F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure the assessment accurately reflected the resident's
status for 1 of 3 residents sampled for discharge review, Resident #115.
Residents Affected - Few
Findings include:
Review of Resident #115's Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing
Home Discharge (BD) Item Set dated 9/15/2022, reads, Section A. Identification Information. A0310. Type
of Assessment . F. Entry/discharge reporting: 10. Discharge assessment- return not anticipated. A1800.
Entered From: 03. Acute hospital. A1900. admission Date (Date this episode of care in this facility began):
08/30/2022. A2000. discharge date : [DATE]. A2100. Discharge Status: 03. Acute Hospital.
Review of Resident #115's Discharge Planning Review dated 9/15/2022 reads, 7. Where resident
discharged to at time of discharge: a. Private residence.
Revie of Social Service Note dated 9/13/22 reads, [Family Member's name and Resident #115's name]
want to discharge to VA hospital to treat his cancer. requested for following provider to advise and it will be
a regular discharge so he can go straight to VA. [Family Member's name] will come pick him up in the
morning between 730 am and 8 am. Has wheel chair, walker and cane at home and will bring wheel chair.
Staff is aware.
During an interview on 12/7/2022 at 8:49 AM, Staff D, Social Services, stated, He went home. He was full
of cancer and the wife wanted to take him to the VA for the cancer. He was discharged home then after a
couple of days went to the VA. He was supposed to go straight to the VA, but I think they wanted to go
home for a couple of days. It is a long trip there. We would not have sent any discharge paperwork to the VA
because he was discharged home.
During an interview on 12/7/2022 at 9:40 AM, Staff E, MDS Coordinator, stated, It looks like there may have
been a data entry error on that. The daughter picked him up to take him to the VA hospital. I'm guessing
that is where the confusion was. We discharged him home. We wouldn't know if the daughter took him to
the VA or not. It looks like we need to do and modification and resubmit the MDS.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
105657
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diamond Ridge Health and Rehabilitation Center
2730 W Marc Knighton CT
Lecanto, FL 34461
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 - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents received wound care
services consistent with professional standards of practice for 1 of 4 sampled residents with pressure
ulcers, Resident #8.
Residents Affected - Few
Findings include:
Review of Resident #8's medical records revealed the resident wat admitted on [DATE] with diagnoses
including pneumonia, acute respiratory failure with hypoxia, chronic diastolic heart failure, dehydration,
chronic obstructive pulmonary disease, interstitial pulmonary disease, muscle weakness, paroxysmal atrial
fibrillation, anemia, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, essential
hypertension, morbid obesity due to excess calories, stage 3 chronic kidney disease, unspecified severe
protein-calorie malnutrition, restless leg syndrome, generalized edema, cystocele, and myocardial infraction
type 2.
Review of physician orders dated 11/30/2022 for Resident #8 reads, Wound Care: Coccyx shear, apply
calmaceptine and cover with dry protective DSG [Dressing] daily as needed if DSG is soiled or dislodged.
During an observation on 12/7/2022 at 9:11 AM, Resident #8 had soiled wound dressing placed on coccyx
dated 12/4/2022.
During an interview on 12/7/2022 at 9:25 AM, the Wound Care Nurse confirmed the dressing date was
12/4/2022, verified the physician order, and stated the dressing changes should be done daily.
During an interview on 12/7/2022 at 9:56 AM, the Assistant Director of Nursing (ADON) stated, Wound
dressing should be done as ordered.
Review of the facility policy and procedure titled Wound Care and Dressing [NAME], Dry/Clean revised on
1/12/2022 reads, Purpose: The purpose of this procedure is to provide guidelines for the application of dry,
clean dressings. Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be
generated from a facility protocol).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 2 of 3
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diamond Ridge Health and Rehabilitation Center
2730 W Marc Knighton CT
Lecanto, FL 34461
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the
facility were stored and labeled in accordance with currently accepted professional principles in 2 of 6
medication carts reviewed.
Findings include:
During an observation of medication cart #2 on [DATE] at 9:58 AM with Staff B, Licensed Practical Nurse
(LPN), there was a bottle of Alphagan P Solution 0.15% expired on [DATE] and a Levemir insulin pen with
expiration date of [DATE].
During an interview on [DATE] at 9:59 AM, Staff B, LPN, stated, Alphagan Solution 0.15% is expired and
Levemir insulin pen not sure if it has been labeled incorrectly.
During an observation of medication cart #3 on [DATE] at 10:09 AM with Staff C, LPN, there was a
Humalog insulin with no opened or expiration dates.
During an interview on [DATE] at 10:10 AM, Staff C, LPN, stated, Not sure why it is not labeled.
During an interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) stated, Medication in
medication carts should be labeled and dated when opened. Once medication is expired, it should be
disposed of.
Review of the facility policy and procedure titled Medications, Labeling of revised on [DATE] reads,
Purpose: The purpose of this procedure is to insure all medications maintained in the facility are properly
labeled in accordance with current state and federal regulation. General Guidelines . 3. Labels for individual
drug containers must include . h. The expiration date.
Review of the facility policy and procedure titled Storage of Medications revised on [DATE] reads,
Procedures . H. Outdated, contaminated, or deteriorated medications and those in containers that are
cracked, soiled or without secure closures are immediately removed from inventory, disposed of according
to procedures for medical disposal, and reordered from the pharmacy, if a current order exists.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 3 of 3
