Diamond Care Center

F-F686.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43844

Residents Affected - Few Based on a review of the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI),

record review, interview, and observation, the provider failed to ensure two of two sampled residents (1 and 4) received necessary care and treatment in a timely manner for the prevention of pressure ulcers. Findings include:

1. Review of the provider's 6/10/24 SD DOH FRI revealed:

*On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks.

-Dressings had been provided on 6/7/24 by hospice to the provider's staff.

-The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks.

-Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed.

*On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she had developed pressure sores to her bilateral buttocks likely over the weekend.

-IDON G then had LPN J place the standing order dressings on the wounds.

Review of resident 1's medical record revealed:

*She was admitted on [DATE REDACTED].

*She was admitted to hospice on 1/9/24.

*On 6/6/24 two reddened areas were identified on her buttocks.

-On 6/7/24 hospice provided Optifoam (foam dressing with adhesive borders) dressings for the reddened area.

*Her family was notified on 6/10/24 of the pressure ulcers and their condition.

*On 6/11/24 a Wound Documentation assessment was completed which indicated the onset date as 6/6/24.

-The 6/11/24 Wound Documentation indicated there were currently six areas identified as pressure wounds.

-Areas identified and the measurements of each were:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 --Two on her left buttock measured 6.0 centimeters (cm) by 8.0 cm. and the other measured 2.5 cm by 2.0 cm. Level of Harm - Actual harm --Two on her right buttock measured 7.0 cm by 7.0 cm and the other measured 1.5 cm by 1.5 cm. Residents Affected - Few --One on her coccyx (tailbone) measured 1.7 cm by 0.8 cm.

--One on her left heel measured 2.9 cm by 2.0 cm.

*Her family requested an air mattress be placed on her bed.

-Hospice ordered that mattress.

*Wound care orders included: Applied cavilon advanced [skin protectant] to peri wound area due to erythema [redness]. Applied heel mepilex [absorbent foam] dressing to buttocks to cover the entire area of the wound. Also applied a 4x4 mepilex to the middle of the dressing to ensure it was sealed. Applied betadine to left heel.

-Her primary care physician was notified.

*On 6/11/24 a hospice standing order for Optifoam Gentle Heel Foam Dressing 9 x 9. Apply to buttock/coccyx area daily. Apply 4 x 4 foam dressing over coccyx area to seal. was entered in her orders.

-On 6/12/24 was the first time that order was documented in her treatment administration record as completed for the first time.

*She passed away on 6/14/24.

Interview on 6/19/24 at 1:14 p.m. with hospice registered nurse (RN) H regarding resident 1 revealed:

*The hospice certified nursing assistant (CNA) K had notified her on 6/7/24 that she was concerned about resident 1's bottom.

*She kept wound dressings in her car and went to gather them.

*When she returned with the dressings, the facility staff had already assisted resident 1 from her bed to her wheelchair.

*Hospice RN H asked licensed practical nurse (LPN) I to evaluate resident 1's bottom after lunch that day.

*When hospice RN H returned on 6/10/24 she was informed the dressings were not applied over the weekend.

-Hospice did not inform the family of the wound as the provider was the primary caregiver.

*The provider managed routine and regular dressing changes of wounds and completed measurements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Hospice would record those measurements in their notes.

Level of Harm - Actual harm *During a hospice nurse visit, contact would be made with the provider's nurse on duty and information would be shared by verbal reports. Residents Affected - Few

Interview on 6/19/24 at 2:10 p.m. with hospice RN L regarding resident 1 revealed:

*Resident 1 previously had skin breakdown off and on for a few months but was healed before she started to decline.

*On 6/6/24 hospice CNA K had provided her pictures of resident 1's skin breakdown of her upper right hip area and her bottom.

-Hospice RN L had informed hospice CNA K by telephone to have the facility use Optifoam and reposition her often.

*On 6/7/24 hospice RN H was notified there was no Optifoam at the facility.

-Hospice RN H brought Optifoam dressings to the facility and gave them to LPN I.

*Hospice RN K came to the facility on [DATE REDACTED] and LPN J reported to her that resident 1's buttocks were much worse.

-LPN J told her that the Optifoam was not applied over the weekend and did not think that resident 1 had been repositioned.

*Hospice RN L notified IDON G and requested that she call resident 1's family and notify them that the recommendations hospice made on 6/7/24 had not been followed.

*Resident 1's daughter then came to facility and took pictures resident 1's buttocks, sent them to hospice RN L and she identified an area as a Stage III pressure ulcer.

*Hospice RN L stated that the hospice agency does not manage pressure ulcer care.

-They would make recommendations and assist the provider's licensed nurses with changing of the dressings when they were at the facility.

-The hospice agency had not required physician orders for Optifoam.

*An order on 6/12/24 Optifoam heel dressing order was by the provider's consulting wound nurse.

*RN L stated the typical hospice communication with the provider's nurses included verbal contact when the hospice nurse arrived, the hospice nurse would visit the resident, and discuss with the provider's nurse again regarding any concerns they had found.

*She thought the communication between the provider and the hospice agency was poor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -The hospice agency would find information regarding the hospice resident through review of the provider's medical records for that resident. Level of Harm - Actual harm *Hospice RN L stated, She [resident 1] had a history of just being pushed to the side and she was very Residents Affected - Few disappointed in the provider's management of her pressure ulcers.

Interview on 6/19/24 at 3:49 p.m. with hospice CNA K regarding resident 1's pressure ulcer revealed:

*On 6/6/24, in the afternoon, she had provided hospice care to resident 1.

-During this visit, she found resident 1 in her bed soaking wet with urine although she had a catheter in place.

--The catheter was removed from underneath of her leg, and it stopped leaking.

-While providing cares, she identified that resident 1 had redness to her buttocks.

--There had been two areas on the right buttock, about as long as her thumb and the other one higher up by her butt crack and a little longer than the first one.

-She notified hospice RN L at that time and was instructed to notify the facility nurse on duty.

*On 6/10/24 hospice CNA K has shown by LPN J resident 1's buttocks.

-CNA K stated she was disturbed and astounded by the change in the appearance of her buttocks.

-She had notified hospice RN L of that change.

*On 6/11/24 IDON G and administrator (ADM) A had called her and asked her who had seen resident 1's pressure ulcer and what had happened, she provided them with same information as above.

Interview on 6/19/24 at 10:26 a.m. with CNA R regarding resident 1 revealed:

*She had assisted hospice CNA K in repositioning her on 6/9/24.

*She had been told that resident 1 had sores and to reposition her more often.

-Resident 1 had refused a couple of times.

Interview on 6/21/24 at 11:25 a.m. with ADM A regarding resident 1's pressure ulcer revealed:

*Resident 1 was on hospice.

*Two licensed practical nurses had been terminated due to this incident.

*Education on abuse and neglect had been provided to all staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *Her expectation would have been for the pressure ulcer to be checked on daily and documented in the resident's EMR. Level of Harm - Actual harm Interim IDON G was unable to be contacted for an interview. Residents Affected - Few 32332

2. Observation on 6/19/24 at 10:30 a.m. of resident 4 revealed:

*She had been in the hallway sitting in a wheelchair (w/c).

*Her feet had been resting on the foot pedals and were covered with small foam boots.

*She was alert, answered only when spoken to, and had denied any foot pain.

Observation on 6/20/24 at 2:00 p.m. of resident 4 revealed she had been:

*Sitting in a recliner with legs elevated and with her feet crossed at the calf.

*Wearing small foam boots.

Observation on 6/18/24 at 1:30 p.m. of resident 4 revealed:

*She had been lying in bed on her left side with foam boots on.

*No other pressure-relieving measures were in place.

3. Review of resident 4's 8/20/23 through 6/21/24 electronic medical record (EMR) revealed:

*She was admitted on [DATE REDACTED].

*Her diagnoses included the following: Alzheimer's disease and dementia (forgetfulness), psychotic disturbance, major depression with mood disturbance, Type 2 diabetes with neurological complication, degenerative joint disease, and malnutrition.

*She had poor memory recall and was unable to participate in decision-making for her care.

*She was dependent upon the staff for:

-The development of her plan of care and to ensure the interventions were implemented for quality of care.

-Assistance with all activities of daily living (ADLs) to include bed mobility, repositioning, and positioning pressure relieving devices.

*On 2/10/24 she was admitted to Hospice for end-of-life care.

*While under the care of the provider she had acquired seven pressure ulcers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *She had:

Level of Harm - Actual harm -One stage 2 pressure ulcer (partial thickness loss) located on her right lateral ankle had worsened to a stage 3 (full thickness skin loss). That wound had been identified on 12/28/23. Residents Affected - Few -A callous formation on her right mid-lateral foot that was identified on 2/21/24 and had worsened to a stage 3 pressure injury.

-A deep tissue pressure injury was identified on 3/4/24 to the right lateral foot. It was a deep purple/brown color and unstageable.

-Two large intact blisters on her left lateral foot that were identified on 4/14/24.

-An unstageable pressure ulcer located by her right little toe that was black in color and was identified on 5/30/24.

-An open pressure area to her left buttock/sacrum was identified on 4/11/24.

*Hospice and a wound nurse had been involved with the care and treatment of her wounds.

-The wound nurse was not available for an interview.

Review of resident 4's 8/20/23 through 6/21/24 progress notes revealed:

*On 12/3/23 at 9:38 p.m. the nurse documented, Nurse was at the nurses station when a loud noise was heard and resident began yelling. Nurse went to room and found resident sitting on the floor of her room near her sink. She was incontinent of stool and had some blood coming from a spot on her R [right] outer ankle.

*On 12/28/23 the director of nursing (DON) B documented, During bath skin assessment, it was noted that resident has a new pressure injury to her right ankle. See wound assessment for details.

*Her Braden score fluctuated between 16 and 18 and indicated she was at risk for skin breakdown.

-She had a potential problem with friction and shearing due to moving feebly and/or requires minimal assistance.

*She had pressure-reducing devices for her chair and bed.

-There was no documentation of a repositioning plan.

*On 1/23/24 the Minimum Data Set coordinator (MDS)/RN C documented, Charge nurse reported that resident's ankle wound looks worse today and has eschar [dead tissue that sloughs off healthy skin after an injury] in the wound bed. FNP [practitioner's name] saw resident today to evaluate the wound. Orders received If no improvement in wound bed by Thursday afternoon, schedule appointment with [practitioners name] on Friday for the area to be debrided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *On 1/24/24 it was decided with the help of hospice to change the treatment and not debride the wound.

Level of Harm - Actual harm *On 2/21/24 DON B spoke with the hospice nurse and confirmed the wound appeared to be larger based on

the measurements completed the day before. Residents Affected - Few -There was no documentation to support the callous formation on the lateral side of her right foot had been identified.

*On 3/4/24 MDS/RN C documented, Wound to right lateral ankle dressing change noted. Slough covers 95% of the wound bed, edges are round, and wound appears to be larger. Resident also has a DTI [deep tissue injury] to lateral edge of right foot. It is dark purple in color. It is pea-size. Resident shoes were removed and gripper socks applied.

-On 3/8/24 the wound had worsened, and MDS/RN C documented: Dressing change completed to right lateral ankle. Wound appears larger and now measures 3.1 x [by] 2.5 x 0.4. There is a small necrotic dark are [area] at 12 o'clock that measures 0.4 x 0.6.

-On 3/9/24 both of the wounds had worsened, and MDS/RN C documented: Wound care provided to right lateral ankle this morning because resident had the dressing off. The wound appears swollen and red and warm to the touch. The wound base is 100% green/yellow slough, there is a necrotic area at 12 o'clock that appears larger than yesterday and then redness and the skin is boggy just above and to the right of necrotic area. Swelling noted to distal end of wound when leg is elevated. Hospice nurse updated this morning. TED hose left off the foot so no pressure is applied to area. New wound care orders received from Hospice.

*On 3/17/24 the charge nurse documented: Wound dressing changed to R [right] lateral ankle per orders. Peri-wound has increased redness and inflammation. Fax sent to PCP [primary care provider] requesting to consider ABX [antibiotic] tx [treatment].

-The physician ordered an antibiotic to be given every 6 hours for 10 days due to right lateral ankle inflammation.

*On 4/11/24 DON B documented: Upon assisting resident to the bathroom, it was noted that resident has an open pressure area to her left buttock/sacrum. Applied a thick layer of calmoseptine over it.

-Twelve days later, on 4/23/24, DON B documented that the wound on the left buttocks had closed.

-There was no other documentation in the EMR to support the size, appearance, drainage, and pressure relieving measures put in place to promote healing of that wound.

*She had a care conference review on 4/11/24.

-She had started to decline further and was sleeping more.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *On 4/14/24 the nurse documented: Resident has a large fluid filled blister to lateral left heel and a medium sized blister to the medial left heel, both intact. Right ankle is larger in size, with foul smelling drainage. Level of Harm - Actual harm Peri-wound bright red, swollen and warm to touch. Wound to lateral right foot open with slough and necrotic tissue. Per-wound bright red, swollen and warm to touch. Residents Affected - Few -The physician was called, and orders were given to start another antibiotic.

*On 4/15/24 the nurse and DON consulted with the Hospice nurse regarding the resident's wounds.

-They had decided to discontinue all wound care and provide comfort care for wounds due to poor circulation.

*On 4/18/24 the physician was notified of the current status of wound care and the physician advised to continue the wound care to the right ankle to maintain current status. They were to paint the left lateral and medial heel wounds with betadine.

-These orders were received three days after the discontinuation of wound care had been decided.

*On 4/28/24:

-Was the first documentation to support a comprehensive skin and positioning evaluation had been completed for her.

-Her Braden score had dropped to 12 and identified her as high risk for skin breakdown.

--That was the first Braden score that supported her at high risk due to her gradual failing condition that was identified when she was admitted to Hospice care on 2/10/24.

-That was the first documentation that indicated:

--Pressure-relieving approaches and interventions were implemented.

--A turning and repositioning program had been implemented.

Review of resident 4's weekly wound documentation revealed there were five separate wounds assessed and documented on weekly versus the seven that had been identified in the progress notes from 12/28/23 through 4/28/24.

Review of resident 4's closet care plan revealed:

*Those care plans were placed in the residents' closets for the certified nursing assistants and temporary staff use for providing care.

*On 1/3/24 a closet care plan was placed in her closet.

-She needed the assistance of one staff member with a walker and transfers.

-Her only indicated special need was oxygen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *The closet care plan was not updated until 5 months later on 6/4/24.

Level of Harm - Actual harm -She was non-ambulatory and needed the assistance of two staff members with transfers.

Residents Affected - Few -She was to be repositioned on rounds and was to be provided with offloading.

--There was no documentation on what should have been should have been offloaded.

-Pressure ulcer was marked.

-Special needs included: Heel boots/gripper sock at all times. O2 [oxygen] at night - HOSPICE.

Review of resident 4's ongoing comprehensive care plan revealed:

*Focus area: ADL [activities of daily living] Self Care Performance Deficit .

-Was created on 1/25/23 and revised on 2/10/23.

*Goals: Will maintain current level of function through the review date. Will not develop complications of immobility. With a target date of 7/27/24.

*Interventions:

-Dressing: [Resident name] requires assistance of 1 with cue with dressing/undressing.

-Oral Care: Independent after set up.

*A 1/25/23 focus area that was revised on 11/28/23 indicated: has limited physical mobility as e/b [evidenced by] shuffling gait r/t dementia and Alzheimer's. will participate in restorative program.

*Goals: Will maintain current level of mobility through review date.

-Will remain free of complications related to immobility including skin-breakdown.

--Was created on 2/10/23 and has a target date of 7/27/24.

*Interventions:

-Ambulation: requires walker and 1 assist.

-Ambulatory status: 1 assist with gait belt and walker for ambulation. When not walking with staff must use a wheelchair.

--Encourage reposition/position changes during rounds.

--Transfer: Can transfer independently with walker in room and with supervision when on the unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 *Focus area: [Resident's name] has the potential for a Nutritional problem r/t dementia and Alzheimer's, and episodes of dysphagia needing nectar thick liquids. Level of Harm - Actual harm -Was created on 1/25/23 and revised on 2/10/23. Residents Affected - Few -The focus area had not been updated to include her declining condition and wound care nutritional support requirements.

*Focus area: [Resident's name] has potential for impairment to skin integrity r/t cardiac history, fall risk and dementia.

-Was created on 2/10/23 and revised on 4/25/23.

*Goal: Will be free from skin alteration/injury through the review date.

-Target date was 7/27/24.

*Interventions:

-Reposition frequently. No documentation on how frequently she was to have been repositioned.

-Required a pressure-relieving mattress when in bed/chair.

-No documentation on other pressure relieving measures to promote the health of her skin.

*Focus area: [Resident's name] has Pressure injury to Right Lateral Ankle, Right Lateral foot and Bilateral heels r/t Braden score of 10 - 12 (high risk), immobility, terminal diagnosis,

-Was initiated on 4/28/24 and created/revised on 5/5/24. That had been four months after the identification of her first pressure ulcer.

-It did not include all seven of her pressure ulcers.

*Goals: Will participate with repositioning. Pressure injury will show signs of healing and will remain free from infection by/through review date. Will have intact skin, free from redness, blisters or discoloration by/through

review date.

-These goals were created on 5/5/24 and had a target date of 7/27/24.

-Interventions: Pressure relieving support surfaces in bed and chair: Standard reduction necessary to reduce pressure and to improve comfort level in relation to positioning/repositioning in bed and chair.

4. Interview on 6/20/24 at 2:44 p.m. with MDS/RN C regarding resident 4's pressure ulcers, pressure ulcer care, and the documentation of the pressure ulcer care was difficult to follow revealed:

-She stated she would bring the timeline and care provided together so the surveyor could review it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -She stated resident 4's physician would be visiting resident 4 on 6/20/24 and she would discuss the pressure ulcers and possible changes in her pressure ulcer care and the two pressure ulcers on her right Level of Harm - Actual harm lateral foot had worsened and were red in color.

Residents Affected - Few 5. Interview on 6/21/24 at 11:30 a.m. with MDS/RN C regarding the pressure ulcers revealed:

-She had not put together the documentation of the timeline of the pressure ulcer care.

-She had discussed with resident 4's physician and was told he was not going to change her ulcer orders.

-She stated the new director of nurses (DON) was wound certified and MDS/RN C felt that the wound care would be changing for the better.

*She stated:

-Hospice cannot provide an air bed because she did not meet the hospice guidelines.

-The provider could provide an air bed, but she was scared the resident would break a hip because she moved in bed.

-Resident 4 had used her own mattress when the pressure ulcers started.

-She accepted a provider pressure relief mattress, and it did provide better relief than her mattress.

-She had long pressure relief boots, but she was too hot in them, and she would take them off.

--She had accepted the small foam boots.

-The first thing resident 4 would do when she would lie in bed was to place her feet sideways, so they are lateral to the mattress, and she felt that caused pressure ulcers.

Review of the provider's undated Charting Expectations policy revealed:

*Rounds:

-The night CNA and the night nurse are expected to do rounds on residents at 1:00 a.m. AND 4:00 a.m. You cannot skip a round as that can be considered neglect

Review of the provider's 10/01/21 Pressure Ulcer Prevention policy revealed:

*Purpose:

-To promote the prevention of pressure ulcer development.

-To promote the healing of pressure ulcers that are present including prevention of infection to the extent possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 435114 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435114 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diamond Care Center 901 N Main Ave Bridgewater, SD 57319

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -To prevent the development of additional pressure ulcer.

Level of Harm - Actual harm *Policy:

Residents Affected - Few -It is the policy of [facility name] to prevent a resident who enters the facility without pressure sores from developing pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and to provide necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing.

Review of the provider's 9/18/19 Care Plan Policy and Procedure revealed:

*Purpose:

-Care plans will be developed by an interdisciplinary team with participation of the resident, family, and/or representative .

-Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care.

*General instructions:

-Care Plans will be reviewed quarterly, annually, and with any significant change in resident condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 435114