Office review·February 20, 2026

On 2/20/26 at 10:00 am, an office meeting was called regarding the Plan of Op at Diamond Care Inc. Attending the meeting was LPM Liza King, LPA Noel Wolf Petersen, Facility Administrator Jenna Silva. Discussion of the items began at 9:58 after introductions. The department has concerns about the plan of op missing/incomplete policies and procedures: Accepting residents with dementia and also mental health diagnosis 1 RN on call versus on multiple RN's on staff versus contracted 3rd party RN Services Restricted/prohibited conditions are mixed together. it will be copied over from the admission agreement Needs and services plan, the preplacement appraisals. It was fine, just out of order. Special equipment needs procedures for the specific needs. resident records checklist was provided to the administrator Personal rights, add all the codes, add a line that says this is not all inclusive of the codes, or make reference to an attached document Like an appendix A where you enumerate the rights. Continued on C page. The emergency plan is missing some components regarding evacuation sites. hospital does not do temporary shelter, transportation will be provided in an emergency, Neither hospice or home health is going to step up and should be excluded from an emergency shelter plan. church, or any environment without bedding, you need to provide a plan for meeting the clients continuing needs including bedding, should to be included in the evacuation plan. Dementia training has required training topics that should be listed with hours in the plan of op. Staff required training topics and hours should be listed.  TSP service referral. If home health falls through with their responsibilities, the facility is responsible to react to that. if there is care outside the scope of a care giver that needs to be done, the facility has to make arrangements for it to happen. Home health and hospice agencies have care plans maintained with the facility to describe the division of labor. Facility is going to arrange for transportation under incidental and medical and dental. The cost like charge for an escort or a transportation has to be outlined into the admission agreement if the responsible party is going to be charged for that as a service. Transport services for someone unconscious/can't do advance in writing requests? Plan of op should describe what the policy for the how the scheduling/transport will work in that scenario. Medical care is going to be scheduled by the facility. Theft and loss policy should specifically address thefts more than 100$, an inventory for safegaurded resident property should be completed soon. Restraints/seclusion are not permitted for use in the facility. Secured perimeter waiver will be dicussed in the ncc, usually its delayed egress. Topline is the department has not made a wavier and the department is aware the fire department is willing to allow it. No citations issued at this time. A copy of the report was read and provided to the administrator via email, and will be filed as signed when returned. exit interview was conducted.