Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Care Center during CMS and state inspections, most recent first.
Failure to Maintain 24-Hour Licensed Nursing Coverage: PBJ review, staff timecards, pay stubs, and the facility assessment showed that licensed nursing coverage could not be verified for 24 hours per day across multiple quarters. The PBJ data also showed many days with no documented 24-hour nursing coverage, and one quarter had no PBJ submission. The administrator stated she was responsible for PBJ submission, had not submitted the third-quarter data, and could not verify 24-hour licensed nursing coverage.
The facility failed to ensure RN coverage for 8 consecutive hours each day and failed to maintain an RN DON on a full-time basis. PBJ data, timecards, pay stubs, and the facility assessment did not verify consistent RN coverage across multiple quarters, and one quarter of PBJ data was not submitted. The administrator stated the RN waiver had been denied, she was responsible for PBJ submission, and the DON was a full-time interim employee.
Failure to submit PBJ staffing data to CMS. CASPER review showed no PBJ data was submitted for the quarter, and the reported metrics were suppressed for invalid data, including excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours per day. Review of timecards and pay stubs did not verify 24-hour licensed nursing coverage or RN coverage 7 days a week, and the administrator acknowledged the data had not been submitted.
Failure to monitor resident refrigerator temperatures was identified for multiple residents with room refrigerators. Observations showed several refrigerators lacked temperature gauges and temperature logs, while the ES supervisor and dietary manager confirmed the units were checked for cleanliness and outdated items but not for temperature monitoring. The facility policy stated that refrigerator temps should be logged daily and kept between 36 and 46 degrees.
Failure to Document Self-Administered Medications and Prevent CNA Administration of Topicals: A resident with intact cognition on BIMS but noted occasional confusion and worsening mental status had several meds kept at bedside for self-administration, including eye drops and topical agents. However, CNAs were applying Tinactin, Voltaren, creams, and powders when asked, while nursing did not document self-administered meds on the eMAR and monthly checks on self-administered meds were not completed.
A resident with severe cognitive impairment, ESRD, and dialysis dependence had a signed DNR advance directive, but the EMR/report sheet showed conflicting code status information and the directive was not sent to the dialysis center. Staff stated the resident was listed as full code on the report sheet, the dialysis center had no advance directive on file, and the facility’s dialysis transfer agreement required any executed advance directive to accompany the resident.
Care plans were not revised to reflect current fall-prevention needs for two residents who were at risk for falls and had fallen. One resident with dementia, severe cognitive impairment, and walker use had Morse scores showing high and moderate fall risk, but her care plan did not identify fall risk or include fall interventions. Another resident with severe cognitive impairment, difficulty walking, hypotension, and anticoagulant use had repeated falls and a high Morse score, but his care plan was not updated to include all current interventions such as gait belt use, shoe use for transfers, bed positioning, or keeping his wheelchair out of reach. Staff gave inconsistent accounts of who was responsible for updating the care plans.
Nursing staff failed to follow physician orders and the blood sugar monitoring policy for a resident with DM, CKD, dementia, and insulin use. The record showed missed BG checks, insulin doses held or missed without physician orders, delayed rechecks after hypoglycemia, missing documentation, and failure to notify the physician after low BG events; one episode involved an unresponsive resident who was given orange juice instead of glucagon. Staff also failed to include another resident with dementia, walker use, fall history, and elevated Morse scores on the care plan as a fall risk.
A resident with recent cognitive decline and hospice involvement was found using an electric wheelchair without a documented assistive device safety assessment, and later became stuck in her bathroom after forgetting how to use the joystick. A second resident with Parkinson's disease and dyskinesia repeatedly ran into doors, carts, and other objects with her motorized wheelchair, despite a prior assessment and staff awareness of her unsafe operation and worsening involuntary movements.
Controlled meds were not maintained per policy. A locked black box in the med refrigerator contained lorazepam oral liquid and injectable for emergency use, but staff were not counting those meds at each shift change or when keys were exchanged. In addition, an opened bottle of morphine sulfate liquid was left in an unlocked drawer at the nurses’ station after an RN removed it from the med cart and forgot it there while waiting for another nurse to destroy it.
Infection control practices were not followed for two residents receiving oxygen and nebulizer therapy because tubing was not dated as required by the facility’s process and orders. In addition, a resident with a coccyx pressure ulcer was not placed on EBP despite the facility policy identifying wounds as an indication for gown and glove use during high-contact care. Staff were observed providing care with missed hand hygiene and without gowns during wound-related assistance.
A facility failed to protect a resident from potential abuse by another resident and did not provide timely care for a resident with pressure ulcers. An incident involved a resident found with her blouse unbuttoned in another resident's room, and the facility delayed notifying authorities. Additionally, a hospice resident developed pressure ulcers that were not treated promptly, leading to further deterioration.
Two residents in hospice care developed and worsened pressure ulcers due to the facility's failure to provide timely and necessary care. Despite hospice recommendations and the provision of dressings, the facility staff did not apply them, leading to multiple pressure wounds for one resident. The second resident developed seven pressure ulcers, with some worsening, due to inadequate repositioning and care planning. Communication issues and poor adherence to care practices were noted.
The facility failed to have an RN on duty for eight consecutive hours per day for 37 days across two fiscal quarters and one day in June 2024. Despite being licensed for skilled nursing care, the facility did not meet staffing requirements and relied on phone availability of RNs and physicians. Staffing was based on resident numbers and acuity, and the facility was actively recruiting RNs.
The provider's Arbitration Agreement lacked essential details, such as the full name and contact information of the arbitration organization, and allowed the provider to choose the arbitration location unilaterally. Interviews revealed that staff were unaware of who developed the agreement, and the administrator acknowledged these deficiencies. Despite this, 26 out of 34 residents had signed the agreement, and no disputes had occurred.
The facility failed to submit accurate PBJ data for two fiscal quarters, resulting in deficiencies such as no RN hours for eight consecutive hours each day for more than four days and no 24-hour nurse coverage for more than four days. The administrator confirmed inaccuracies in the data submission and acknowledged the absence of an RN for the required hours, although a licensed nurse was present 24 hours each day.
The facility failed to update and revise care plans for several residents, leading to discrepancies between documented care needs and actual requirements. For example, a resident's fluid restriction was not updated after being discontinued, and another resident's smoking safety was inaccurately documented. Additionally, fall risk interventions were not properly reflected in a resident's care plan, and new safety interventions for vulnerable adults were not included. The MDS/RN was responsible for ensuring care plan accuracy, but this was not consistently achieved.
The facility failed to monitor and remove expired medications and personal care products. Expired PRN medications for three residents were found in a medication cart, and four medications lacked opened or expiration date stickers. Additionally, prescription personal care products in a tub room were not securely stored or discarded when expired. The facility's policy on medication storage and expiration monitoring was not followed.
A registered nurse failed to follow infection control practices during dressing changes for two residents on enhanced barrier precautions. The nurse did not perform hand hygiene at critical points, used the same gloves for multiple tasks, and directly touched residents' wounds without proper glove changes. Despite receiving training, the nurse was unaware of the missed opportunities for hand hygiene, contrary to the facility's policies.
Two residents were not routinely assessed for safe self-administration of medications, despite having intact cognition and orders for self-administration. One resident had a nasal spray without a self-administration order, and the other had not been assessed for over a year. The facility's policy required quarterly assessments, which were not conducted.
A provider failed to accurately code MDS assessments for two residents, leading to documentation errors. One resident's pressure ulcers were not recorded in the MDS, and another resident was incorrectly noted to have a catheter. The MDS/RN responsible did not review necessary documentation or was unaware of the errors, relying on basic training and the RAI manual for guidance.
A resident receiving dialysis twice weekly was not properly monitored for vital signs and fistula site abnormalities upon returning from treatment on four occasions. The charge nurse was responsible for this task, but documentation was missing, particularly on days when an LPN with known documentation issues was on duty. The facility's policy required such monitoring and reporting of concerns to medical professionals.
The facility failed to properly assess and document the use of bed side rails for two residents. One resident used side rails for turning after a hip fracture, but documentation inconsistencies were noted between physician orders and evaluations. Another resident had a side rail for repositioning, but assessments were not updated as required. The facility's policy mandated quarterly assessments, which were not completed, and the MDS coordinator was unaware of the oversight.
Failure to Maintain 24-Hour Licensed Nursing Coverage
Penalty
Summary
Licensed nursing coverage for 24 hours per day was not maintained in the facility, based on review of CASPER/PBJ data, staff timecards and pay stubs, the facility assessment, and interview. PBJ review showed multiple days in Quarter 1, Quarter 2, and Quarter 4 with no documented 24-hour nursing coverage, and Quarter 3 PBJ data was not submitted at all. The report specifically identified numerous dates in October, November, and December 2024; January, February, and March 2025; and July, August, and September 2024 when no 24-hour nursing coverage was documented. Review of staff timecards and pay stubs did not verify licensed nursing coverage for 24 hours per day for Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024. The updated January 2025 facility assessment stated that one to three licensed nurses were needed for each shift, that an RN or LPN was needed for each shift, and that the DON RN was to work full time day shifts. During interview, the administrator stated she was responsible for submitting PBJ information, had not submitted the PBJ data for the third quarter, and could not verify licensed nursing coverage for 24 hours a day for the dates listed in the PBJ report.
RN Coverage and Full-Time DON Requirement Not Met
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was present in the building for eight consecutive hours each day and failed to select an RN to serve as director of nurses on a full-time basis. Review of CASPER data, PBJ staffing records, staff timecards, pay stubs, the facility assessment, and interview findings showed that RN coverage could not be verified for multiple days across several quarters. The PBJ data showed missing eight-hour RN coverage on numerous dates in Quarter 1, Quarter 2, and Quarter 4, and the facility failed to submit PBJ data for Quarter 3. The facility assessment dated January 2025 stated that one to three licensed nurses were needed for each shift, that an RN or LPN was needed for each shift, and that the DON RN was to work full-time day shifts. Review of staff timecards and pay stubs did not verify eight consecutive hours of RN coverage seven days a week. During interview, the administrator stated she had applied for an RN waiver but it was denied, that she was responsible for submitting the PBJ report, that she had not submitted the PBJ data for the third quarter, that she could not verify RN coverage for eight consecutive hours a day during the triggered dates, and that the DON was a full-time interim employee.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The provider failed to electronically submit complete and accurate PBJ direct care staffing information to CMS based on payroll and other verifiable and auditable data for Quarter 3, 2024. CASPER data review showed that no PBJ data had been submitted for April 1, 2024 through June 30, 2024, and the submitted metrics were suppressed for invalid data, including excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours per day. Review of staff timecards and pay stubs did not verify licensed nursing coverage for 24 hours a day or RN coverage for seven days a week during the quarter. During interview, the administrator stated she was responsible for submitting the PBJ report to CMS, acknowledged that she had not submitted the third-quarter data, and could not verify licensed nursing coverage 24 hours per day or RN coverage eight consecutive hours a day for seven days a week during the quarter.
Failure to Monitor Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor refrigerator temperatures to ensure safe food storage for six sampled residents who had refrigerators in their rooms. During observation and interview, resident 31 stated she had a refrigerator in her room and that there was nothing in it that could spoil, but there was no temperature gauge inside the refrigerator or temperature monitor log to record temperatures. Similar observations in the rooms of resident 29, residents 14 and 30 in a shared room, and residents 20 and 13 in a shared room showed that their refrigerators also did not have temperature gauges or temperature monitor logs. Interviews with the environmental services supervisor and the dietary manager confirmed that resident refrigerators were checked twice weekly for cleanliness and outdated items, but none of the resident refrigerators had temperature gauges to monitor temperatures. The dietary manager stated she was not aware the refrigerators did not have temperature gauges, although she thought they should have. The revised refrigerator policy stated that facility refrigerators will have a daily temperature log and that refrigerator temperatures should be between 36 and 46 degrees.
Failure to Document Self-Administered Medications and Prevent CNA Administration of Topicals
Penalty
Summary
The provider failed to ensure certified nursing assistants (CNAs) did not administer a resident’s topical medications and failed to document self-administered medications for one resident who was allowed to self-administer some medications. During observation in the resident’s room, two bottles of eye drops were on the bedside table, along with Tinactin antifungal spray on the nightstand, Voltaren gel, and additional antifungal cream, Calmoseptine cream, and Nystatin powder in the nightstand drawer. The resident stated she self-administered the eye drops after naptime, but CNAs sprayed Tinactin on her toes every night, applied Voltaren gel a few times a day when she asked, and used other topical medications for her when requested. Record review showed the resident was admitted with diagnoses including a history of blood clots, obesity, anxiety, unspecified encephalopathy, and paralytic syndrome, and she returned to the nursing home with hospice services after hospitalization. Her BIMS score was 15, but her self-administration assessment noted occasional confusion and altered mental status while indicating she could self-administer eye drops, nasal spray, and keep creams safely in her room. A hospice note later stated her confusion had been getting noticeably worse. Physician orders allowed several medications to be kept at bedside and self-administered, but Nystatin powder and Lotrisone cream did not indicate self-administration or bedside storage. Nursing did not document Tinactin and Voltaren gel as self-administered on the eMAR, monthly checks on self-administered medications were not completed, and staff interviews confirmed CNAs were applying the resident’s topical medications and that self-administered medications were not being documented.
Advance Directive Not Communicated to Dialysis Center
Penalty
Summary
The provider failed to ensure a resident’s chosen advance directive was accurately reflected in the medical record and communicated to the dialysis center for a resident who received hemodialysis twice a week. The resident had severe cognitive impairment with a BIMS score of 6 and diagnoses including end-stage renal disease, dependence on renal dialysis, unspecified encephalopathy, unspecified dementia, dysphagia following cerebral infarctions, hypertension, COPD, anxiety disorder, weakness, and a history of prostate cancer. His EMR listed him as DNR/DNI, and his Diamond Care Center Directives to Define Scope of Medical Care form showed that he and his POA chose DNR, signed by the POA. During interviews, RN G stated the resident’s report sheet showed him as full code, while his current orders and signed advance directive indicated DNR/DNI. She also verified that the advance directive was not included in the communication sheets sent with him to dialysis. MDS RN B and the interim DON stated they expected the EMR and report sheet to match the signed advance directive, but the nursing report sheets had indicated full code until updated. They explained the resident’s daughter completed the advance directive form while he was at the dialysis center and sent it back to the nursing home, and they assumed she would have provided a copy to the dialysis center. The dialysis center nurse stated no advance directive was on file for the resident and that, without one, he would be treated as full code there. The facility’s dialysis transfer agreement required that any executed advance directive accompany the resident to the dialysis center, and the facility’s advance directive policy stated resident wishes would be communicated to staff and physician and documented in the care plan and orders.
Care plans not revised to reflect current fall-prevention needs
Penalty
Summary
The provider failed to ensure resident care plans were revised to reflect current fall-prevention needs for two residents who were identified as being at risk for falls and who had fallen. For one resident, observation showed she was sitting in a recliner at the nurse’s station with her walker in front of her and glasses missing an earpiece. Her EMR showed severe cognitive impairment, dementia, walker use for ambulation, Morse Fall assessments indicating high and moderate fall risk at different times, and nursing notes documenting falls. Although post-fall assessments stated the care plan had been reviewed, the care plan did not identify her fall risk or include fall-prevention interventions. For the second resident, observation showed he was in bed, mumbled when speaking, and had abrasions on both knees covered with dressings. His EMR showed severe cognitive impairment, multiple diagnoses including difficulty walking and hypotension, anticoagulant use, and a high Morse Fall Scale score. His care plan already identified him as a high fall risk and listed several interventions, but it had not been reviewed or revised since the prior year except for adding a physical therapy evaluation after a fall. The care plan did not include interventions noted by staff such as keeping his wheelchair away from him in his room, transferring with shoes on or with a gait belt, or keeping his bed in a lower position. Interviews showed confusion and inconsistency among staff about who was responsible for updating care plans. One RN stated she had never updated a care plan because she did not have access and believed the MDS coordinator handled it. The MDS coordinator stated she was responsible for updating care plans and confirmed the first resident’s fall risk and fall-prevention interventions had not been included, and that the resident’s Morse assessments were completed incorrectly because walker use was not marked. The interim DON stated care plans were expected to be updated when new orders or assessments were completed and that the facility’s fall protocol was to update the care plan with new interventions after a resident fell.
Insulin Monitoring and Fall Risk Care Plan Failures
Penalty
Summary
Nursing staff failed to follow physician orders and the facility’s blood sugar monitoring policy for a resident with type 2 diabetes, chronic kidney disease, dementia, legal blindness, and long-term insulin use. The resident had severe cognitive impairment with a BIMS score of 4 and orders for a FreeStyle Libre sensor, blood sugar checks before meals, two hours after meals, and as needed, along with scheduled Novolog and Lantus insulin and weekly Ozempic. The record showed multiple missed blood sugar checks before meals across July, August, and September 2025, along with numerous held or refused insulin doses, including doses held for reasons not supported by physician orders and doses that were missed without documentation of physician notification. The facility’s policy required blood sugar rechecks 15 minutes after treatment for hypoglycemia, notification of the PCP for repeated low readings, and glucagon for an unresponsive resident unable to swallow. Several hypoglycemic events were not handled according to that policy. On one occasion, the resident’s blood sugar was 62 and was rechecked about an hour later at 119 rather than after 15 minutes. On another occasion, the resident’s blood sugar dropped to 58 and later rose to 102, but the low reading and treatment were not documented on the glucose log and the blood sugar was not rechecked after 15 minutes. Additional low blood sugar episodes were documented with delayed rechecks, missing glucose log entries, and no physician notification when two blood sugars were less than 70 within 24 hours. One event involved the resident being not arousable and unable to swallow bedtime medications while her glucose monitor alarmed at 52. Orange juice was given even though she did not open her eyes, her Lantus was held, and her blood sugar was not rechecked for an hour. The nurse did not administer glucagon as required by policy for an unresponsive resident unable to swallow, did not recheck the blood sugar after 15 minutes, and did not notify the physician of the hypoglycemic event. Staff interviews confirmed they expected low blood sugars to be treated, rechecked every 15 minutes until normal, documented, and reported to the physician, and they verified there were no physician orders authorizing insulin to be held. Nursing staff also failed to assess and plan for fall risk for another resident. That resident had dementia with a BIMS score of 6, used a walker, had Morse Fall assessments showing high and moderate fall risk, and had documented falls on 3/28/25 and 8/31/25. Despite this history, the care plan did not identify the resident as a fall risk. The resident was observed sitting at the nurse’s station with her walker in front of her, and her glasses were missing the right earpiece. The facility’s fall policy stated that a licensed nurse would update the care plan to reflect interventions to prevent further falls and that the fall would be discussed by the interdisciplinary team as soon as possible after the fall.
Unsafe Motorized Wheelchair Use Not Properly Assessed
Penalty
Summary
The nursing home failed to ensure safe use of motorized wheelchairs for two residents who used them. One resident, who had diagnoses including anxiety, unspecified encephalopathy, and paralytic syndrome, had a recent decline, was on hospice services, and was noted by hospice staff and facility staff to be increasingly confused. She was observed being transferred into her electric wheelchair with a total-body lift, and later a progress note documented that she became stuck in her bathroom in the wheelchair and told the CNA she had forgotten how to use the joystick. The record showed no assistive device assessment had been completed to evaluate her ability to safely use the electric wheelchair, and the COTA stated she had not completed such an assessment because she had not received an order to do so. A second resident with Parkinson's disease with dyskinesia was observed driving her motorized wheelchair into the bathroom door while entering and again while exiting, and later required her daughter's assistance to operate the wheelchair safely around other residents. Her EMR showed a prior assessment stating she could operate the device independently for routine use with occasional assistance in excessive congestion, but task documentation showed she had been observed running into objects 14 times over a recent period. Staff interviews reflected awareness that she had been running into doorways and other objects, and one RN noted progression of her involuntary arm and leg movements related to Parkinson's disease. The facility's policy required a therapy assessment for safe operation of motorized devices, with a new assessment quarterly and after any acute change in condition or poor safety awareness.
Controlled Medications Not Counted and Left Unsecured
Penalty
Summary
Controlled medications were not maintained according to the facility’s policy. During observation and interview, a small locked black box in the medication refrigerator contained one lorazepam oral liquid and one lorazepam injectable for emergency use, but staff were not counting those medications at each shift change. RN G stated she was unsure why they had not been counted, agreed they should have been counted at shift change, and acknowledged that the amounts should have been counted the same way as medications locked in the medication cart. She also stated that nurses were the only people with access to the keys for the medication storage room and the locked box. An opened bottle of morphine sulfate liquid was also observed in an unlocked drawer at the nurses’ station. RN G stated she had removed the bottle from the locked compartment in the medication cart that morning and placed it in the drawer while waiting for another nurse to destroy it, then forgot it was there. The MDS coordinator/infection preventionist also confirmed that the lorazepam in the medication refrigerator had not been counted and agreed those amounts should have been counted at each shift change with each exchange of keys. The facility policy stated that controlled substances, including refrigerator items, are to be physically inventoried at each shift change or when keys are transferred, and that controlled substances remaining in the facility after discontinuation or discharge are to be retained in a securely locked area with restricted access until destroyed.
Failure to Follow Infection Control Practices for Oxygen Tubing and Wound Precautions
Penalty
Summary
Infection prevention and control practices were not followed for two residents who were receiving oxygen and nebulizer treatments. Resident 29 was observed seated in his recliner wearing a nasal cannula connected to oxygen at 2 liters via concentrator, and he also had a portable oxygen tank attached to his wheelchair with an undated nasal cannula. The nebulizer tubing in his room was dated 8/25/25 at 5:00 a.m., while the treatment administration record directed that oxygen tubing and nebulizer set up and tubing be changed weekly and dated and timed when changed. The oxygen tubing and nebulizer setup had been signed off as changed on 9/7/25, but the tubing in the room was not dated as required by the provider’s process. Resident 9 was also observed receiving oxygen by nasal cannula tubing that was not dated. Her electronic medical record showed diagnoses including COPD, CHF, dependence on supplemental oxygen, hypoxia, and anxiety, and her orders directed that oxygen tubing be changed every Sunday night shift with the date and time labeled on the tubing. A CNA stated that night shift nurses would replace residents’ oxygen tubing weekly and that he sometimes saw oxygen tubing dated. Resident 1, who had a pressure ulcer on the coccyx identified on 9/2/25 and ordered for daily skin and wound monitoring, was not placed on enhanced barrier precautions despite the facility’s policy stating that EBP are recommended for residents with wounds and that wound care is a high-contact activity requiring gown and glove use. During care, two CNAs assisted the resident with dressing, applied Calmoseptine to groin folds, changed gloves without hand hygiene, moved the resident in bed, handled trash, and transferred the resident using a full body lift. One RN stated the resident should have been on EBP, while the MDS coordinator stated she did not think EBP were needed until the wound became chronic.
Failure to Protect Resident from Abuse and Neglect and Inadequate Pressure Ulcer Care
Penalty
Summary
The provider failed to protect a resident who was mentally incapable of identifying safety risks from potential abuse and neglect by another resident. An incident occurred where a resident was found in another resident's room with her blouse unbuttoned and her breasts exposed. The resident was unable to unbutton her shirt herself due to a physical disability, raising concerns about inappropriate behavior. The facility did not notify law enforcement or the Department of Human Services immediately, as required, and waited for guidance from the South Dakota Department of Health. Additionally, the provider failed to provide necessary care for a resident with pressure ulcers. The resident, who was on hospice care, developed multiple pressure ulcers on her buttocks and heel. Despite the availability of dressings provided by hospice, the facility staff did not apply them in a timely manner, leading to the deterioration of the resident's condition. The pressure ulcers were not documented or treated appropriately until several days after they were first identified. The facility's inaction in both cases highlights a lack of adherence to protocols for reporting and addressing potential abuse and neglect, as well as a failure to provide timely and adequate care for pressure ulcers. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The provider failed to ensure timely and necessary care for two residents, leading to the development and worsening of pressure ulcers. For the first resident, hospice staff identified reddened areas on the buttocks on June 6, 2024, and provided dressings on June 7, 2024. However, the facility staff did not apply these dressings and instead placed the resident in a wheelchair, applying only cream. By June 10, 2024, the resident's condition had worsened, with multiple pressure wounds identified, including on the buttocks, coccyx, and heel. The family was not informed until June 10, 2024, and the appropriate wound care orders were not documented as completed until June 12, 2024. The resident passed away on June 14, 2024. The second resident, who was also under hospice care, developed multiple pressure ulcers while in the facility's care. Despite being at high risk for skin breakdown, as indicated by fluctuating Braden scores, there was a lack of documentation and implementation of a comprehensive repositioning plan. The resident acquired seven pressure ulcers, with some worsening from stage 2 to stage 3. The facility's documentation was inconsistent, and there was a delay in updating care plans to reflect the resident's declining condition and the need for pressure-relieving interventions. Interviews with hospice staff and facility personnel revealed communication issues and a lack of adherence to recommended care practices. Hospice staff expressed concerns about the facility's management of pressure ulcer care, noting that recommendations were not followed, and there was poor communication between the hospice agency and the facility. The facility's policies on pressure ulcer prevention and care planning were not effectively implemented, contributing to the deficiencies observed.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours per day for a total of 37 days across Federal Fiscal Quarters 1 and 2, as well as one day in June 2024. This deficiency was identified through a review of Payroll Based Journal (PBJ) reports, interviews, and record reviews. The specific dates without adequate RN coverage were detailed in the report, spanning multiple months from October 2023 to March 2024, and included an additional day in June 2024. The facility did not have a nurse waiver and was licensed to provide skilled nursing care, yet failed to meet the staffing requirement. Interviews with the facility's administrator and the Minimum Data Set (MDS) coordinator revealed that the PBJ data was entered manually, and there were issues accessing reports online. The administrator confirmed the absence of an RN for the required hours on the specified days and noted that while an RN was not always present, a physician and an RN were available by phone. The facility was actively advertising for RN positions through various channels, and staffing decisions were based on resident numbers and acuity levels. However, the facility did not have residents requiring RN care at the time of the deficiency.
Deficiency in Arbitration Agreement Details
Penalty
Summary
The provider failed to ensure that their Arbitration Agreement included the necessary details for a fair arbitration process. The agreement did not specify the full name of the arbitration organization or provide contact information for it. Additionally, the agreement allowed the provider to unilaterally select the location for arbitration, rather than ensuring it was convenient for both parties involved. Interviews with the administrator and the business office/social service designee revealed that they were unaware of who developed or approved the agreement, and that the agreement's deficiencies were not recognized until the survey. The administrator acknowledged that the agreement should have included the arbitration agency's full name and contact information, and that the location for arbitration should not be solely determined by the provider. It was also noted that not all residents had signed the arbitration agreement, and the administrator was unsure why some had not. Despite these issues, no disputes had occurred to date. A review of the provider's records showed that 26 out of 34 current residents had signed the Arbitration Agreement.
Inaccurate PBJ Data Submission and Staffing Deficiencies
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for Federal Fiscal Quarters 1 and 2. The PBJ CASPER reports indicated that there were no registered nurse (RN) hours for eight consecutive hours each day for more than four days, and no 24-hour nurse coverage each day for more than four days. Additionally, the weekend staffing metric was suppressed due to excessively low data submission. The administrator confirmed that the data for these quarters had not been submitted accurately, and there was no nurse waiver in place. Interviews revealed that the Minimum Data Set Coordinator (MDS)/RN was responsible for submitting the PBJ data until January 1, 2024, after which the administrator took over. The facility's time clock system did not automatically upload payroll data to the PBJ system, requiring manual entry. The administrator acknowledged that there was not always an RN present for eight consecutive hours each day, although a licensed nurse was present 24 hours each day. The administrator also declined to answer questions regarding the accuracy of low weekend staffing data.
Failure to Update and Revise Care Plans
Penalty
Summary
The provider failed to review and revise comprehensive care plans for six of twelve sampled residents, leading to discrepancies between the care plans and the actual care needs of the residents. For instance, a resident receiving dialysis treatments had a care plan indicating fluid restrictions, which were no longer applicable as the dialysis provider had discontinued them. This discrepancy was not communicated effectively to the staff, resulting in confusion about the resident's current care needs. Another resident, who smoked cigarettes, was assessed as safe to smoke independently, but the care plan inaccurately indicated that he was not safe to smoke on his own. This inconsistency in the care plan could lead to inappropriate supervision and care. Additionally, a resident with a high risk of falls had a care plan that did not reflect the necessary interventions, such as positioning the bed low to the floor and using a fall mat at night, which were crucial for her safety. Furthermore, the care plans for two residents who were considered vulnerable adults due to their conditions were not updated to include new interventions for their safety. The facility's policy required care plans to be updated with any significant changes in the resident's condition, but this was not consistently done. The MDS/RN was responsible for ensuring the accuracy of the care plans, but the documentation did not support that the care plans were updated as required.
Expired Medications and Improper Storage in Facility
Penalty
Summary
The provider failed to ensure proper monitoring and removal of expired medications and personal care products in the facility. During an observation, it was found that PRN medications stored in blister pack cards for three residents were expired and had not been removed for destruction. Additionally, four medications for three residents lacked opened or expiration date stickers. The facility's policy requires that expiration dates be determined by the pharmacist at dispensing and that medications be marked with an opened date. However, these procedures were not followed, leading to expired medications remaining in the medication cart. In a separate observation, prescription personal care products in a resident tub room were not securely stored or discarded when expired. The tub room contained prescription products with expired dates, including Selsun Blue shampoo, anti-itch lotion, Desitin, and Nystatin powder. The MDS coordinator/RN confirmed that prescription items should have been stored in a locked medication cart or room and that expiration dates should have been monitored and expired items discarded. However, these practices were not adhered to, resulting in expired and improperly stored prescription products in the tub room.
Infection Control Deficiency During Dressing Changes
Penalty
Summary
The provider failed to adhere to acceptable infection control practices during dressing changes for two residents, both of whom were on enhanced barrier precautions (EBP). Registered Nurse (RN) N was observed performing dressing changes for these residents without following proper hand hygiene protocols. During the dressing change for the first resident, RN N donned gloves and a gown in the hallway, then proceeded to touch various surfaces and the resident's personal items without changing gloves or performing hand hygiene. She also touched the resident's wound area directly with gloved hands that had been in contact with potentially contaminated surfaces. After removing her gloves, she did not wash her hands before applying tape to the gauze and the resident's toe, which is considered hands-on care. In a similar incident with the second resident, RN N again failed to perform hand hygiene at critical points during the dressing change. She used the same pair of gloves to handle supplies, touch the resident's skin, and apply wound care products. After removing her gloves, she did not wash her hands before securing the dressing with tape, directly touching the resident's toe. These actions were contrary to the facility's hand hygiene and personal protective equipment policies, which require hand hygiene before and after resident care and the use of gloves. Interviews with RN N revealed a lack of awareness regarding the missed opportunities for hand hygiene and glove changes. Despite receiving ongoing training from her staffing agency, RN N did not follow the facility's infection control policies. The Minimum Data Set (MDS) coordinator confirmed that agency staff were expected to adhere to the facility's policies, although orientation did not cover handwashing or glove use. The facility's policies clearly outlined the need for hand hygiene and proper use of personal protective equipment, which were not followed in these instances.
Failure to Routinely Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as residents 8 and 9, were routinely assessed for the safe self-administration of medications. During an interview and observation, it was noted that resident 8 had a bottle of nasal spray on her bedside table, but the registered nurse (RN) was unsure if there was a physician order for self-administration, leading her to administer the medication herself. Resident 8's medical record indicated she had a BIMS score of 15, showing intact cognition, and had several medications she was allowed to self-administer, but there was no self-administration order for the nasal spray. Resident 9 also had a BIMS score of 15, indicating intact cognition, and had an order for unsupervised self-administration of a medication for constipation. However, her most recent self-administration assessment was completed over a year ago. The facility's policy required quarterly assessments for self-administration, which were not conducted for either resident. The minimum data set coordinator confirmed that these assessments should have been completed quarterly. The facility's policy on self-administration of medications outlined the need for an initial screening tool to evaluate residents' ability to self-administer medications, with quarterly evaluations thereafter. Despite this policy, the facility did not perform the required quarterly assessments for residents 8 and 9, leading to a deficiency in ensuring the safe self-administration of medications.
Inaccurate MDS Assessments for Pressure Ulcers and Catheter Use
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical conditions. For one resident with pressure ulcers, the MDS assessment completed on 5/11/2024 inaccurately indicated that the resident had no unhealed pressure ulcers, despite weekly wound documentation on 5/6/2024 showing two grade 2 coccyx pressure wounds. The MDS/registered nurse (RN) responsible for the assessment admitted to not reviewing the weekly wound documentation before completing the MDS, resulting in incorrect coding. In another case, a resident's MDS assessment on 5/4/2024 incorrectly noted the presence of an indwelling urinary catheter, although the resident had not had a catheter since admission. The MDS/RN responsible for this assessment was unaware that the section had been marked incorrectly. The RN's training included basic online resources, and she relied on the RAI manual for guidance when needed. These inaccuracies highlight a failure to adhere to the CMS Resident Assessment Instrument (RAI) Manual guidelines, which require thorough review and confirmation of medical records and resident conditions.
Failure to Monitor Dialysis Patient Post-Treatment
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment. Resident 16, who received dialysis twice a week, had a physician's order dated December 4, 2023, which required the assessment of vital signs and the fistula site for any abnormalities upon returning from dialysis. This assessment was to be documented, and any abnormal findings were to be reported to the primary care provider. However, there was no documentation of such monitoring for four out of sixteen opportunities between April 19, 2024, and June 10, 2024. The specific dates lacking documentation were April 19, May 13, May 20, and June 10, 2024. Interviews revealed that the charge nurse on duty was responsible for monitoring and documenting the resident's condition in the electronic medical record. The minimum data set coordinator/registered nurse indicated that LPN J was responsible for the documentation on three of the four days it was not completed. However, LPN J's documentation had been problematic, and she was no longer employed at the facility. The provider's dialysis policy, dated October 29, 2024, stated that nurses should monitor the dialysis catheter and/or AV fistula site every shift for signs of infection or malfunction, and report any concerns to the appropriate medical professionals.
Failure to Assess and Document Bed Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents using bed side rails were appropriately assessed, and the documentation accurately reflected the type of bed side rail in use. Resident 8 was observed using side rails on both sides of the upper half of her bed, which she had been using since 2023 to assist with turning in bed after a hip fracture. Her medical record indicated a physician's order for a 1/4 side rail/grab bar, but the Physical Device Evaluation noted the use of 1/2 side rails. No further evaluations were completed after April 2023, and her care plan mentioned the use of a 1/4 side rail/grab bar, indicating inconsistencies in documentation and assessment. Resident 2 was observed with a side rail on the right side of his bed, with a physician's order for a U-shaped grab or 1/4 side rail to assist with independence and repositioning. An Assistive Device Assessment and a Physical Device Assessment were completed in January 2024, but no further assessments were conducted. The facility's policy required quarterly assessments for side rail use, which were not completed for these residents. The MDS coordinator acknowledged the lack of current assessments and was unsure why they were not completed. The facility's restraint policy outlined the need for assessments and care plan reviews, which were not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Canistota | 10.7 mi | ★★★★★ | 11 | 0 |
| Oakview Terrace | 14.9 mi | ★★★★★ | 0 | 0 |
| Tieszen Memorial Home | 15.3 mi | ★★★★★ | 0 | 0 |
| Menno-olivet Care Center | 22.3 mi | ★★★★★ | 1 | 0 |
| Avera Bormann Manor | 26.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Diamond Care Center.
100% money-back within 48 hours.
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.