TROY, NY - Federal inspectors found Diamond Hill Nursing and Rehabilitation Center failed to properly investigate serious incidents involving residents and did not report investigation results to state authorities within required timeframes.
Missing Investigation Files and Reporting Failures
The facility faced citations for failing to complete investigations of a resident-to-resident altercation and a fall incident that required hospitalization. In both cases, the nursing home did not submit investigation results to the State Survey Agency within the mandatory five working days.
The most serious incident involved Resident #48, who has diabetes, dementia, and major depressive disorder, striking Resident #78 in the face while grabbing a personal item. Resident #78, who has communication difficulties due to aphasia following a stroke, was the victim of this altercation on September 22, 2024.
The facility's comprehensive care plan specifically identified Resident #48 as having "potential to be an aggressor related to mental illness" and included interventions to monitor the resident closely around others. Despite this known risk, proper investigation protocols were not followed after the incident occurred.
Administrative Breakdown and Lost Documentation
During the federal inspection in April 2025, the Director of Nursing revealed a concerning administrative failure. When asked about the investigation file for the resident altercation, the director stated they "did not have the Investigative File for review" because "the previous administrator did not leave the file where it could be located." Staff indicated they would need to "recreate the file."
This administrative breakdown demonstrates a fundamental failure in record-keeping and incident management. Federal regulations require nursing homes to maintain detailed documentation of all investigations to ensure accountability and prevent future incidents.
Fall Incident Investigation Gaps
A second investigation failure involved Resident #416, who has right-side paralysis following a stroke, Parkinson's disease, and severe cognitive impairment. On June 4, 2024, nursing staff found the resident lying on the floor beside their bed with abnormally low blood pressure and pallor.
The resident required assistance off the floor using a mechanical lift and was hospitalized at family request. While the facility submitted an initial incident report the same day, investigators found no evidence that investigation results were reported to state authorities within the required timeframe.
Medical Implications of Investigation Failures
Proper incident investigation serves critical medical and safety functions in nursing home care. When residents with cognitive impairments like dementia are involved in altercations, immediate assessment of both physical injuries and psychological trauma is essential.
For residents with communication disorders like aphasia, standard assessment methods may not capture the full impact of an incident. These residents may be unable to verbally report pain, fear, or other consequences, making thorough investigation and follow-up care even more crucial.
Fall incidents in residents with multiple medical conditions require comprehensive evaluation to determine underlying causes. Factors such as medication effects, blood pressure changes, or environmental hazards must be analyzed to prevent recurrence.
Regulatory Requirements and Oversight
Federal regulations mandate that nursing homes complete thorough investigations of all incidents that could constitute abuse, neglect, or violation of residents' rights. These investigations must be reported to state survey agencies within five working days to enable proper oversight and corrective action.
The investigation process should include interviews with witnesses, medical evaluations, review of care plans, and analysis of contributing factors. For facilities caring for residents with behavioral issues or cognitive impairments, this process becomes even more critical.
New York state regulations specifically require facilities to analyze "key times, places, circumstances, triggers and what de-escalates behavior" for residents with potential for aggression. This analysis forms the foundation for preventing future incidents and protecting vulnerable residents.
Staffing and Leadership Changes
The facility experienced multiple administrator changes during the timeframe of these incidents, contributing to the documentation and reporting failures. The current administrator acknowledged that "some things were not filed as they should have been" due to the leadership transitions.
Such administrative instability can compromise resident safety by disrupting established protocols and creating gaps in oversight. When investigation files are lost or misplaced, facilities lose the opportunity to identify patterns and implement effective preventive measures.
Assessment Deficiencies
Beyond investigation failures, inspectors identified additional deficiencies in resident assessments. The facility failed to conduct comprehensive assessments for two residents, missing evaluation of edema in one case and baseline care plan items in another.
These assessment gaps can lead to undetected health changes and inadequate care planning. Regular comprehensive assessments are designed to identify emerging medical issues before they become serious problems requiring emergency intervention.
Industry Standards and Best Practices
Effective incident investigation requires trained staff, standardized protocols, and consistent documentation practices. Leading nursing homes maintain detailed investigation procedures that include immediate response, thorough fact-finding, medical evaluation, and preventive planning.
Best practices include maintaining secure investigation files, conducting regular training on incident reporting, and implementing quality assurance reviews to ensure all requirements are met. Facilities should also establish clear communication protocols during administrator transitions to prevent documentation losses.
Consequences and Corrective Action
The violation findings resulted in citations for failure to ensure freedom from abuse and neglect, as well as failure to conduct proper resident assessments. The facility must develop and implement corrective action plans to address these deficiencies.
Federal inspectors will conduct follow-up reviews to verify that proper investigation protocols are established and that all incident reporting requirements are met. The facility must also demonstrate improved record-keeping and staff training to prevent similar failures.
This case highlights the critical importance of maintaining consistent administrative oversight and proper documentation in nursing home care. When investigation protocols fail, vulnerable residents remain at risk, and facilities cannot fulfill their fundamental obligation to provide safe, quality care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diamond Hill Nursing and Rehabilitation Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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