Diamond Ridge Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Diamond Ridge Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF644Jul 23, 2025

  Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident mental disorder for 5 of 6 resident reviewed (Residents #1, #12, #14, #87, and #139). Findings include: 1) Review of Resident #12's Preadmission Screening and Resident Review (PASRR) dated 10/4/2023 revealed anxiety disorder was checked under mental illness. No other diagnosis was checked. Review of Resident #12's admission record revealed the resident was admitted on [DATE] and was subsequently diagnosed with recurrent mild major depressive disorder with onset date of 12/12/2023 and Post Traumatic Stress Disorder (PTSD) with onset date of 10/5/2023. […]

• No harm, potential for more than minimal, patternF880Apr 4, 2024

  Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene during medication administration between residents and failed to ensure resident care reusable items were cleaned and disinfected to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 4/2/2024 at 8:33 AM, Staff A, Licensed Practical nurse (LPN) started preparing medications for Resident #8 without performing hand hygiene. During obtaining medication from the medication cart for Resident #8, Staff A stopped and locked the medication cart and entered the common room to assist Resident #36 with pencils and a coloring book. […]

• No harm, potential for more than minimal, patternF695Mar 7, 2022

  Based on record review, observation, and interview, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 3 of 5 residents reviewed for respiratory care, Residents #1, #4, and #6. Findings: 1. Review of Resident #1's medical record noted the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's record revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF656Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to implement a person-centered comprehensive care plan for 1 of 3 residents reviewed for falls (Resident #15). Findings include: During an observation on 7/20/2025 at 11:22 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed (Photographic evidence obtained). During an observation on 7/21/2025 at 9:46 AM, Resident #15 was lying flat in the bed. There was a fall mat lying on the left side of bed and no fall mat on the right side of the bed. There was a fall mat folded up and lying under the bed. […]

• No harm, potential for more than minimal, isolatedF684Jul 23, 2025

  Based on record review and interview, the facility failed to ensure physician-ordered parameters for administering hypertension medications were followed for 2 of 7 residents reviewed for medication administration (Residents #39, #139). Findings include: 1) Review of Resident #139’s physician order dated 6/20/2025 read, “Olmesartan Medoxomil Tablet 20 MG [milligram], Give 1 tablet by mouth one time a day for hypertension, hold for SBP [Systolic Blood Pressure] less than 130.” Review of Resident #139’s Medication Administration Record (MAR) for July 2025 for administration of Olmesartan Medoxomil showed the medication was administered outside the ordered parameters on 7/2/2025 for blood pressure of 121/63, on 7/3/2025 for blood pressure of 121/66, on 7/12/2025 for blood pressure of 114/63,… […]