was being transported in a wheelchair to a cardiologist appointment. During the transport, the resident's wheelchair tipped over, causing the resident to strike the left side of her face against the window, resulting in a zygoma fracture. The transport driver, a Certified Nursing Assistant (CNA), did not call 911 immediately after the accident, despite the resident showing signs of injury, including bleeding and pain. Instead, the driver continued to the cardiologist's office, where the resident was later sent to the emergency room for further evaluation. The facility's policy requires that any accident or incident involving a resident that results in suspected or confirmed injury should be reported immediately, and medical assistance should be sought. However, the transport driver did not follow this protocol, as confirmed by the Director of Nursing, who stated that the driver should have called 911 and waited for emergency services. The resident's condition, including being anticoagulated, increased the risk of complications, yet the necessary immediate medical response was not initiated by the staff involved.
Inadequate Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during medication administration between residents and did not clean and disinfect reusable resident care items, leading to potential infection risks. During an observation, an LPN was seen preparing and administering medications to multiple residents without performing hand hygiene. Additionally, a contaminated pill cutter with a white powdery substance was found in multiple medication carts, indicating a failure to clean and disinfect the equipment properly. Staff interviews confirmed the lack of adherence to hand hygiene and cleaning protocols, despite the facility's policies requiring hand hygiene before and after handling medications and cleaning reusable items with appropriate disinfectants. The Director of Nursing confirmed that pill cutters should be cleaned with purple wipes after each use, but observations and staff statements revealed that this practice was not consistently followed. The facility's policies on hand hygiene and cleaning and disinfection of resident-care items were reviewed, highlighting the requirement for hand hygiene before preparing or handling medications and the need to clean and disinfect reusable items between residents. The failure to follow these protocols was evident in the observations and staff interviews, leading to the identified deficiencies.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure residents received as needed narcotic pain medication according to physician orders for two residents. Resident #9, who had diagnoses including chronic kidney disease, osteoarthritis, and dementia, was prescribed Oxycodone 5 mg to be administered for pain levels between 6-10. However, the resident received the medication multiple times when their pain level was documented as 5. Similarly, Resident #15, with diagnoses including chronic obstructive pulmonary disease and diabetic polyneuropathy, was prescribed Oxycodone 10 mg for pain levels between 6-10 but received the medication when their pain level was documented as 5. Both residents' care plans included instructions to administer medication as ordered, which was not followed in these instances. Interviews with staff revealed a misunderstanding of the pain medication administration parameters. Staff A and Staff C, both LPNs, stated that they would administer alternative pain relief like Tylenol if the pain level was below the prescribed range and would call the doctor for additional orders if needed. The Assistant Director of Nursing confirmed that physician orders must be followed and documented in the eMAR, and the Director of Nursing acknowledged that the orders were not followed correctly. The facility's pain management policy emphasized using appropriate pain intensity scales based on the resident's cognitive ability, which was not adhered to in these cases.
Incomplete and Inaccurate Documentation of IV Care
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for two residents receiving intravenous infusion. For Resident #103, the physician's order required a transparent dressing change on the PICC line every Wednesday. However, the Treatment Administration Record showed discrepancies, with the dressing change documented on 3/22/2024 and 3/27/2024, but the Director of Nursing confirmed only the 3/22/2024 change. This inconsistency indicates a failure to accurately document the care provided as per the physician's order. For Resident #176, the physician's order included saline flushes and monitoring of the IV site for signs of infection. The Medication Administration Record lacked documentation after the morning shift of 3/29/2024, despite staff confirming that care continued as per standards. Staff interviews revealed that there was no place to document the continued care on the MAR, indicating a gap in the facility's documentation process. The facility's policy requires accurate and complete documentation of care, which was not adhered to in these cases.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Brentwood | 0.8 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Citrus County | 2.4 mi | ★★★★★ | 10 | 0 |
| Grove Healthcare And Rehabilitation Center And Reh | 2.5 mi | ★★★★★ | 0 | 0 |
| Crystal River Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 26 | 0 |
| Cypress Cove Care Center | 7.1 mi | ★★★★★ | 2 | 0 |
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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 July 2026) and official state health department websites.