Diamond Care Center: Pressure Ulcer Prevention Failures - SD
Pressure injuries, sometimes called bedsores, develop when sustained weight on skin cuts off circulation to tissue. They can begin as redness or minor skin breakdown and progress within days to open wounds that reach bone. For residents who are immobile, elderly, or medically fragile, they are among the most preventable harms a nursing home can allow — and among the most painful to treat once they take hold.
The inspection, conducted June 21, 2024, resulted in a citation under F686, the federal tag covering a nursing home's obligation to prevent and heal pressure ulcers in residents who are admitted without them or who develop them during a stay.
The facility's plan of correction centered on education. On July 5, 2024, Diamond Care Center conducted training for nursing staff on repositioning and offloading techniques — the basic physical interventions that reduce pressure on vulnerable skin. Staff were required to complete a quiz after the session. The facility also committed to building the training into new hire orientation going forward, so that future nursing employees would complete the same quiz before beginning work with residents.
Nineteen staff members completed the training.
Of those 19, one worked in dietary. Eighteen were nursing staff, the people responsible for turning residents, checking skin, and catching early signs of breakdown before they become wounds.
The inspection report does not say how many nursing staff Diamond Care Center employs in total. It does not say whether 18 represents every nurse, medication aide, and certified nursing assistant on staff, or whether it represents a fraction of the workforce. It does not say how many residents were affected by the underlying violation, what stage any pressure injuries reached, or whether any resident required hospitalization or wound care as a result.
What the report does say is that the standard of care was not being met, that staff needed to be taught the fundamentals of repositioning and pressure relief, and that the facility's answer was a single training session followed by a quiz.
Repositioning a resident sounds simple. In practice, it means checking on immobile residents at regular intervals, shifting their position to move weight off bony prominences like heels, hips, and the base of the spine, and documenting that it was done. It means recognizing that a resident who cannot feel pain in a limb cannot tell staff that something is wrong. It means catching the redness before it becomes a blister, and the blister before it becomes an open wound.
When that chain breaks down — when staff are not trained, or not reminded, or simply too stretched to make every turn on schedule — the consequences accumulate quietly in residents' skin.
Diamond Care Center serves residents in Bridgewater, a small city in Davison County in southeast South Dakota. The June inspection was a health survey. The plan of correction the facility submitted was accepted.
Nineteen people took a quiz. Whether that is enough depends on questions the inspection report does not answer: how many residents are at risk, how many staff are responsible for their care, and whether a one-time training session in the middle of summer will hold when the next new aide starts, or when the unit is short-staffed, or when a resident stops being able to say that something hurts.
The training happened. The quiz was completed. Somewhere in that facility, residents who cannot reposition themselves are relying on the 18 nursing staff members who passed it.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
DIAMOND CARE CENTER in BRIDGEWATER, SD was cited for violations during a health inspection on June 21, 2024.
Pressure injuries, sometimes called bedsores, develop when sustained weight on skin cuts off circulation to tissue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.