Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 residents received as needed narcotic pain
medication as per physician order for 2 of 5 reviewed residents, Residents #9 and #15.
Residents Affected - Few
Findings include:
Review of Resident #9's admission record showed the resident was most recently admitted on [DATE] with
diagnoses that included chronic kidney disease, fracture of neck of left femur, osteoarthritis, dementia, and
type 2 diabetes mellitus.
Review of Resident #9's physician order dated 3/21/2024 read, Oxycodone HCl [hydrochloride] oral tablet 5
mg [milligram] (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for pain 6-10.
Review of Resident #9's Medication Administration Record (MAR) for March and April 2024 showed the
resident received Oxycodone 5 mg on 3/21/2024 (pain level 5), 3/22/2024 (pain level 5), 3/23/2024 (pain
level 5), 3/26/2024 (pain level 5), 3/30/2024 (pain level 5), 4/1/2024 (pain level 5), 4/3/2024 (pain level 5).
Review of Resident #9's care plan dated 2/1/2024 read, Focus: [Resident #9's name] has chronic pain r/t
[related to] arthritis, diabetic neuropathy, spinal stenosis, degenerative disc disease, Fx [fracture] to left hip .
Intervention: Administer medication as ordered.
Review of Resident #15's admission record showed the resident was most recently admitted on [DATE] with
the diagnoses that included chronic obstructive pulmonary disease, chronic systolic heart failure, type 2
diabetes mellitus with diabetic polyneuropathy, and peripheral vascular disease.
Review of Resident #15's physician order dated 3/20/2024 read, Oxycodone HCl Oral Tablet 10 mg
(Oxycodone HCl), Give 1 tablet orally every 6 hours as needed for pain 6-10.
Review of Resident #15's MAR for March showed the resident received Oxycodone 10 mg on 3/25/2024
(pain level 5).
Review of Resident #15's care plan dated 12/8/2023 read, Focus: [Resident #15's name] has chronic pain
r/t arthritis, diabetic neuropathy, peripheral vascular disease . Interventions: Administer medication as per
orders.
During an interview on 4/3/2024 at 7:20 AM, Staff A, Licensed Practical Nurse (LPN), stated, If a pain
medication order is written with parameters for pain such as administer for pain on scale 6-10,
(continued on next page)
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 6
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
04/04/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
then that medication can only be given if the pain is rated by the resident between the parameters. If the
pain is less than the parameter written for that narcotic, then the resident is to be given something less
such as Tylenol as long as there is an order. If resident needed something stronger, I would call the doctor
and request additional orders for pain medication.
During an interview on 4/3/2024 at 7:55 AM, Staff C, LPN, stated, The pain medication with parameters can
only be given if the pain is rated on the scale denoted in the orders and parameters, such as medication to
be administered for pain on scale 6-10. Then, the resident must rate their pain and if the pain is between
6-10, the narcotic can be given. If not, I would administer Tylenol or whatever pain medication that is
ordered instead of the narcotic. I would have to call the doctor for additional orders if the resident needed
medication or inform the resident that her pain would need to be rated at least a 6 before she could receive
the medication.
During an interview on 4/3/2024 at 9:00 AM, the Assistant Director of Nursing stated, Physician orders
must be followed. The nurse would need to call the doctor and document in the eMAR [electronic
medication administration record] that the doctor was notified, and new orders received. The new orders for
different parameters or different pain medication would be documented and initiated.
During an interview on 4/3/2024 at 10:05 AM, the Director of Nursing stated, Physician orders were not
followed. [Resident #9's Name] was administered narcotic Oxycodone 5 mg five times when [Resident #9's
Name]'s pain was not rated within the parameters of the physician orders (acute pain 6-10) and one time
for [Resident #15's Name]. Pain is to be assessed on a scale from 1-10 and documented each shift before
administering pain medication and after administering pain medication for reassessment. [Resident #9's
Name] pain was assessed using PAINAD [pain assessment in advanced dementia scale) used for the
cognitively impaired rated 1-10 based on observation. [Resident #9's Name] should have been scored
between 6-10 for pain prior to administering the oxycodone.
Review of the facility's policy and procedures titled Pain Management reviewed on 1/10/2024 read, The
pain intensity scale used to describe resident pain will be based on the cognitive ability of the resident. For
those residents who are cognitively intact, the Numerical (0-10) Rating Scale and/or the Wong-Baker
FACES Pain (0-10) Rating Scale may be used. For those residents who are cognitively impaired, the
Wong-Baker FACES pain (0-10) Rating Scale may be used. For the resident with severely impaired
cognition, The Behavioral Observation Scale (B.O.S) may be used.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 2 of 6
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
04/04/2024
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, the facility failed to ensure resident records were complete and
accurate for 2 of 4 residents reviewed for intravenous infusion, Residents #103 and# 176.
Findings include:
1. Review of Resident #103's admission record showed the resident was most recently admitted on [DATE]
with diagnoses that included encounter for surgical aftercare following surgery on the nervous system,
Methicillin susceptible staphylococcus aureus infection, unspecified dementia, and bilateral primary
osteoarthritis of hip.
During an observation on 4/1/2024 at 9:57 AM, Resident #103 had a transparent dressing on his left upper
arm, covering Peripherally Inserted Central Catheter (PICC) line, which was dated 3/22/2024.
Review of Resident #103's physician order dated 3/18/2024 read, IV [Intravenous]: Central Line- PICC Line:
Change transparent dressing every day shift every Wed [Wednesday] for preventative care.
Review of Resident #103's Treatment Administration Record for March 2024 showed the dressing change
was completed on 3/22/2024 and 3/27/2024.
During an interview on 4/1/2024 at 11:40 AM, the Director of Nursing stated, That's my initials. I completed
that dressing change on 3/22/2024. I don't know why it was signed off on 3/27/2024 as being completed.
2. Review of Resident #176's admission record showed the resident was admitted on [DATE] with
diagnoses including fracture of right acetabulum, fracture of one rib, chronic obstructive pulmonary disease,
pneumonia, type II diabetes mellitus, chronic kidney disease stage 3, and heart failure.
During an observation on 4/1/2024 at 10:37 AM, Resident #176 had a transparent dressing on his right
upper arm, covering the PICC line. The dressing was dated 3/22/2024.
Review of Resident #176's physician order dated 3/28/2024 read, Order Summary: Saline Flush
Intravenous Solution 0.9% (Sodium Chloride Flush), Use 5 ml [milliliters] intravenously two times a day for
flushing . Order Status: Discontinued . Order Summary: 2. Monitor IV site for S/SX [signs and symptoms of ]
infection . Check dressing and ensure the IV is secure and infusing properly, every shift for routine
monitoring . Order Status: Discontinued.
Review of Resident #176's Medication Administration Record for March 2024 showed no documentation of
after the morning shift of March 29, 2024.
During an interview on 4/2/2024 at 2:00 PM, Staff G, RN, Unit Manager, stated, The nurses who provided
care for [Resident #176's Name] have said that they continued to provide care according to standards of
care until his line was removed. My expectation is that they would document it on the MAR.
During an interview on 4/3/2024 at 10:32 AM, Staff F, LPN stated, We continued to flush [Resident #176's
Name]'s IV twice a day and monitored for signs of infection, but we did not have anywhere to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 3 of 6
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
04/04/2024
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 0842
document it on the MAR.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy and procedure titled Nursing- Documentation, Clinical last reviewed on
1/10/2024 read, Policy: The facility clinical staff will document the provision of care and services according
to nursing standards and regulatory requirements . Documentation in the medical record of each resident
should provide: 1. A complete account of resident's care treatment and response to the care
Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated and timed.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 4 of 6
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
04/04/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, and interview, the facility failed to ensure staff performed hand
hygiene during medication administration between residents and failed to ensure resident care reusable
items were cleaned and disinfected to prevent the possible spread of infection and communicable diseases.
Residents Affected - Some
Findings include:
During an observation on 4/2/2024 at 8:33 AM, Staff A, Licensed Practical nurse (LPN) started preparing
medications for Resident #8 without performing hand hygiene. During obtaining medication from the
medication cart for Resident #8, Staff A stopped and locked the medication cart and entered the common
room to assist Resident #36 with pencils and a coloring book. Staff A, then, returned to the locked
medication cart and retrieved additional 8:00 AM medications for Resident #8. Staff A proceeded to
Resident #8's room and administered the medications. Staff A did not perform hand hygiene. Staff A
proceeded to the medication cart and started preparing medications for Resident #107. Staff A
administered the medications for Resident #107 and did not perform hand hygiene. There was one blue pill
cutter contaminated with white powdery substance inside the pill cutter in the medication cart.
During an interview on 4/2/2024 at 9:10 AM, Staff A, LPN, stated, I should complete hand hygiene before
and after each resident. I normally do hand hygiene more often. Staff A confirmed the white powdery
substance inside the pill cutter and stated, We clean the pill cutters with purple wipes. I don't use the pill
cutter, but it is dirty.
During an observation of Back Westminster Medication Cart on 4/2/2024 at 9:42 AM with Staff B, LPN,
there was one blue pill cutter contaminated with white powdery substance inside the pill cutter.
During an interview on 4/2/2024 at 9:48 AM, Staff B, LPN, confirmed the white powdery substance inside
the pill cutter and stated, I did not use this pill cutter, but they are supposed to be cleaned after each use
with an alcohol wipe.
During an observation of Front Westminster Medication Cart on 4/2/2024 at 09:54 AM with Staff C, LPN,
there was one blue pill cutter contaminated with white powdery substance inside the pill cutter.
During an interview on 4/2/2024 at 10:00 AM, Staff C, LPN, confirmed the white substance inside the pill
cutter and stated, Pill cutters are supposed to be clean after each use.
During an observation of Cambridge Court Medication Cart on 4/2/2024 at 10:08 AM with Staff D,
Registered Nurse (RN), there was one blue pill cutter contaminated with white powdery substance inside
the pill cutter.
During an interview on 4/2/2024 at 10:08 AM, Staff D, RN, confirmed the white substance in the pill cutter
and stated, I don't know what this facility cleans the pill cutters with, but I will use a tissue or alcohol wipe.
During an interview on 4/2/2024 at 3:47 PM, the Director of Nursing stated, Pill cutters should be cleaned
with purple wipes after each use.
Review of the facility policy and procedure titled Handwashing/Hand Hygiene last reviewed on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105657
If continuation sheet
Page 5 of 6
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
04/04/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
1/10/2024 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the
spread of infections. Policy Interpretation and Implementation . 5. Use an alcohol-based hand rub
containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the
following situations . c. Before preparing or handling medications.
Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and
Equipment last reviewed on 1/10/2024 read, Policy Statement: Resident-care equipment, including
reusable items and durable medical equipment will be cleaned and disinfected according to current CDC
recommendation for disinfection and the OSHA [Occupational Safety and Health Administration]
Bloodborne Pathogens Standard . d. Reusable items are cleaned and disinfected between residents (e.g.,
stethoscopes, durable medical equipment) . 3. Durable medical equipment (DME) must be cleaned and
disinfected before reuse by another resident. 4. Reusable resident care equipment will be disinfected and
sterilized between residents according to manufacturers' instructions.
Event ID:
Facility ID:
105657
If continuation sheet
Page 6 of 6
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
FAQ · About this visit
Common questions about this visit
What happened during the April 4, 2024 survey of DIAMOND RIDGE HEALTH AND REHABILITATION CENTER?
This was a inspection survey of DIAMOND RIDGE HEALTH AND REHABILITATION CENTER on April 4, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DIAMOND RIDGE HEALTH AND REHABILITATION CENTER on April 4, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.