Diplomat Healthcare

In the surveyor’s words

From the most serious findings on record at Diplomat Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 25, 2025

  Based 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… […]

• Actual harm, isolatedF684Dec 12, 2024

  Based 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. […]

• Actual harm, isolatedF684Oct 10, 2024

  Based 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. Findings include: Review of Resident #203's Solid Tumor Service History and Physical Exam form dated 08/28/24 at 2:25 P.M. indicated the resident endorses that about two weeks ago he had his port placed and developed generalized weakness, decreased appetite, fatigue and widespread blisters. During this time, the resident also noted that he began having oozing and bloody drainage from his penile condyloma. He stated that the condyloma initially was small and first noted approximately [AGE] years ago but had since increased in size. […]

• Actual harm, isolatedF689Aug 12, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility Self-Reported Incident (SRI) review, facility policy and procedure review, and interview, the facility failed to ensure Resident #40 was free from resident-to-resident physical abuse. Actual harm occurred on 07/27/23 when Resident #45 pushed Resident #40 to the floor after Resident #40 wandered into his room causing Resident #40 to fall to the floor and suffer a hip fracture that required surgical intervention at a local hospital. […]

• Actual harm, isolatedF600Oct 7, 2021

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, observation, review of a facility Self-Reported Incident (SRI), review of the facility investigation, and review of facility policy and procedures, the facility failed to ensure Resident #105 was free from physical abuse by Resident #106, who had known physical behaviors towards others. Actual Harm occurred on 09/11/21 when Resident #106 struck Resident #105 causing Resident #105 to sustain a bloody lip and caused Resident #105 to fall to the floor. Both residents were cognitively impaired. Resident #105 required supervision for walking and eating and required supervision of one staff with physical assist for bed mobility and transferring. […]