Diamond Care Center

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, facility assessment review, and interview, the provider failed to have licensed nursing coverage for 24-hours per day in the facility for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, facility assessment review, and interview, the provider failed to ensure a registered nurse (RN) was in the facility for eight consecutive hours daily for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data was submitted to the Centers for Medicare and Medicaid (CMS) for one of four federal fiscal quarters (Quarter 3, 2024).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to monitor refrigerator temperatures to ensure safe food storage for six of six sampled residents (13, 14, 20, 29, 30, and 31) with refrigerators in their rooms.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure certified nursing assistants (CNAs) did not administer a resident's topical (applied to the body) medications and self-administered medications were documented for one of (one) sampled resident (1) who self-administered medications and, at times, requested CNAs to administer her topical medications stored in her room.

Inspectors wroteBased on record review, interview, review the providers dialysis agreement, and policy review, the provider failed to ensure the resident's chosen advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) was accurately reflected in the resident's medical record and communicated to the dialysis center for one of one sampled resident (7) who received dialysis services.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure resident care plans had been revised to reflect their current needs for fall prevention for two of two sampled residents (25 and 3) who were identified to have a risk for falling and had fallen.

Inspectors wroteBased on policy review, record review, and interview the provider failed to follow nursing professional standards of practice to ensure nursing staff:*Followed physician orders, and provider's policy for one of two sampled residents (5) with orders for insulin administration and blood sugar level monitoring, and to ensure low blood sugars were reported to the physician per the provider's policy.*Assessed one of one sampled resident (25) for risk of falling, fall prevention interventions had been in place. Findings Include:1. Review of the provider's 6/7/22 Blood Sugar Monitoring policy revealed:*1. Check physicians [physician's] order for blood sugar testing frequency.2. Notify provider if 2 glucose checks are <70 [less than 70] or >400 [greater than 400] in 24 hours and/or change in condition. If no change in condition, notify the PCP [primary care provider] the next day. Hypoglycemia1. [...]

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the safety of:*Two of two sampled residents (1 and 4) who used motorized wheelchairs had been assessed for their ability to safely use motorized wheelchairs according to the provider's policy and ensure the safety of other residents.

Inspectors wroteBased on observation, interview, and policy review, the provider to maintain the supply of controlled medication (medication at risk for abuse and addiction) according to the provider's policy to ensure:*Oral and injectable lorazepam (controlled anti-anxiety medication) stored in one of one medication storage room had been accounted for with each shift change.*One of one bottle of oral liquid morphine sulfate (pain medication) observed in a drawer at the nurses' station had been stored in a secure area.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow infection control practices to ensure:*Two of two sampled residents (29 and 9) oxygen and nebulizer tubing was dated to identify when the tubing had been placed in the residents' room for use according to the provider's process. *One of one sampled resident (1) with an open wound caused by prolonged pressure (pressure ulcer) had been placed on enhanced barrier precautions according to the provider's policy.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), observations, interviews, and record review, the provider failed to ensure: *One of one sampled resident (10) who was mentally incapable of identifying safety risks was free from the potential of abuse and neglect by one of one sampled resident (37). *One of one sampled resident (1) received necessary care related to pressure ulcers.

Inspectors wroteBased on a review of the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, and observation, the provider failed to ensure two of two sampled residents (1 and 4) received necessary care and treatment in a timely manner for the prevention of pressure ulcers.

Inspectors wroteBased on Payroll Based Journal (PBJ) reports, interview, and record review, the provider failed to ensure there was a registered nurse (RN) working for eight consecutive hours per day for 36 days in Federal Fiscal Quarters 1 (October, November, and December 2023) and Quarter 2 (January, February, and March 2024), and one day from June 6th, 2024, through June 14, 2024.

Inspectors wroteBased on interview, Arbitration Agreement review, and record review, the provider failed to ensure the Arbitration Agreement: *Included the arbitration organizations name and how to contact that organization. *Provided for a location that was convenient for both parties for an arbitration dispute.

Inspectors wroteReview of the provider's PBJ CASPER reports revealed the following items triggered: *Federal Fiscal Quarter 1 and Federal Fiscal Quarter 2: -No registered nurse (RN) hours for eight consecutive hours each day for more than four days. -No 24-hour nurse coverage each day for more than four days. -The weekend staffing metric was suppressed, meaning the data submitted was excessively low. Interview on 6/21/24 at 11:30 a.m. with administrator A regarding PBJ reporting revealed: *Minimum Data Set Coordinator(MDS)/registered nurse (RN) C had been responsible to submit the PBJ data to CMS. *The time clock system was not able to automatically upload the payroll data to the PBJ system. -The information had to be entered manually. *Administrator A had recently gained access to the PBJ online reporting site, and the time clock had uploaded the data successfully. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to review and revise comprehensive care plans to ensure care needs were accurately reflected for six of twelve sampled residents (3, 10, 16, 23, 26, and 37).

Inspectors wroteBased on plan of correction review for survey date 6/21/24, staff member listing, record review and interview, the provider failed to ensure the plan of correction (PoC) review from the 6/21/24 with a completion date of 7/23/24, staff member listing review, record review, and interview, the provider failed to ensure the PoC was followed regarding staff education for the previously cited following citations: F554, F686, F761, and F880.

Inspectors wroteA. Based on observation, interview, and policy review, the provider failed to ensure: *As needed (PRN) medications stored in blister pack cards with pharmacist-determined expiration dates had been monitored for expiration and removed for destruction for three of three sampled residents (14, 22, and 31) in one of one medication cart. *Four of four medications had opened or expiration dates indicated, for three of three sampled residents (7, 15, and 33) in one of one medication cart.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow acceptable infection control practices during two of two observed dressing changes for two of two sampled residents (4 and 15) by registered nurse (RN) N.

Inspectors wroteBased on interview, observation, record review, and policy review the provider failed to ensure two of two sampled residents (8 and 9) had been routinely assessed for safe self-administration of medication.

Inspectors wroteBased on record review, interview, and Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (RAI) Manual, the provider failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for: *One of one resident (15) who had pressure ulcers. *One of one resident (27) who did not have a catheter. 1. Review of resident 15's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Weekly wound documentation completed on 5/6/24 indicated two grade 2 coccyx pressure wounds. -Resident has two new open sores to coccyx- one on the left and right side. *Her 5/11/2024 Quarterly Minimum Data Set (MDS) assessment, section M (Skin Conditions) indicated the resident had no unhealed pressure ulcers. Interview on 6/20/24 at 2:47 p.m. with MDS/registered nurse (RN) C regarding resident 15's pressure ulcers revealed: [...]

Inspectors wroteBased on interview, record review and policy review the provider failed to ensure one of one sampled resident (16) who required dialysis treatment was monitored for abnormalities upon returning from his dialysis treatment.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure two of two sampled residents (2 and 8) who used bed side rails were appropriately assessed and documentation accurately reflected the type of bed side rail in use.

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notice was provided for three of three sampled residents (7, 13, and 35) following their discharge from part A skilled services.