The woman's wounds grew from two small reddened areas on June 6 to six open sores by June 11, with the largest measuring 7 centimeters by 7 centimeters on her right buttock. She died three days later.
Hospice registered nurse H had brought foam dressings to the facility on June 7 after being notified there was no wound care supplies available. She gave the dressings to licensed practical nurse I and asked her to apply them after the resident was put back in bed following lunch.
The dressings were never applied.
When hospice nurse L returned on June 10, she was told by facility staff that the Optifoam dressings "were not applied over the weekend" and that they "did not think that resident 1 had been repositioned," according to the inspection report.
The resident's daughter came to the facility that day and took photographs of her mother's deteriorated condition, sending them to hospice nurse L, who identified one area as a Stage III pressure ulcer.
By June 11, wound documentation revealed six separate pressure injuries: two on her left buttock measuring 6.0 by 8.0 centimeters and 2.5 by 2.0 centimeters, two on her right buttock measuring 7.0 by 7.0 centimeters and 1.5 by 1.5 centimeters, one on her tailbone measuring 1.7 by 0.8 centimeters, and one on her left heel measuring 2.9 by 2.0 centimeters.
Hospice certified nursing assistant K described being "disturbed and astounded by the change in the appearance of her buttocks" when she saw the resident on June 10.
Administrator A confirmed that two licensed practical nurses were terminated because of this incident.
Hospice nurse L told inspectors she thought "the communication between the provider and the hospice agency was poor" and stated, "She [resident 1] had a history of just being pushed to the side and she was very disappointed in the provider's management of her pressure ulcers."
The facility's failure to prevent pressure ulcers extended to other residents. A second hospice patient developed seven pressure wounds while under Diamond Care Center's care, including multiple injuries to both feet that became infected and required antibiotics.
That resident's first pressure ulcer was identified on December 28, 2023, on her right ankle after she fell and was found sitting on her bathroom floor. The wound steadily worsened over the following months despite treatment attempts.
By March, nurses documented that the ankle wound "appears swollen and red and warm to the touch" with "100% green/yellow slough" and a necrotic area that "appears larger than yesterday." The physician ordered antibiotics due to inflammation.
Two large blisters developed on her left foot in April. By April 14, nurses noted "foul smelling drainage" from the right ankle and described the peri-wound area as "bright red, swollen and warm to touch."
The facility's care planning for this resident was severely deficient. Her first comprehensive skin assessment wasn't completed until April 28 — four months after her initial pressure ulcer was identified. Her Braden score, which measures pressure ulcer risk, had dropped to 12, indicating high risk, but this was the first time her score reflected her actual condition since being admitted to hospice care in February.
A turning and repositioning program wasn't implemented until late April, and pressure-relieving approaches weren't put in place until then either.
The resident's closet care plan, used by nursing assistants to guide daily care, wasn't updated for five months after her condition changed. Until June, the plan still indicated she needed assistance from only one staff member with a walker, when she had actually become non-ambulatory and required two staff members for transfers.
Federal inspectors found that Diamond Care Center had no registered nurse working eight consecutive hours per day for 37 days between October 2023 and June 2024. This included 21 days in December and January alone.
Administrator A confirmed there wasn't always a registered nurse for eight consecutive hours each day at the facility, stating that when an RN wasn't present, "a physician and an RN were available by phone."
The facility is licensed to provide skilled nursing care and does not have a nurse waiver that would allow operation without full-time registered nurse coverage.
The nursing shortage contributed to other care failures. Inspectors found expired medications throughout the facility, including acetaminophen that had expired two months earlier and loperamide that had been expired for nearly two months.
In the facility's tub room, inspectors discovered prescription medications dating back to 2021, including Nystatin antifungal powder that expired in March 2023 and anti-itch lotion that expired in March 2024.
Multiple medications lacked proper dating when opened, including diabetes injection pens and nasal sprays that had no indication of when they were first used or when they should be discarded.
The facility also failed to properly monitor a dialysis patient who was supposed to have vital signs checked and his fistula site examined for bleeding or abnormalities after each treatment. Documentation was missing for four of 16 scheduled monitoring sessions between April and June.
Two residents using bed rails lacked current safety assessments. One resident had been using half-side rails on both sides of her bed since 2023 to help with positioning, but the facility's documentation incorrectly described them as quarter-rails. Neither resident had received the required quarterly assessments to ensure the rails remained appropriate and safe.
The facility's arbitration agreement, signed by 26 of 34 current residents, contained multiple deficiencies. It allowed Diamond Care Center to unilaterally choose the location for any dispute resolution and provided only initials for the arbitration organization without spelling out the full name or providing contact information.
Business office designee D told inspectors that residents could "search the Internet on their phone to obtain the name and how to contact that arbitration agency."
Administrator A acknowledged the agreement should have included the arbitration agency's full name and contact information, and agreed that the facility "should not have been independent in selecting the location for an arbitration dispute."
Diamond Care Center's data reporting to federal authorities was also problematic. The facility's submissions to the Payroll Based Journal system, which tracks nursing home staffing, contained significant inaccuracies for both quarters reviewed.
The reports triggered multiple red flags, including no registered nurse coverage for eight consecutive hours on more than four days and suppressed weekend staffing metrics, indicating the submitted data was "excessively low."
Administrator A confirmed the data submitted for the first two quarters of fiscal year 2024 "had not been submitted accurately."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diamond Care Center from 2024-06-21 including all violations, facility responses, and corrective action plans.