Diamond Care Center

F-F554, Resident Self-Administration of Medications, indicated, All nursing staff are required to complete medication education with post test. All new hired nurses/CMAs [certified medication aides] will be required to complete medication storage training.

-There were 17 employees who had completed the training.

--Those staff included seven nursing staff members, four dietary staff members, two housekeeping staff members, one laundry staff member, one maintenance staff member, one activity staff member, and the administrator.

*The provider's PoC for citation

F-F686, Treatment/Services to Prevent/Heal Pressure Ulcer, indicated, Education on repositioning and offloading including techniques to prevent pressure injuries implement for nursing staff on 7/5/24. Education to be reviewed and quiz to be completed for Nurses, CMAS [medication aides] and CNA's [Certified Nurse Aides]. New hires for nursing staff will be required to complete the quiz as part of the new hire orientation.

-There were 19 staff members who had completed the training.

--Those staff included one dietary staff member and 18 were nursing staff members.

*The provider's PoC for citation

F-F727.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 54 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49958 potential for actual harm Based on observation, interview, and policy review, the provider failed to follow acceptable infection control Residents Affected - Some practices during two of two observed dressing changes for two of two sampled residents (4 and 15) by registered nurse (RN) N. Findings include:

1. Observation on 6/20/24 at 11:29 a.m. with registered RN N during a dressing change for resident 15 who was on enhanced barrier precautions (EBP) revealed she:

*Put on a gown and a pair of gloves while in the hallway outside resident 15's room and with those gloved hands she:

-Picked up a basket of supplies from the shelf in the hall.

-Entered the room and turned the light switch on

-Moved the resident's personal items off the bedside table.

-Placed a paper towel on the bedside table and placed the basket on that paper towel.

-Touched the bed control to raise the bed.

-Moved blankets to uncover the resident.

-Opened the resident's brief to view the pressure area and then closed the brief.

-Covered the resident.

-Uncovered the resident's foot and removed the resident's sock.

-Sprayed wound spray on several pieces of gauze.

-Sprayed the resident's toe with the wound spray, touched a darkened area on the resident's toe with the wet gauze, and then touched that darkened area directly with those same gloved hands.

*Removed and discarded those gloves then washed her hands.

*Opened the bathroom door, gathered new gloves, closed the door, moved the curtain, and then put on those gloves. With those gloved hands she:

-Moved the bedside table closer to the bed.

-Opened a package of betadine swabs and wiped the resident's toe with the swab.

-Took a gauze pad from the basket and placed it on the barrier next to the basket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 54 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 0880 -Attempted to wet the gauze with betadine.

Level of Harm - Minimal harm or --Touched the gauze pad directly with those gloved fingers. potential for actual harm ---Placed that gauze pad on the resident's toe. Residents Affected - Some *Removed those gloves and discarded them.

*Without washing her hands, she used tape to secure the gauze in place and directly touched the resident's toe while she held the gauze in place.

*Placed the sock back on the resident's foot and covered her without wearing any gloves.

*Left the room with the basket of supplies.

Interview on 6/20/24 at 4:36 p.m. RN N regarding the above dressing change revealed she:

*Was an agency nurse and had worked in this facility on and off for the past five years.

*Stated she had completed all dirty tasks while wearing one pair of gloves and all clean tasks while wearing

a second pair of gloves.

*Preferred not to use hand sanitizer and elected to wash her hands when necessary.

*Stated that all residents with wounds are on EBP and that gloves and gowns are required for all hands-on care.

*Confirmed that she had removed her gloves to apply the tape to the gauze and toe because the tape would have stuck to my gloves.

-Acknowledged that applying tape to the gauze and the resident's toe would have been considered hands-on care.

*Was unable to identify the missed opportunities for changing her gloves and performing hand hygiene.

*Stated she received ongoing educational training from the staff agency she worked for.

Interview on 6/21/24 at 9:57 a.m. with Minimum Data set (MDS)/RN C regarding the above dressing change revealed:

*She would have expected RN N to complete hand hygiene (wash her hands) before putting on gloves and

after removing them.

*There had been several missed opportunities for RN N to have performed hand hygiene and to have changed her gloves during the observed dressing change.

*Agency staff had been provided orientation when they first came to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 54 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 0880 -Orientation did not include hand washing or glove use.

Level of Harm - Minimal harm or *Agency staff are expected to follow the facility's policies. potential for actual harm *She would have expected the staffing agency to provide specific ongoing training on handwashing and Residents Affected - Some glove use that was to the national standard.

*She stated if staff chose not to use hand sanitizer then they should have washed their hands when hand hygiene was expected.

32332

2. Observation on 6/20/24 at 2:15 p.m. with registered nurse (RN) N during dressing changes for resident 4 who was on enhanced barrier precautions (EBP) revealed she:

*Put on a gown and then gloves while in the hallway outside the resident room and with those gloved hands she:

-Picked up a basket of supplies from the shelf in the hall.

-Entered the room and turned the light switch on.

-Moved the resident's items off the bedside table.

-Placed a paper towel on the bedside table and placed the basket on that paper towel.

-Moved the blankets to uncover the resident.

-Touched the resident's brief.

-Touched the resident's bottom to expose the pressure area.

-Closed the resident's brief and covered the resident.

-Uncovered the resident's foot and removed her sock.

-Used wound spray to spray several pieces of gauze.

-Sprayed the resident's toe with the wound spray and touched a darkened area on the resident's toe first with

the wet gauze and then directly with those gloved hands.

*Removed those gloves for the first time and washed her hands.

*Opened the bathroom door to get gloves, closed the door, moved the curtain, and then put on those gloves. With those gloved hands she:

-Moved the bedside table closer to the bed,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 54 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 0880 -Opened a package of betadine swabs and wiped the resident's toe with the swab.

Level of Harm - Minimal harm or -Took a gauze pad from the basket and placed it on the barrier next to the basket. potential for actual harm -She attempted to wet the gauze with betadine. Residents Affected - Some --She touched the gauze pad directly with those gloved fingers.

---Then placed that gauze pad on the resident's toe.

*Removed those gloves and discarded them.

*Without performing hand hygiene, she used tape to secure the gauze in place directly touching the resident's toe.

*Placed the sock back on the resident's foot and covered her without wearing any gloves.

*Left the room with the basket of supplies.

Interview on 6/20/24 at 4:36 p.m. RN N regarding the above dressing change revealed she:

*Was an agency nurse and had worked in this facility on and off for the past five years.

*Stated she had completed all dirty tasks while wearing one pair of gloves and all clean tasks while wearing

a second pair of gloves.

*Preferred not to use hand sanitizer and elected to wash her hands when necessary.

*Stated that all residents with wounds are on EBP and that gloves and gowns were required for all hands-on care.

*Confirmed that she had removed her gloves to apply the tape to the gauze and toe because the tape would have stuck to my gloves.

-Acknowledged that applying tape to the gauze and the resident's toe would have been considered hands-on care.

*Was unable to identify the missed opportunities for changing her gloves and performing hand hygiene.

*Received ongoing educational training from the staff agency she worked for.

Interview on 6/21/24 at 9:57 a.m. with Minimum Data set (MDS) coordinator/registered nurse (RN) C regarding the above dressing change revealed:

*She would have expected RN C to complete hand hygiene before putting on gloves and after removing them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 54 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 0880 *There had been several missed opportunities for RN N to have performed hand hygiene and to have changed her gloves during the dressing change. Level of Harm - Minimal harm or potential for actual harm *Agency staff had been provided orientation when they first came to the facility.

Residents Affected - Some -Orientation did not include hand washing or glove use.

*Agency staff are expected to follow the facility's policies.

*She expected the staffing agency to provide specific ongoing training on handwashing and glove use that was to the national standard.

*If staff chose not to use hand sanitizer then they needed to wash their hands when hand hygiene is expected.

Review of the provider's undated Hand Hygiene policy revealed:

*Staff must perform hand hygiene:

-Immediately before and after resident care.

-Immediately before putting PPE [personal protective equipment] and immediately after removing PPE.

*The use of gloves does not replace handwashing or the use of alcohol-based hand sanitizer.

Review of the provider's undated Personal Protective Equipment policy revealed:

*Wear gloves for all resident care/contact and/or tasks where the potential for contact with blood or body fluid may exist.

*Remove gloves before touching equipment such as telephones, charts, computers, monitors, doorknobs, refrigerator handles, food, pens, pencils etc.

Review of the provider's 4/1/2024 Enhance Barrier Precautions policy revealed:

*Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents . at increased risk of MDRO [multidrug-resistant organisms] acquisition (e.g.' residents with wounds .).

*High-Contact resident activities include: .

-Wound care: any skin opening requiring a dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 54 435114

F-F761, Label/Store Drugs and Biologicals, indicated, All nursing staff are required to complete medication storage education with a post test. All new hire nurses/CMA's [CMAs] will be required to complete medication storage training.

-There were 11 staff members who had completed the training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 54 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 0658 --Those staff included one dietary staff member, one RN, three licensed practical nurses (LPN's), and six CNA's. Level of Harm - Minimal harm or potential for actual harm *The provider's PoC for citation

F-F880, Infection Prevention and Control, indicated, Nursing staff are required to complete hand hygiene education with post test. All new hires will be required to complete hand hygiene Residents Affected - Some training.

-The provider's staff member listing indicated there were 25 nursing staff that included RN's, LPN's, and CNA's.

--There was one agency nurse not listed.

-There were 17 nursing staff members who had completed the hand hygiene training, which included the agency nurse.

Interview on 7/25/24 at 12:10 p.m. with director of nursing (DON) B regarding education for staff members revealed:

-She created a PowerPoint presentation, staff reviewed the presentation, and signed electronically that they had completed the training.

-Staff members who had not completed that education would have been educated on a one-to-one basis.

Interview on 7/25/24 at 3:09 p.m. with administrator A and DON B confirmed the PoC education was not completed by 7/23/24 as stated in the PoC's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 54 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 25 of 54 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 26 of 54 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 27 of 54 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 28 of 54 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 29 of 54 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 30 of 54 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 31 of 54 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 32 of 54 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 33 of 54 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 34 of 54 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 35 of 54 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 36 of 54 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or 43844 potential for actual harm Based on interview, record review and policy review the provider failed to ensure one of one sampled Residents Affected - Few resident (16) who required dialysis treatment was monitored for abnormalities upon returning from his dialysis treatment. Findings include:

1. Interview on 6/19/24 at 8:27 a.m. with administrator A revealed resident 16 received dialysis two days per week.

Review of resident 16's medical record revealed:

*A 12/4/23 physician's order for, Upon return from dialysis: Assess Vital Signs and fistula [a connection between an artery and a vein for dialysis treatment] for bleeding, bruising or other abnormalities prior to resident returning to his room. Document V/S [vital signs] and fistula site. Any abnormal findings or concerns

a progress note must be made and faxed to PCP [primary care provider].

*There was no documentation in his treatment administration records that monitoring had occurred for four of sixteen opportunities from April 19, 2024 through June 10, 2024.

-Those dates had included 4/19/24, 5/13/24, 5/20/24, and 6/10/24.

Interview on 6/20/24 at 10:41 with minimum data set coordinator/registered nurse C regarding monitoring of resident who received dialysis revealed:

*The charge nurse who worked that day was responsible to ]have monitored and documented in that resident's electronic medical record.

*She had no knowledge of why the monitoring of resident 16 had not been completed.

*Resident 16 went for dialysis two days each week.

*She said licensed practical nurse (LPN) J should have completed and documented the monitoring for three of the four days that it had not been done for resident 16.

-LPN J's documentation had been a problem.

--She was no longer employed there.

Review of the provider's 10/29/24 Dialysis policy revealed:

*[The provider] will ensure resident follows dialysis schedule as ordered by the physician.

*Nurses will monitor dialysis catheter and/or AV [arteriovenous] fistula site every shift for signs and symptoms of infection an/or malfunction. All concerns will be reported to the dialysis center, nephrologist, surgeon, and/or primary care physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 54 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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 43844 Residents Affected - Few Based on observation, interview, record review, and policy review the provider failed to ensure two of two sampled residents (2 and 8) who used bed side rails were appropriately assessed and documentation accurately reflected the type of bed side rail in use. Findings include:

1. Observation and interview on 6/19/24 at 9:03 a.m. with resident 8 revealed:

*She was in her bed, eating breakfast.

*The side rails on both sides of the upper one-half of her bed were in the up position.

*She indicated she had started using the side rails in 2023 to assist her in turning while in bed after she had fractured her her hip.

Review of resident 8's medical record revealed:

*Her 5/4/24 Brief Interview of Mental Status (BIMS) score was a 15, which indicated her cognition was intact.

*An 8/12/20 physician order for OK to use 1/4 side rail/grab bar for assist with bed mobility and turning.

*A Physical Device Evaluation completed on 4/9/23 included:

-Rails on Bed, 1/2 side rail, bilateral (both sides), and Pain medications work well but resident requests side rails to help reposition in bed.

*There were no other Physical Device Evaluations completed for the use of side rails after that.

*Her 6/20/24 care plan included she used an assistive device 1/4 side rail/grab bar on both sides of bed to assist with reposition and turn in bed. Is not able to pull any of her own weight. Uses bar to hold while turning.

2. Observation on 6/18/24 at 4:22 p.m. and again on 6/19/24 at 1:40 p.m. of resident 2 revealed:

*He was in his bed lying on his right side, with his eyes closed.

*A side rail attached to the right, upper half of his bed was in the up position.

Review of resident 2's medical record revealed:

*A 1/18/24 physician order for a U-shaped grab or 1/4 Side to bed on right side to assist resident in maintaining independence and assist in repositioning self.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 54 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 0700 *An Assistive Device Assessment completed on 1/18/24 had Bed Assist Bar, and Alternatives to Restraints Attempted was marked as Not Applicable. Level of Harm - Minimal harm or potential for actual harm *A Physical Device Assessment completed on 1/29/24 included the use of Rails on Bed, U type grab bar, Location on bed was marked as (right side] checked, the Device will be used for area had mobility Residents Affected - Few enabler/enhancer, positioning, and safety checked.

*There were no other Assistive Device Assessments or Physical Device Assessments completed.

*His 6/20/24 care plan included that he used a U-shaped grab bar to right side head of bed to aid in transfers and repositioning.

3. Interview on 6/19/24 at 10:26 a.m. with certified nursing assistant R regarding resident's side rail use revealed:

*Resident 8 used her side rail to help her turn and hold herself in position when care was provided to her.

-She had used this side rail for at least a year.

*Resident 2 used his side rail to turn, sit up in bed, to hold his television remote, towels, and his call light.

4. Interview on 06/20/24 at 5:48 p.m. with minimum data set coordinator (MDS)/registered nurse (RN) C regarding resident assessments for safe and appropriate side rail use revealed:

*Those assessments were to be completed on a quarterly basis.

*Residents 2 and 8 did not have current assessments for side rail use completed and she:

-Was responsible for the completion of those assessments.

-Did not know why she had not completed them.

5. Review of the provider's undated Restraint policy revealed:

*Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or near your body so a resident can't remove the restraint easily. Physical restraints, prevent freedom of movement or normal access to one's own body.

*Physical or chemical restraints are not to be used, unless it's necessary to treat medical symptoms.

*The following items are considered restraints:

-*Side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 54 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 0700 *To properly use one of the previous items to assist a resident in maintaining independence, the resident and

the device must be assessed for the following: Level of Harm - Minimal harm or potential for actual harm -The resident is able to remove the device without assistance from staff.

Residents Affected - Few -The device has to assist resident in maintaining independence.

-Device must be approved by resident, family, and IDT committee.

-Device must be in care plan and reviewed quarterly (or sooner if issues).

*Siderails: Side rails can be used on a bed to increase a resident's mobility, ability to reposition self, and to maintain independence. Side rails can also be a hazard and detrimental to a resident and cause injury.

*Procedure to Implement a Device that can be considered a Restraint:

-All devices must be added to the care plan and assessed quarterly for resident's ability to independently use device and the safety of the device.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 54 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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 43844

Residents Affected - Many Based on Payroll Based Journal (PBJ) reports, interview, and record review, the provider failed to ensure there was a registered nurse (RN) working for eight consecutive hours per day for 36 days in Federal Fiscal Quarters 1 (October, November, and December 2023) and Quarter 2 (January, February, and March 2024), and one day from June 6th, 2024, through June 14, 2024.

Findings include:

1. Review of the provider's Federal Fiscal Quarter 1 (October, November, and December 2023) PBJ Certification and Survey Provider Enhanced Reporting (CASPER) report revealed the following:

*There were no eight consecutive hours worked by an RN on the following days:

-October 14th, 22nd, and 28th.

-November 10th, 11th, 12th, 14th, 24th, 25th, and 26th.

-December 3rd, 9th, 10th, 14th, 15th, 17th, 18th, 22nd, 23rd, 24th, 25th, and 31st.

Review of the provider's Federal Fiscal Quarter 2 (January, February, and March 2024) PBJ CASPER report revealed the following:

*There were no eight consecutive hours worked by an RN on the following days:

-January 1st, 6th, 7th, 8th, 13th, 20th, and 27th.

-February 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th.

-March 1st, 2nd, 3rd, 16th, 17th, 23rd, 24th, 25th, 30th and 31st.

Review of provider's timecards and nurse schedules for the time frames above revealed:

*There were no eight consecutive hours worked by an RN on the following days:

-October 14th, 18th, 22nd, and 28th.

-November 4th, 10th, 11th, 12th, 25th, and 26th.

-December 3rd, 8th, 9th, 21st, 23rd, 24th, 27th, 29th, and 31st.

-January 13th, 14th, and 20th.

-February 1st, 2nd, 3rd, 4th, 18th, 23rd, and 24th.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 54 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 0727 -March 2nd, 16th, 17th, 23rd, 24th, 30th, and 31st.

Level of Harm - Minimal harm or Additional review of the provider's time cards and nurse schedules from 6/6/24 through 6/14/24 revealed the potential for actual harm were no eight-hour consecutive hours worked by an RN on 6/8/24.

Residents Affected - Many Interview on 6/21/24 at 11:30 a.m. with administrator (ADM) A confirmed there were 37 days that had no eight consecutive hours worked by an RN.

Interview on 6/21/24 at 11:35 a.m. with Minimum Data Set coordinator (MDS)/registered nurse (RN) C regarding the PBJ revealed:

*She had been responsible for submitting PBJ data to the Centers for Medicare and Medicaid Services (CMS) until January 1, 2024, ADM A was then responsible to submit the data.

-The information was entered manually, as their time clock system information did not carry over into the PBJ system.

*She had not been able to access those Reports online.

Continued interview on 6/21/24 at 2:07 p.m. with ADM A regarding having an RN work for eight consecutive hours each day revealed:

*The provider was licensed to provide skilled nursing care and did not have a nurse waiver.

*She confirmed there was not always a registered nurse for eight consecutive hours each day at the facility.

-When an RN was not in the facility, a physician and an RN were available by phone.

*She stated there were no residents in the facility that required an RN for care.

-She stated, If that were needed [an RN], we would have RNs available, the Hospice nurse is also an RN and available when she is here.

*The provider was advertising with online employment companies, Facebook, local television stations, and

the local newspaper.

*The staffing for weekends was Based upon residents we have and acuity level [of the residents].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 54 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 32332 Residents Affected - Some A. Based on observation, interview, and policy review, the provider failed to ensure:

*As needed (PRN) medications stored in blister pack cards with pharmacist-determined expiration dates had been monitored for expiration and removed for destruction for three of three sampled residents (14, 22, and 31) in one of one medication cart.

*Four of four medications had opened or expiration dates indicated, for three of three sampled residents (7, 15, and 33) in one of one medication cart.

Findings include:

1. Observation, medication review, and interview on 6/20/24 at 11:38 a.m. with registered nurse (RN) N of one of one medication cart revealed:

*PRN blister pack cards (medication cards) with expired medications for three residents (14, 22, and 31):

-Resident 14's acetaminophen was dispensed from the pharmacy on 6/10/23 and expired on 6/8/24.

-Resident 22's loperamide caplets were dispensed from the pharmacy on 9/14/23 and expired on 4/30/24.

-Resident 31's acetaminophen was dispensed from the pharmacy on 4/5/23 and expired on 4/4/24.

*Four of four medications had no opened date or expiration date stickers, for three of three sampled residents (7, 15, and 33):

-Resident 7's two bottles of fluticasone propionate (nasal spray) were dispensed on 11/16/23. The bottles had no opened date or expiration date indicated.

-Resident 15's Ozempic injection pen (for diabetes) had no opened date or expiration date indicated.

-Resident 33's bottle of PRN fluticasone propionate was dispensed on 12/26/22.

--The bottle had no opened date or expiration date indicated.

Interview during the above observations with RN N revealed she confirmed:

*Those medications were outdated and should have been removed from the medication cart.

*The provider normally would mark the medications with an opened date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 54 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 0761 Review of the provider's undated Medication Storage In The Facility policy revealed:

Level of Harm - Minimal harm or *Expiration dates of dispensed medications should be determined by the pharmacist at the time of potential for actual harm dispensing.

Residents Affected - Some *Certain medications or package types, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity an potency.

*Drugs re-packaged by the pharmacy staff would generally carry an expiration date as follows:

-The pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation.

-Blister pack cards six months from the date of dispensing (when the manufacturer's expiration date is longer than six months). If the manufactures expiration date on the label will be the manufacturer's date.

*When the original seal of the a manufacturers's is initially broken the container or vial would be dated.

-The nurse should place a date opened sticker on the medication and enter the date opened and the new date of expiration '(note: the best stickers to affix containers both a date opened and expiration notation line)

The expiration date of the container would be 30 days unless the manufacturer recommended another date or regulations/guidelines.

*No expired medication would be administered to a resident.

*All expired medications would be removed from the active supply and destroyed in the facility, regardless of amount remaining.

*Disposal of any medications prior to the expiration dating would be required if contamination or decomposition is apparent.

Nursing staff should consult with the dispensing pharmacist of any questions related to medication expiration dates.

49958

B. Based on observation, interview, and policy review, the provider failed to ensure prescription personal care products in one of one resident tub rooms were:

*Securely stored in accordance with accepted professional principles.

*Discarded when expired.

Findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 54 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 0761 Observation on 06/20/24 at 8:34 a.m. of the cabinets in the tub room revealed they contained the following prescription products: Level of Harm - Minimal harm or potential for actual harm *Two bottles of Selsun Blue shampoo with prescription labels.

Residents Affected - Some -One was resident 2's bottle and was dated 5/8/23.

-One was a resident's who had been discharged from the facility on 1/16/24 and was dated 12/28/23.

*One bottle of resident 11's prescription anti-itch lotion was dated 8/23/22 and had a manufacturer's expiration date of 3/24.

*Two tubes of resident 16's prescription labeled Desitin (skin protectant).

-One was dated 3/23/23, one was dated 3/2/24.

*A bottle of resident 11's prescription labeled Nystatin (antifungal) powder dated 12/30/21 and had a manufacturer's expiration date of 3/23.

Interview on 6/21/24 at 9:57 a.m. with MDS coordinator/RN C revealed:

*She confirmed no staff worked that day who completed baths.

*The items stored in the tub room were used during resident baths.

*She was unaware that prescription items and expired items had been stored in the tub room.

*She would have expected:

-Prescription items to have been stored in the locked medication cart or the locked medication room.

-Expiration dates on prescription products to have been monitored by the nurse on duty and discarded when expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 54 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 43844 potential for actual harm Based on interview, Arbitration Agreement review, and record review, the provider failed to ensure the Residents Affected - Many Arbitration Agreement:

*Included the arbitration organizations name and how to contact that organization.

*Provided for a location that was convenient for both parties for an arbitration dispute.

Findings include:

1. Interview on 6/18/24 at 11:14 a.m. with administrator A revealed the provider had an Arbitration Agreement that was reviewed and requested to be signed by newly admitted residents or their representative.

Review of the provider's Arbitration Agreement revealed the following:

*Location of Arbitration - The Arbitration will be conducted at a site selected by [provider] which shall be either at [the provider] or somewhere within a reasonable distance of [the provider].

*Time limitation for Arbitration - any request to arbitrate a Dispute must be submitted to [initials of the arbitration agency] (2) years from the date the event giving rising to the dispute occurred.

*The agreement provided the initials of the name of the arbitration agency, but did not specify what those initials meant.

*The agreement did not provide for a way to contact that arbitration agency.

Interview on 6/20/24 at 9:28 a.m. with administrator A regarding the Arbitration Agreement revealed:

*All current residents or their representative had signed an arbitration agreement.

*She was not aware of who had developed and approved the agreement.

*Business office/social service designee (BO/SSD) D was responsible for having residents sign the agreement.

Interview on 6/20/24 at 10:32 a.m. with BO/SSD D revealed:

*She was responsible to have new residents sign the arbitration agreement.

*She was not aware of who had developed and approved the agreement.

*She confirmed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 54 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 0848 -The location for a dispute was for the provider to determine and not both parties.

Level of Harm - Minimal harm or -The agreement provided the initials of the name of the arbitration agency, but did not specify what those potential for actual harm initials meant.

Residents Affected - Many -The agreement did not provide for a way to contact that arbitration agency.

*She stated the resident or resident's representative could search the Internet on their phone to obtain the name and how to contact that arbitration agency.

Interview on 6/21/24 at 7:55 a.m. with administrator A regarding the Arbitration Agreement revealed she:

*Agreed agreement should have had the arbitration agency name spelled out and a way to contact them.

*Agreed facility should not have been independent in selecting the location for an arbitration dispute.

*Stated not all residents had signed the arbitration agreement, and was not sure why some had not.

*To her knowledge, no disputes had occurred.

Review of the provider's listing of residents revealed 26 of 34 of the current residents had signed an Arbitration Agreement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 54 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 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 43844

Residents Affected - Many Review of the provider's PBJ CASPER reports revealed the following items triggered:

*Federal Fiscal Quarter 1 and Federal Fiscal Quarter 2:

-No registered nurse (RN) hours for eight consecutive hours each day for more than four days.

-No 24-hour nurse coverage each day for more than four days.

-The weekend staffing metric was suppressed, meaning the data submitted was excessively low.

Interview on 6/21/24 at 11:30 a.m. with administrator A regarding PBJ reporting revealed:

*Minimum Data Set Coordinator(MDS)/registered nurse (RN) C had been responsible to submit the PBJ data to CMS.

*The time clock system was not able to automatically upload the payroll data to the PBJ system.

-The information had to be entered manually.

*Administrator A had recently gained access to the PBJ online reporting site, and the time clock had uploaded the data successfully.

*She confirmed the data for Federal Fiscal Year 2024 for Quarter's 1 and 2 had not been submitted accurately.

Interview on 6/21/24 at 11:35 a.m. with MDS/RN C regarding PBJ reporting revealed:

*She had been responsible to submit PBJ data to CMS until January 1, 2024, administrator A was then responsible to submit the data.

-The information was entered manually, as their time clock system information did not automatically transfer into the PBJ system.

*She had not been able to access the validation reports after submission.

Continued interview on 6/21/24 at 2:07 p.m. with administrator A regarding PBJ Data submission revealed:

*She confirmed there was not always an RN for eight consecutive hours each day at the facility.

*She confirmed there was no nurse waiver.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 54 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 0851 *She stated there were no residents in the facility that required a RN for care, if that were needed (an RN),

we would have RNs available, the Hospice nurse is also an RN and available when she is here. Level of Harm - Minimal harm or potential for actual harm *She confirmed there had been a licensed nurse in the facility at least 24 hours each day and that the PBJ submitted was inaccurate. Residents Affected - Many *When asked about how staff were scheduled for the weekend hours she stated, Based upon residents we have and acuity level [of the residents].

*When asked if the PBJ data was accurate for low weekend staffing, she declined to answer.

Refer to