Medication Safety Failures Put Residents at Risk
The inspection revealed a 36 percent medication error rate for one resident, far exceeding the acceptable 5 percent threshold required by state regulations. Licensed Practical Nurse #7 consistently administered morning medications 45 minutes to over an hour late due to an overwhelming patient load of 28 residents.
The nurse reported to inspectors that Human Resources had spoken with them about the delays, explaining that "the medications pass was too heavy for one person," yet no assistance was provided. The facility's response was to conduct future audits rather than address the underlying staffing problem.
This pattern of late medication administration creates cascading health risks for residents. Heart medications like Cardizem CD for cardiovascular conditions must be given on schedule to maintain steady blood levels. Blood thinners such as Eliquis require precise timing to prevent dangerous fluctuations in clotting factors. When these critical medications are delayed, residents face increased risks of cardiac events, stroke, and bleeding complications.
The inspection also uncovered instances where medications were completely missed. Two residents requiring antibiotic eye treatments for conjunctivitis went without prescribed doses for multiple days. One resident missed their Rocephin antibiotic injection due to claimed unavailability of lidocaine, despite staff confirming the pain-relief medication was always in stock.
Most concerning was a case where a resident received 40 units of insulin without any physician order, causing dangerous blood sugar fluctuations that required emergency monitoring and treatment.
Narcotic Control System Failures
The facility's controlled substance management system showed significant gaps that could enable drug diversion or create accountability issues. Inspectors found that narcotic count sheets frequently lacked required signatures from both outgoing and incoming nurses across multiple shifts on both floors.
For one resident prescribed Oxycodone, the facility failed to document proper receipt procedures from the pharmacy. The controlled substance record lacked the signature of the receiving staff member, the date received, and the amount received - fundamental requirements for tracking powerful pain medications.
On the second floor, the narcotic storage box had both inside and outside locks broken for several weeks, with maintenance attempting repairs but failing to restore security. The first floor abandoned using their narcotic box entirely due to administrative disagreements, instead storing controlled substances on medication carts - a practice that increases security risks.
These documentation and storage failures represent serious regulatory violations that compromise patient safety and drug security. Proper narcotic controls prevent diversion while ensuring accurate tracking of medications that carry high abuse potential and strict federal oversight requirements.
Chronic Understaffing Creates Care Delays
Residents reported waiting one to three hours for responses to call lights, with some staff members entering rooms only to turn off the call light and leave without providing assistance. During a resident meeting, participants described being "yelled at by staff" who were "rude and disrespectful" due to overwhelming workloads.
Resident #22 described particularly troubling experiences: "when they put their call light on, some Certified Nurse Aides would come into the room and tell them that they were not their aide, then turn the call light off, leave the room and not come back." The resident reported lying in bed after accidents because staff failed to respond to calls for bathroom assistance.
Staffing records from March and April 2025 showed the facility consistently failed to meet its own assessed minimum staffing levels. On multiple shifts, the facility operated with as few as two nurses for the entire night shift and insufficient certified nursing assistants to provide adequate care for 108 residents.
The facility's staffing plan called for 11 certified nursing assistants during day shifts, but actual schedules showed as few as five aides covering all residents. This staffing shortage meant each aide was responsible for 15-20 residents instead of the 8-10 ratio that allows for quality care delivery.
Staff members confirmed these challenges directly impacted patient care. Certified Nursing Aide #1 told inspectors that staff "were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed." The facility ombudsman noted that residents weren't receiving proper care and that showers had become an ongoing issue, with staff telling residents they were too short-staffed to provide basic hygiene services.
Monthly Pharmacy Reviews Completely Absent
For three consecutive months - January, February, and March 2025 - the facility failed to conduct required monthly drug regimen reviews by a licensed pharmacist. These reviews serve as critical safety checks to identify dangerous drug interactions, inappropriate dosages, and potential medication complications.
Without these professional reviews, residents faced increased risks from medication-related problems that could have been prevented through proper oversight. The facility's policy failed to establish required timeframes for the medication review process, contributing to the systematic breakdown in pharmaceutical safety protocols.
Monthly pharmacy reviews examine each resident's complete medication profile to identify potential issues such as duplicate therapies, dangerous drug combinations, and opportunities to reduce medication burdens. These reviews are particularly important in nursing home settings where residents often take multiple medications and may have complex medical conditions requiring careful coordination.
Additional Issues Identified
The inspection documented numerous other violations affecting resident safety and quality of life:
Food Service Problems: Test trays revealed unpalatable meals with overcooked, mushy vegetables and dry meat covered in overly salty gravy. Residents complained that food was often "inedible" and "unidentifiable," with menu items frequently substituted without notice.
Kitchen Safety Hazards: The dishwashing machine operated with zero water pressure during final rinse cycles, failing to meet manufacturer specifications for proper sanitation. Multiple equipment failures, missing tiles, and widespread cleanliness issues created food safety risks.
Infection Control Lapses: Enhanced barrier precautions were not implemented for residents with indwelling catheters, despite physician orders requiring such protections. Nebulizer equipment was stored improperly, creating contamination risks for respiratory treatments.
Facility Maintenance: Call bell systems failed in multiple resident rooms, preventing patients from summoning help during emergencies. Broken handrails with sharp edges posed injury risks, while inadequate ventilation created persistent odors in bathing and soiled utility areas.
Pest Control: Inspectors documented ongoing insect infestations including wasps in resident rooms, gnats in common areas, and fruit flies in food service areas, indicating inadequate pest management programs.
The comprehensive inspection revealed systemic failures across multiple care domains, from basic medication safety to fundamental infection control practices. These violations demonstrate how understaffing creates cascading problems that compromise resident safety and quality of life across all aspects of nursing home operations.
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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