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Diamond Care Center: Medication Self-Administration Failure - SD
On paper, it was a reasonable system....
Latest reports, citations, and penalties from CMS data
On paper, it was a reasonable system....
The facility responded with a plan of correction, the standard mechanism by which nursing homes acknowledge a problem and commit, in writing, to solving it....
The first citation came during a survey ending April 25, 2024....
The inspection resulted in a citation under F842, the federal tag that covers clinical records....
That is the core finding from a March 2025 inspection of Embassy of Hillsdale Park in Hillsdale, Pennsylvania....
Federal inspectors who arrived at Addolorata Villa on January 16 found the facility wasn't following it....
Two surveyors documented the skin tear on March 31, 2025, at 11:22 in the morning....
It is not a paperwork violation....
The citation, issued under F689, covers the requirement that a nursing home identify and remove hazards that put residents at risk of accidents....
Nearly a year had passed since the facility signed its name to a corrective action....
Chronic wounds and indwelling catheters are not minor clinical concerns....
When inspectors asked about it, the Social Services Director was direct about why: she does not do resident visits in the room....
Inspectors cited the facility under F689, the federal tag that covers accident hazards and supervision, noting that a few residents were affected....
The jeopardy, inspectors determined, had actually begun six days earlier, on February 26....
The violations ranged from missing paperwork before emergencies to a resident left without an intervention to prevent a skin tear....
The findings, documented under federal tag F692, go beyond individual oversights....
The result, according to the inspection report finalized this month, was permanent....
The violations they cited involved food, the conditions under which it was prepared, stored, and served to residents who depend on the facility for every meal....
Finding failures in two of those eight is a rate that regulators consider significant enough to cite....
The finding was tagged under F0552, a federal citation that addresses the basic obligation of nursing homes to communicate with residents about their health....