Diplomat Healthcare

Inspectors wroteBased on closed record review, review of hospital medical records, review of a local in-progress police report, policy review and interview, the facility failed to adequately and accurately identify and record a decline in a wound for Resident #150. This affected one resident (#150) of three residents reviewed for wounds and skin impairments. The facility census was 108. Actual Harm occurred on 10/21/25 when Resident #150 was admitted to the hospital with altered mental status, a urinary tract infection, dehydration, and malnutrition and assessed to have an unstageable pressure ulcer (a full-thickness wound where the depth of the damage cannot be determined because the wound bed is obscured by dead tissue) to the coccyx (tailbone area) that measured seven centimeters (cm) in length by eight cm in width. [...]

Inspectors wroteBased on resident interview, medical record review, staff interview, and facility policy review, the facility failed to ensure routine care plan conferences were conducted. This affected two residents (#150 and #73) of five residents reviewed for care plan conferences. The census was 108.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to inform a resident's physician of ongoing medication refusals and failed to ensure resident representative were notified of changes. This affected three residents (#62, #103 and #106) of six residents reviewed for notification of change in condition. The facility census was 108.

Inspectors wroteBased on observation, interview and record review The facility failed to ensure medication consumption was monitored to ensure medications were safely swallowed. This affected one resident (#28) of four residents observed and reviewed for medication administration. The facility census was 108.

Inspectors wroteBased on interview, record review, facility fall investigation, emergency medical services (EMS) run report, and facility policy review, the facility failed to ensure an accurate and thorough fall investigation was completed. This affected one resident (#150) of three residents reviewed for falls. The facility census was 108.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure adequate incontinence care was provided to Resident #28. This affected one resident (#28) of three residents reviewed for incontinence care. The facility census was 108.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health. This affected one resident (#150) and had the potential to affect all residents residing in the facility. The facility census was 108.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure laboratory results were timely obtained and results timely reported to the provider to allow for timely treatment of a urinary tract infection (UTI). This affected one resident (#12) of three residents reviewed for UTIs. The facility census was 108.

Inspectors wroteBased on observation, record review, review of hospice notes, review of a facility self-reported incident, review of hospital records, facility policy review and interview, the facility failed to provide adequate, necessary and timely treatment for Resident #67, a resident with cognitive impairment who was dependent on staff for activities of daily living, following an acute change in condition. The facility also failed to thoroughly investigate the change in condition to determine the circumstances surrounding the change. Actual Harm occurred beginning on 11/21/24 when Licensed Practical Nurse (LPN) #279 observed Resident #67's normally contracted left arm to be flaccid with increased pain noted. There was no evidence a hospice-ordered x-ray examination was completed on 11/21/24. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents who received meals from the kitchen with the exception of one resident, Resident #63 who received nothing by mouth. The facility census was 101.

Inspectors wroteBased on family and staff interview, medical record review, and facility policy review, the facility failed to timely notify Resident #67's representative of a change in condition. This affected one (Resident #67) of three residents reviewed for change in condition. The facility census was 101.

Inspectors wroteBased on observation, family, resident, and staff interview, record review and review of the facility policy, the facility failed to ensure a clean environment free of consistent foul odors for the residents. This affected two (Residents #5 and #39) of three resident reviewed for incontinence care. The facility census was 101.

Inspectors wroteBased on staff interview, review of the facilities Self-Reported Incidents (SRI) and investigations, review of policy, and medical record review, the facility failed to timely report an injury of unknown origin to the State Survey Agency and failed to complete self-report incident investigations within five days of the required timeline. This affected two (Residents #67 and #78) of seven residents reviewed for abuse. The facility census was 101.

Inspectors wroteBased on staff interview, review of facility self-reported incident (SRI) investigation, review of facility policy, hospice record review, and medical record review, the facility failed to thoroughly investigate a resident's injury of unknown origin. This affected one (Resident #67) of seven residents reviewed for abuse. The facility census was 101.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure physician orders were implemented to promote healing of a resident's wound to his foot. This affected one (Resident #67) of three residents reviewed for wounds. The facility census was 101.

Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure a resident received appropriate assistance during incontinence care to prevent accidents. This affected one (Resident #67) of three residents reviewed for accidents. The facility census was 101.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #11, who was cognitively impaired, dependent on staff for incontinence care/management and had moisture associated dermatitis (MASD) was provided necessary incontinence care to promote optimal skin integrity and prevent additional complications from the MASD. This affected one resident (#11) of three residents reviewed for incontinence care. The facility census was 101.

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate assessments and resident care was completed for Resident #203's groin condyloma (genital warts). This finding affected one (Resident #203) of three residents reviewed for wound care.

Inspectors wroteBased on medical record review, facility policy review, and interview, the facility failed to ensure resident-to-resident physical altercations were reported the State Agency as required. This affected ten Residents (#28, #30, #39, #48, #57, #58, #69, #77, #85, and #357) of 39 residents who reside on the secured memory care unit. The facility census was 99.

Inspectors wroteBased on record review and interview, the facility failed to ensure individualized cared planned interventions were in place to prevent resident behaviors resulting in resident to resident altercations on the secured memory care unit (SCMU). This affected nine Residents (#28, #30, #39, #48, #57, #58, #69, #77, and #85) of ten residents reviewed for behavioral health services. The facility census was 99.

Inspectors wroteBased on observation record review and interview the facility failed to ensure Resident #10 was assisted with eating his meal in a timely manner. This affected one resident (Resident #10) out of three residents reviewed for meal assistance. The facility census was 99.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to secure medications appropriately. This had the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on record review, observations, and interview, the facility failed to sanitize blood sugar glucometers appropriately. This had the potential to affect five residents (Resident #20, #21, #37, #80, and #95) of 13 residents who required blood sugar testing and monitoring.

Inspectors wroteBased on observation, facility policy, facility staff and contractor interview, the facility failed to maintain an effective pest control management system related to gnats in the kitchen. This has the potential to affect all 99 residents who receive meals from the kitchen. The facility indicated there were no residents who received nothing by mouth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not left unattended in resident rooms. This affected one of three residents (Resident #43) reviewed for medication storage. The census was 101. Findings Include: Review of the medical record for Resident #43 revealed an admission date of 09/21/23. Diagnoses included congestive heart failure, hypertension, chronic obstructive pulmonary disease, and acute kidney disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #43 had impaired cognition. [...]

Inspectors wroteBased on record review, interview, facilities self reported investigation review, and facilities policy review, the facility failed to timely report an allegation of physical abuse to the State Agency for Resident #85. This affected one (Resident #85) of three residents reviewed for abuse. The facility census was 100.

Inspectors wroteBased on observation, review of cleaning schedules, and interview the facility failed to ensure a clean and sanitary environment for residents. This affected Residents #7, #32, and #58 and had the potential to affect all residents. The facility census was 101.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to update Resident #118's comprehensive fall prevention care plan to ensure fall prevention interventions were implemented. This affected one resident (Resident #118) of three residents reviewed for falls. The facility census was 117 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were faxed timely to receiving providers for prompt scheduling of services. This affected one resident (Resident #118) of three residents reviewed for accidents. The facility census was 117 residents.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure proper wound treatment and pressure relieving interventions were implemented timely for Resident #18's unstageable pressure ulcer. This affected one (Resident #118) out of three residents reviewed for pressure ulcers. The facility census was 117.

Inspectors wroteBased on record review and interview the facility failed to implement a comprehensive and effective infection control program to properly and timely diagnosis, implement necessary infection control precautions, conduct adequate and timely education for staff on infection control relative to preventing the spread of potentially contagious/communicable rashes (scabies) and failed to notify the local health department of potentially contagious skin rashes. This affected three residents (#1, #41, and #81) of three residents reviewed for skin rashes and infection control and had the potential to affect all residents residing at the facility. The facility census was 108.

Inspectors wroteBased on observation and staff interview the facility failed to ensure medications were properly secured in the medication cart on the second floor and failed to ensure medications were discarded when expired. This had the potential to affect the 28 residents (#4, #8 ,#13,#16, #17, #21, #26, #31, #39, #43, #46, #50, #62, #66, #68, #69, #74, #77, #79, #80, #82, #84, #87, #89, #92, #101, #108 and #111) who resided on the second floor. The facility census was 108.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #5's advance directives/code status was accurately reflected in both the medical record and the electronic medical record. This affected one resident (#5) of 21 residents reviewed for advanced directives.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure a dressing change/wound care was completed for Resident #14 in a manner to decrease the risk of wound infection. This affected one resident (#14) of one resident observed for wound care.

Inspectors wroteBased on record review, review of a facility investigation, facility policy and procedure review, manufacturer's guideline review and interview the facility failed to ensure Resident #101 was provided adequate assistance during a staff assisted transfer to prevent the resident from being bumped in the face by the metal support bar of the mechanical (Hoyer) lift. This affected one resident (#101) of two residents reviewed who required a mechanical lift for transfers.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper sanitation of dishes and food preparation areas. This had the potential to affect 111 of 113 residents who ate by mouth. Residents #6 and #26 received no food by mouth.

Inspectors wroteBased on observation and staff interview the facility failed to ensure resident shower rooms and resident equipment were maintained in a clean and sanitary manner. This affected four out of six shower rooms during two environmental tours and 71 out of 113 residents. Residents #2, #3, #4, #6, #9, #11, #14, #15, #18, 319, #20, #21, #28, #30, #2, #36, #38, #45, #52, #54, #55, #58, #60, #63, #66, #69, #78, #83, #87, #92, #93, #96, #97, #98, #101, #102, #104, #106, #108, #114, #115, #370, and #372 who resided on the third floor were not affected. The facility census was 113.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected five (Residents #50, Resident #74, Resident #79, Resident #87 and Resident #110) of seven residents whose assessments were reviewed for accuracy. The facility census was 113.

Inspectors wroteBased on observation, record review and interview the facility failed to store medications in a secure manner on the 300 unit. This had the potential to affect 32 of 44 residents residing on the secured unit who were cognitively impaired and independently mobile, Residents #3, #4, #9, #11, #14, #15, #18, #20 #21, #28, #32, #36, #38, #45, #52, #58, #60, #66, #78, #79, #83, #87, #92, #96, #98, #101, #102, #104, #106, #108, #115, and #370. The facility also failed to ensure medications on the 100 A/B halls and 300 C cart were labeled as required. This had the potential to affect 33 residents, Residents #6, #7, #10, #13, #27, #33, #37, #39, #41, #46, #47, #49, #53, #64, #65, #72, #74, #91, #94, #95, #100, #103, #105, #4, #15, #36, #58, #69, #76, #87, #98, #109, and #114. The facility census was 113. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control standards were followed during a dressing change for Resident #26. This affected one resident observed for dressing change, with a facility census of 113.