Diamond Care Center
Bridgewater, South Dakota · CCN 435114
13 surveys since 2011. The first finding at harm level was recorded in 2021.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 63
- Surveys
- 13
- Harm or worse
- 3
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 36
- Ownership
- For profit - Corporation
- Chain
- LIFESPARK
- County
- Mc Cook
- Medicare-certified since
- 1998
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 1
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 18 for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
Sep 11, 2025
424 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 2.44 | 3.20 |
| Registered-nurse hours per resident day | 0.37 | — |
| Annual nurse turnover | 54.5% | 43.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $69,512 across 2 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G28.0% | H— | I— |
| No harm, potential for more than minimal | D1144.0% | E624.0% | F624.0% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5542×
Allow residents to self-administer drugs if determined clinically appropriate.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F7272×
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
- F8512×
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
In the surveyor’s words
From the most serious findings on record at Diamond Care Center, in the surveyor’s own words.
- Actual harm, isolatedF600Jun 21, 2024
Based 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. Findings include: 1. Review of the provider's 6/14/24 submitted SD DOH FRI revealed: *On 6/13/2024 at 12:58 p.m. a suspicion/allegation of abuse/neglect regarding resident-to-resident inappropriate sexual behavior involving resident 10 and resident 37. *At 9:01 p.m. […]
- Actual harm, isolatedF686Jun 21, 2024
Based 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. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. […]
- Actual harm, isolatedF686Dec 21, 2021
Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (14, 23, and 174) who had developed pressure ulcers had been assessed, received care, on-going assessments, and interventions to prevent new ulcers from developing or prevent wounds from worsening. Findings include: 1. Observation and interview on 12/20/21 at 8:07 a.m. with resident 174 revealed: *He was lying on a pressure-reducing alternating air mattress in his room. *When asked if he had any skin problems, he replied he had sores on his bottom. Review of resident 174's electronic medical record (EMR) revealed: *He had been admitted to the facility on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cerebral infarction. […]
- No harm, potential for more than minimal, widespreadF725Sep 11, 2025
Based 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).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October, November, and December 2024) revealed:*There was no 24-hour nursing coverage documented for seventeen days (October 1, 3, 4, 5, 6, 7, 8, 12, 13, 16, 17, 21, 22, 25, 26, 27, and 31) in October 2024.*There was no 24-hour nursing coverage documented… […]
- No harm, potential for more than minimal, widespreadF727Sep 11, 2025
Based 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).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October 2024 - December 2024) revealed:*There was no eight-hour nurse coverage documented for seven days (October 12, 13, 19, 20, 25, 26, and 27) in October 2024.*There was no eight-hour nurse coverage documented for thirteen days (November… […]
Read 21 findings in full →The most serious and the most recent: 21 of 63 on record.
Every survey on record
FindingsAt actual harm or above
- Sep 11, 2025Standard11 findings
- Jun 21, 2024Standard and complaint14 findings · 2 harm
- May 18, 2023Standard1 finding
- Dec 21, 2021Standard8 findings · 1 harm
- Jan 13, 2021Infection control1 finding
- Jul 24, 2019Standard7 findings
- May 2, 2018Standard2 findings
- Jun 1, 2017Standard5 findings
Show the 5 earlier surveys
- Apr 6, 2016Standard and complaint3 findings
- Jun 25, 2015Standard1 finding
- May 1, 2014Standard1 finding
- Feb 27, 2013—6 findings
- Jun 22, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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