State inspectors responding to a complaint at Diplomat Healthcare found that staff prescribed a steroid and a skin treatment to residents who could rarely or never be understood, then failed to document any attempt to contact their representatives about the new drugs.
Resident 103 received an order for Permethin on October 30 for a new skin rash treatment. The nursing note mentioned the new medication but made no reference to notifying the resident's representative. No progress notes referenced the Permethin order at all.
When inspectors interviewed the Director of Nursing on November 18, she confirmed there was no evidence the resident's representative had been notified of the new orders. She acknowledged that medication changes should be discussed with residents' representatives.
The second case involved a resident with an even more complex medical picture.
Resident 106 had been admitted in October 2024 with diagnoses of dementia, Huntington's disease, and restlessness. The resident's cognitive assessment showed no cognition score because they were rarely or never understood.
On October 13, a licensed practical nurse documented a new seven-day order for prednisone, a steroid prescribed for inflammation. The progress note mentioned the new medication but included no reference to notifying the resident's representative.
Again, the Director of Nursing confirmed to inspectors that there was no evidence the resident's family had been told about the steroid prescription.
Both cases violated the facility's own written policy. Diplomat Healthcare's Resident Change in Condition Policy, reviewed as recently as June 2025, explicitly states that physicians, families, and responsible parties will be notified when there is a need to alter a resident's medical treatment.
The violations occurred despite clear federal requirements that nursing homes keep families informed about changes in their loved ones' care, particularly when residents cannot advocate for themselves due to cognitive impairment.
Prednisone, the steroid prescribed to Resident 106, can cause significant side effects including mood changes, increased infection risk, and blood sugar fluctuations. For residents with dementia and other neurological conditions, such medications require careful monitoring and family awareness of potential complications.
The inspection was conducted in response to Complaint Number 2656169, suggesting someone had raised concerns about the facility's communication practices with families.
Both residents' cases highlight a fundamental breakdown in the facility's notification system. Despite having a clear written policy requiring family notification for treatment changes, staff failed to follow through on documenting such communications or ensuring they occurred.
The Director of Nursing's acknowledgment that medication changes should be discussed with representatives indicates awareness of the requirement, making the failures more concerning from a compliance standpoint.
For families with loved ones in nursing homes, these violations underscore the importance of maintaining regular communication with facility staff and asking specific questions about any changes in medications or treatments.
The inspection found the violations caused minimal harm or potential for actual harm to the residents involved, but the failure to notify families prevented them from participating in medical decisions for their cognitively impaired relatives.
State inspectors classified the deficiency under federal regulation F 0580, which governs facilities' obligations to inform residents and their representatives about changes in condition and treatment plans.
The facility must now submit a plan of correction detailing how it will ensure proper family notification procedures going forward and prevent similar communication failures with other residents' representatives.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diplomat Healthcare from 2025-11-25 including all violations, facility responses, and corrective action plans.