Inspection·December 6, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's physician was immediately informed of an accident that resulted in injury for 1 of 3 residents reviewed, Resident #1. Findings include: Review of Resident #1's health record documented an appointment to see the cardiologist on 7/15/2024. Review of Resident #1's Emergency Department documentation dated 7/15/2024 showed the resident was in a wheelchair in a transfer vehicle and struck the left side of her face. CT (Computed Tomography) of head demonstrated a zygoma (cheekbone) fracture. The resident was anticoagulated but had no intracranial hemorrhage. Minimal blood in the sinus was noted and the resident had no signs of entrapment. During an interview on 12/6/2024 at 11:07 AM, the Administrator stated, I completed a thorough investigation of this incident on 7/16/2024 after the transport van incident, with [Resident #1's name] on 7/15/2024. I interviewed her twice on 7/16/2024 and [Resident #1's name] stated that the van driver [Staff A's name] buckled her down properly and wasn't speeding when this happened. It was just a bumpy road due to construction. The resident stated there was no abuse or neglect. It was just an accident. During an interview on 12/6/2024 at 12:08 PM, Resident #1 stated, I was going to see my cardiologist on 7/15/2024 for a routine appointment. There was a lot of construction on the main road, so I asked the van driver to go a different route since I grew up in this town and am aware of shortcuts to avoid construction and bumpy roads. The van driver took a quick turn which landed my left side of my face on the window. I yelled help and the van driver pulled over immediately, put the hazards [hazard lights] on and transferred me to the ground of the van. It took the van driver 7-8 attempts to get me back in the wheelchair. Once I was back in the wheelchair, I was re-buckled in. During the interview on 12/6/2024 at 12:39 PM, Staff A, Certified Nursing Assistant (CNA), and Transport Driver, stated, I backed her [Resident #1] up next to the window to the left side, placed the seatbelt over her chest and waist and tightened all 4 anchors. The resident told me not to follow the GPS [Global Positioning System] and was telling me the directions turn by turn to go. I took a right turn. Then, I heard an Ouch. I pulled over and put my hazards on. She [Resident #1] was in her wheelchair tipped over with her face on the window. I tried to put the wheelchair up with the straps on it, but I couldn't. I had to unstrap all the seatbelts; I had to slide her [Resident #1] to the (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 2 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 12/06/2024 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)