Diamond Ridge Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat Resident 1 with respect and dignity when Certified Nursing Assistant (CNA) 1 did not wash Resident 1's buttocks when CNA 1 gave Resident 1 a shower. This failure resulted in Resident 1 feeling upset and angry. During an interview on 1/13/26 at 11:07 a.m., with Resident 1, the resident stated CNA 1 did not wash her buttocks when CNA 1 gave her a shower on 12/27/25 at 10 a.m. Resident 1 stated she asked CNA 1 to wash her buttocks because the resident could not reach it. Resident 1 stated CNA told her that CNA 1 did not want to hurt her back if CNA 1 bent too much to wash Resident 1's buttocks. Resident 1 stated she felt upset and angry. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident 2's family member (FM) 1 was provided proper training in the use of broda wheelchair (a broda wheelchair is a specialized, highly adjustable positioning wheelchair). This failure resulted in Resident 2 falling from the broda wheelchair and hitting her face on the floor while being wheeled by FM 1. During an interview on 1/13/26 at 10:14 a.m., with Resident 2, the resident stated that on 12/16/25, while being wheeled by FM 1, she fell from her wheelchair and hit her face in the floor. Further stated her fall could have been prevented if the facility trained FM 1 on how to safely and properly wheel Resident 2 with the broda wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician and responsible party (RP) were promptly notified for one of three sampled residents (Resident 1) when Resident 1 had respiratory distress (difficulty breathing). This failure had the potential for Resident 1 to develop further exacerbated medical complications and/or need for emergency medical treatment at the acute hospital. During a review of Resident 1's admission Record, dated 12/29/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included asthma (asthma is a long-term lung disease that makes it difficult to breathe. The tubes that carry air in and out of the lungs become swollen, narrow, and produce extra mucus, similar to trying to breathe through a very thin or clogged straw). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store and prepare foods in a sanitary manner that prevented foodborne illness for the facility when: 1. Eleven unlabeled and undated sandwiches were stored in the refrigerator, 2. Multiple food items were stored in the dry storage room beyond use by date, and 3. Two outdated sandwiches and eight grapes with mold was stored on Resident 54's bedside table. These failures had the potential for residents to be exposed to food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to timely develop and provide a baseline care plan for three of 32 sampled residents (Resident 108, 109, and 363) when the baseline care plans were not developed within 48 hours of Resident 108, 109 and 363's admission and the baseline care plan written summaries were not provided to the Resident 108, 109, 363 and the representatives. This failure had the potential to reduce the continuity of care and communication between Resident 108, 109, 363, the representatives, and the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 28, 21, 63 and 84) received necessary care to maintain good grooming and personal hygiene when: 1. Resident 28 had long facial hair and long fingernails with black matter underneath, 2. Resident 21 had long fingernails with black matter underneath, 3. Resident 63 had long, thick facial hair, and 4. Resident 84 had long facial hair. This failure resulted in Residents 28, 21, 63 and 84 at risk for skin irritation and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 4 did not wear face shield inside COVID-19 isolation room, 2. CNA 5 did not perform hand hygiene before entering Resident 166's room, 3. a glucometer (a device used to check blood sugar level) was stored inside the medication cart had traces of dark red stains around it, 4. a tray full of multiple single-use lancet supplies (a small sharp device that pricks the skin to draw a blood sample for testing blood sugar levels), a bottle of blood sugar test strips, alcohol pads and a glucometer device was placed on top of Resident 35's bed was not disinfected by Licensed Vocational Nurse (LVN) 4 after use, 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three closed resident records sampled (Resident 112) was not coded correctly on the Minimum Data Set (MDS-a standardized assessment tool used to direct health care needs) when Resident 112 was discharged home. This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS) regarding Resident 112's discharge status.

Inspectors wroteBased on interview and record review, the facility failed to develop new interventions to address behavioral care and treatment for one of 32 sampled residents (Resident 264) with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) when Resident 264 exhibited physical and/or verbal aggression towards others 24 days of out 31 days in May 2024. This deficient practice had the potential for Resident 264 to harm herself and other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 364) received Cromolyn Sodium Ophthalmic Solution (a prescription eye drop medication used to treat allergic eye conditions) according to physician's order. This failure resulted in Resident 364 not receiving appropriate treatment to control eye allergy symptoms and experiencing very itchy eyes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 52) was free from unnecessary medication, when Resident 52 was prescribed and given Risperidone (medication to treat symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions)) and did not have schizophrenia. This failure resulted in Resident 52 being administered an unnecessary medication and had the potential for increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 110, when: 1. Resident 5's inhalation medication with limited shelf life after opening was not dated for beyond used date in medication cart #2b, and 2. Resident 59's intravaginal (insertion through the vagina or birth canal) medication was stored together with the oral medications in medication cart #2a. These failures had the potential to contribute to unsafe use of medications and potential for medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant 1 (CNA 1) raised her arm at Resident 1, as if she was to strike Resident 1. CNA 1 had previously exhibited aggressive verbal behavior towards Resident 4 and 5. This failure placed Resident 1 at risk for emotional and psychological distress.

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 was unable to sleep despite the use of sleep medication. This failure potentially contributed to increase in episodes of negative behavior and falls and had the potential to result in delayed modification of treatment regimen.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was administered olanzapine (treats psychosis, a mental illness), lexapro (anti-depressant, treats depression) and trazodone (anti-depressant) with adequate monitoring of adverse effects from the medications. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication.

Inspectors wroteBased on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at risk for aspiration, was provided honey thick liquids (thicker than nectar thick, less pourable from a cup or a bowl) as ordered by the physician when nectar thick consistency liquid (easily pourable than honey thick, like thicker cream soups) was served. This failure had the potential to result in aspiration (when food or liquid enters the airway and goes into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to have a baseline care plan for four of five sampled residents when Residents 41, 254, 255, and 257 did not have baseline care plans within 48 hours of admission. This deficient practice had the potential to decrease the continuity of care and communication between care givers resulting in poor quality care and potential adverse outcomes.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain sufficient staffing to provide care for five of five sampled residents, Resident 13, Resident 38, Resident 58, Resident 254, and Resident 255. This deficient practice resulted in Residents not getting call lights answered, not getting showers, not having assistance to use the bathroom which lowers the quality of care and the potential to cause an accident and psychosocial harm.

Inspectors wroteBased on interview and record review , the facility failed to follow the policy and procedure for Medication Regimen Review to act upon the Consultant Pharmacist's (CP) report of medication irregularity for one (Resident 84) sampled resident when Resident 84 CP recommendation for use of quetiapine (Seroquel- antipsychotic medication) was not followed up in a timely fashion. {According to the manufacturer of Seroquel, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular e.g. heart failure, sudden death}. [Reference: [...]

Inspectors wroteBased on observation and interview, the facility failed to serve palatable food when meatballs were served for lunch that lacked flavor. This deficient practice had the potential to decrease meal enjoyment and residents to decline to eat.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow proper sanitation and food storage practices when: a. Kitchen floor tiles had brownish black residual discoloration, b. Two dishwasher racks had brownish/black discoloration, c. Ten cans of applesauce had used-by-date that expired 9/30/21. These deficient practices had the potential for an unsanitary food environment or serving expired food resulting in foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices during storage and handling of resident's respiratory equipment for four of four sampled residents. For Resident 255, Resident 256, and Resident 257, their oxygen cannula tubing was not dated for staff to know when the next tubing change should occur. For Resident 254, the Continuous Positive Airway Pressure (C-PAP, a machine to keep the airway open while sleeping) mask and tubing were undated and left exposed to the air on the night stand. This failure had the potential for the spread of infection and cross-contamination.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for two ( Resident 82 and 90) sampled residents when Resident 82 and 90's preadmission screening for serious mental illness was not coded accurately. This deficient practice had the potential for residents to not received appropriate mental health care and services.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and goals for dialysis (artificial kidney machine to remove waste products and excess fluids) care for one (Resident 88) of one sampled resident. This deficient practice had the potential to negatively impact Resident 88's quality of life, and quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry services (foot care including cutting of toenails) for one of two sampled residents (Resident 33). This failure had the potential to cause injury including ingrown toenails and scratches to feet and legs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain respiratory care orders or follow orders for three of four sampled residents when Resident 254 did not have an order for C-PAP (a machine that provides continuous positive airway pressure to keep airway open while sleeping). Resident 256 did not have the correct flow of oxygen being delivered, and Resident 257 did not have an order for oxygen. This failure had the potential to cause harm by delivering too much oxygen to Resident 256 with chronic obstructive pulmonary (lung) disease (COPD) or giving unnecessary supplemental oxygen or C-PAP to Resident 257.

Inspectors wroteBased on observation, interview and record review, the skilled nursing facility did not effectively manage the pain for one of 20 residents (Resident 155). Resident 155 did not receive pain medication as ordered by the doctor. This failure resulted in unnecessary pain for Resident 155.

Inspectors wroteBased on interview and record review, the facility failed to consistently supply a medication prescribed by a physician for one (Resident 9) of five sampled residents. This failure resulted in Resident 9 experiencing nausea, dizziness and headaches. A review of Resident 9's Face sheet (document with residents' general information) indicated an initial admission date of 3/2/17 with multiple diagnoses including, chronic pain and neuropathy (a condition causing weakness, numbness, and pain from nerve damage). During an interview on 4/11/22 at 12:45 p.m., with Resident 9, Resident 9 stated recently, there were missed multiple doses of Nortriptyline (medication used to treat nerve pain and depression) because the facility ran out. Resident 9 stated with missed doses of the medication, resident felt nauseous, dizzy and got headaches. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two sampled residents (Resident 60 and 84) were free from unnecessary drugs as follows: 1. Resident 60 was administered buspirone (antianxiety) without adequate monitoring of behavior manifestations and medication side effects. 2. Resident 84 was administered quetiapine (Seroquel- antipsychotics) without adequate monitoring of behavior manifestations and medication side effects. Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. According to the manufacturer of Seroquel, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the skills competency evaluations were completed for dietary staff. The dietary Aide (DA) and one [NAME] (CK) competency skills evaluations were not completed for providing the residents' food services. This deficient practice had the potential to result in unsafe food preparation practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one (Resident 59) sampled resident's wheelchair in good working condition when Resident 59's wheelchair was squeaky and difficult to maneuver. This deficient practice resulted in Resident 59 having difficulty moving around the facility in his wheelchair.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure (P&P) for staff requesting COVID-19 (a contagious respiratory infection mainly affecting the lungs) vaccine religious exemption. This failure had the potential for unvaccinated staff to work in the facility without the administrators' and other staff awareness which could expose residents and staff to COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the infection control program was implemented and to use the proper sanitary technique when: 1. Registered Nurse/Nursing Supervisor (NS 1) used gloves that was removed from her uniform pocket to clean an opened wound and applied a dressing. 2. One staff used their bare hands to cut a biscuit while serving breakfast. 3. Four of seven staffs' health records did not have proof of their vaccination against Measles, Mumps and Rubella (MMR-contagious viral infections) and Tdap (Tetanus, Diphtheria, Pertussis-whooping cough) which are communicable bacterial infections, with the exception of Tetanus. These failures had the potential for the transmission of infection.

Inspectors wroteBased on interview and record review, the facility failed to implement the Advance Directive (legal document with written instructions for the provision of health care) policy at the time of admission for two (Residents 55 and 209) of 30 sampled residents, or their legal representative about future healthcare choices, and name a person to make decisions when the resident is unable to do so. For Residents 55 and 209, this failure resulted in not verifying if there were existing advance directives for healthcare to guide choices for doctors and caregivers or contact the resident/representative if they wish assistance in formulating an advance directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care and nail hygiene for two (Resident 79 and 85) of 30 sampled residents as follows: 1. Resident 79 had hand contractures (the shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and long curved fingernails that were digging into the resident's right palm. 2. Resident 85 had long fingernails with brownish residue underneath the nails and chipped nail polish. These failures had the potential for nail bed injury, poor skin integrity, and harboring dirt and bacteria underneath the fingernails that could contribute to the spread of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one (Resident 79) of 30 sampled residents received restorative care services (assists patient to gain strength and mobility) according to the comprehensive care plan. For Resident 79, staff failed to apply a hand, palm roll for protection and intervention for contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). This failure had the potential to cause further decline of range of motion (ROM), joint mobility, and skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance and arrange services to restore the hearing aids for one (Resident 7) of 30 sampled residents to maintain hearing ability . This failure resulted in no services to assist with repairing the faulty hearing aid and caused Resident 7 frustration due to impaired communication with staff and others.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 66) of 30 sampled residents, the facility failed to elevate the head of bed (HOB) to 30-45 degrees to prevent potential complications while receiving enteral nutritional feeding (liquid formula via the gastrointestinal tract) through the percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed tube into the patient's stomach). This failure had the potential for aspiration (fluids entering the windpipe) or aspiration pneumonia (lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled (count verification) to prevent potential diversion or tampering when one of five medication carts (Med Cart 1 A) had a blister-pack (pills stored in bubble seal and popped out through a paper or foil backing) of Hydrocodone (opioid pain medication) had a torn backing exposing the drug. In addition, one of five medication carts had no completed Controlled Drug-Count Record. These failures had the potential for unauthorized access, diversion, and abuse of controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy for Medication Regimen Reviews (MRR) for one (Resident 46) of thirty sampled residents when the antidepressant medication was not reviewed monthly. This deficient practice had the potential to result in physical, mental or psychosocial harm for Resident 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from unnecessary drugs for three (Resident 46, 85, 93,) of 30 sampled residents as follows: 1. For Resident 46, an antidepressant (Paxil) was ordered without a medical indication for its use. 2. For Resident 85, an antipsychotic (Seroquel) medication was administered without supporting documentation for its continued use. 3. For Resident 93, a sedative medication was ordered with no monitoring of hours of sleep and adverse effects of the drug. These deficient practices had the potential for physical, mental or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled, stored, and secured in accordance with the facility's policy as follows: 1. An opened bottle of Procrit [used to treat anemia (low red blood cell count)] was expired, unlabeled, and had no opened date. 2. A half bottle of expired anticholinergic Glycopyrrolate (reduces excessive drooling) medication was stored with currently used medications in the top drawer of Medicine Cart 1 C. 3. One of two treatment carts was left unlocked and unattended. These practices had the potential for reduced potency of the medications due to improper storage, and placed residents at risk for accidental use or ingestion of topical medications when left unlocked.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage of laboratory test supplies when expired laboratory sample collection kits were stored with currently used laboratory test kits. This failure had the potential for inaccurate test results and affect the medical provision of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents with a nourishing, well balanced diet that meets their daily nutritional intake and special dietary needs for two (Residents 16 and 162) of 30 sampled residents when: 1. Resident 16 did not receive his diet vanilla pudding and low sugar house shake. 2. Resident 162 did not receive his preferred scrambled eggs and biscuit. This failure resulted in residents not meeting their dietary needs and meals preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow the policy and procedure to store, clean floors, and keep equipment under sanitary conditions when: - The Kitchen floor tiles had brown sediments and drainage pipe area had yellowish buildup. - The Ice machine had pink-white build up on the front panel cover plate, back plate, and around the condensing unit. - Emergency food supplies were missing eight cans of beef steak - The food processor, mixing bowl, and slicer had white & brown sediment. These failures had the potential to result in waterborne illnesses from the unsanitary ice machine, contamination from using unclean cooking equipment or not enough supplies to meet emergency preparedness.

Inspectors wroteBased on observations, interviews, and record reviews for three (Residents 160, 93, and 161) of 30 sampled residents, the facility failed to ensure the clinical records contained accurate health status information as required. 1. For Residents 160 and Resident 93, a care plan for the pacemaker (device to help control abnormal heart rhythms) did not contain the type of pacemaker, set rate and insertion date. This failure had the potential for not detecting a pacemaker malfunction. 2. For Resident 161, there was no complete labeling with date/time and initialed by the registered nurse (RN) for IV (intravenous, into the vein) antibiotic medication. This failure had the potential for medication errors.