Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diamond Care Center during CMS and state inspections, most recent first.
A facility failed to protect a resident from potential abuse by another resident and did not provide timely care for a resident with pressure ulcers. An incident involved a resident found with her blouse unbuttoned in another resident's room, and the facility delayed notifying authorities. Additionally, a hospice resident developed pressure ulcers that were not treated promptly, leading to further deterioration.
Two residents in hospice care developed and worsened pressure ulcers due to the facility's failure to provide timely and necessary care. Despite hospice recommendations and the provision of dressings, the facility staff did not apply them, leading to multiple pressure wounds for one resident. The second resident developed seven pressure ulcers, with some worsening, due to inadequate repositioning and care planning. Communication issues and poor adherence to care practices were noted.
The facility failed to have an RN on duty for eight consecutive hours per day for 37 days across two fiscal quarters and one day in June 2024. Despite being licensed for skilled nursing care, the facility did not meet staffing requirements and relied on phone availability of RNs and physicians. Staffing was based on resident numbers and acuity, and the facility was actively recruiting RNs.
The provider's Arbitration Agreement lacked essential details, such as the full name and contact information of the arbitration organization, and allowed the provider to choose the arbitration location unilaterally. Interviews revealed that staff were unaware of who developed the agreement, and the administrator acknowledged these deficiencies. Despite this, 26 out of 34 residents had signed the agreement, and no disputes had occurred.
The facility failed to submit accurate PBJ data for two fiscal quarters, resulting in deficiencies such as no RN hours for eight consecutive hours each day for more than four days and no 24-hour nurse coverage for more than four days. The administrator confirmed inaccuracies in the data submission and acknowledged the absence of an RN for the required hours, although a licensed nurse was present 24 hours each day.
The facility failed to update and revise care plans for several residents, leading to discrepancies between documented care needs and actual requirements. For example, a resident's fluid restriction was not updated after being discontinued, and another resident's smoking safety was inaccurately documented. Additionally, fall risk interventions were not properly reflected in a resident's care plan, and new safety interventions for vulnerable adults were not included. The MDS/RN was responsible for ensuring care plan accuracy, but this was not consistently achieved.
The facility failed to monitor and remove expired medications and personal care products. Expired PRN medications for three residents were found in a medication cart, and four medications lacked opened or expiration date stickers. Additionally, prescription personal care products in a tub room were not securely stored or discarded when expired. The facility's policy on medication storage and expiration monitoring was not followed.
A registered nurse failed to follow infection control practices during dressing changes for two residents on enhanced barrier precautions. The nurse did not perform hand hygiene at critical points, used the same gloves for multiple tasks, and directly touched residents' wounds without proper glove changes. Despite receiving training, the nurse was unaware of the missed opportunities for hand hygiene, contrary to the facility's policies.
Two residents were not routinely assessed for safe self-administration of medications, despite having intact cognition and orders for self-administration. One resident had a nasal spray without a self-administration order, and the other had not been assessed for over a year. The facility's policy required quarterly assessments, which were not conducted.
A provider failed to accurately code MDS assessments for two residents, leading to documentation errors. One resident's pressure ulcers were not recorded in the MDS, and another resident was incorrectly noted to have a catheter. The MDS/RN responsible did not review necessary documentation or was unaware of the errors, relying on basic training and the RAI manual for guidance.
A resident receiving dialysis twice weekly was not properly monitored for vital signs and fistula site abnormalities upon returning from treatment on four occasions. The charge nurse was responsible for this task, but documentation was missing, particularly on days when an LPN with known documentation issues was on duty. The facility's policy required such monitoring and reporting of concerns to medical professionals.
The facility failed to properly assess and document the use of bed side rails for two residents. One resident used side rails for turning after a hip fracture, but documentation inconsistencies were noted between physician orders and evaluations. Another resident had a side rail for repositioning, but assessments were not updated as required. The facility's policy mandated quarterly assessments, which were not completed, and the MDS coordinator was unaware of the oversight.
Failure to Protect Resident from Abuse and Neglect and Inadequate Pressure Ulcer Care
Penalty
Summary
The provider failed to protect a resident who was mentally incapable of identifying safety risks from potential abuse and neglect by another resident. An incident occurred where a resident was found in another resident's room with her blouse unbuttoned and her breasts exposed. The resident was unable to unbutton her shirt herself due to a physical disability, raising concerns about inappropriate behavior. The facility did not notify law enforcement or the Department of Human Services immediately, as required, and waited for guidance from the South Dakota Department of Health. Additionally, the provider failed to provide necessary care for a resident with pressure ulcers. The resident, who was on hospice care, developed multiple pressure ulcers on her buttocks and heel. Despite the availability of dressings provided by hospice, the facility staff did not apply them in a timely manner, leading to the deterioration of the resident's condition. The pressure ulcers were not documented or treated appropriately until several days after they were first identified. The facility's inaction in both cases highlights a lack of adherence to protocols for reporting and addressing potential abuse and neglect, as well as a failure to provide timely and adequate care for pressure ulcers. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The provider failed to ensure timely and necessary care for two residents, leading to the development and worsening of pressure ulcers. For the first resident, hospice staff identified reddened areas on the buttocks on June 6, 2024, and provided dressings on June 7, 2024. However, the facility staff did not apply these dressings and instead placed the resident in a wheelchair, applying only cream. By June 10, 2024, the resident's condition had worsened, with multiple pressure wounds identified, including on the buttocks, coccyx, and heel. The family was not informed until June 10, 2024, and the appropriate wound care orders were not documented as completed until June 12, 2024. The resident passed away on June 14, 2024. The second resident, who was also under hospice care, developed multiple pressure ulcers while in the facility's care. Despite being at high risk for skin breakdown, as indicated by fluctuating Braden scores, there was a lack of documentation and implementation of a comprehensive repositioning plan. The resident acquired seven pressure ulcers, with some worsening from stage 2 to stage 3. The facility's documentation was inconsistent, and there was a delay in updating care plans to reflect the resident's declining condition and the need for pressure-relieving interventions. Interviews with hospice staff and facility personnel revealed communication issues and a lack of adherence to recommended care practices. Hospice staff expressed concerns about the facility's management of pressure ulcer care, noting that recommendations were not followed, and there was poor communication between the hospice agency and the facility. The facility's policies on pressure ulcer prevention and care planning were not effectively implemented, contributing to the deficiencies observed.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours per day for a total of 37 days across Federal Fiscal Quarters 1 and 2, as well as one day in June 2024. This deficiency was identified through a review of Payroll Based Journal (PBJ) reports, interviews, and record reviews. The specific dates without adequate RN coverage were detailed in the report, spanning multiple months from October 2023 to March 2024, and included an additional day in June 2024. The facility did not have a nurse waiver and was licensed to provide skilled nursing care, yet failed to meet the staffing requirement. Interviews with the facility's administrator and the Minimum Data Set (MDS) coordinator revealed that the PBJ data was entered manually, and there were issues accessing reports online. The administrator confirmed the absence of an RN for the required hours on the specified days and noted that while an RN was not always present, a physician and an RN were available by phone. The facility was actively advertising for RN positions through various channels, and staffing decisions were based on resident numbers and acuity levels. However, the facility did not have residents requiring RN care at the time of the deficiency.
Deficiency in Arbitration Agreement Details
Penalty
Summary
The provider failed to ensure that their Arbitration Agreement included the necessary details for a fair arbitration process. The agreement did not specify the full name of the arbitration organization or provide contact information for it. Additionally, the agreement allowed the provider to unilaterally select the location for arbitration, rather than ensuring it was convenient for both parties involved. Interviews with the administrator and the business office/social service designee revealed that they were unaware of who developed or approved the agreement, and that the agreement's deficiencies were not recognized until the survey. The administrator acknowledged that the agreement should have included the arbitration agency's full name and contact information, and that the location for arbitration should not be solely determined by the provider. It was also noted that not all residents had signed the arbitration agreement, and the administrator was unsure why some had not. Despite these issues, no disputes had occurred to date. A review of the provider's records showed that 26 out of 34 current residents had signed the Arbitration Agreement.
Inaccurate PBJ Data Submission and Staffing Deficiencies
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for Federal Fiscal Quarters 1 and 2. The PBJ CASPER reports indicated that there were no registered nurse (RN) hours for eight consecutive hours each day for more than four days, and no 24-hour nurse coverage each day for more than four days. Additionally, the weekend staffing metric was suppressed due to excessively low data submission. The administrator confirmed that the data for these quarters had not been submitted accurately, and there was no nurse waiver in place. Interviews revealed that the Minimum Data Set Coordinator (MDS)/RN was responsible for submitting the PBJ data until January 1, 2024, after which the administrator took over. The facility's time clock system did not automatically upload payroll data to the PBJ system, requiring manual entry. The administrator acknowledged that there was not always an RN present for eight consecutive hours each day, although a licensed nurse was present 24 hours each day. The administrator also declined to answer questions regarding the accuracy of low weekend staffing data.
Failure to Update and Revise Care Plans
Penalty
Summary
The provider failed to review and revise comprehensive care plans for six of twelve sampled residents, leading to discrepancies between the care plans and the actual care needs of the residents. For instance, a resident receiving dialysis treatments had a care plan indicating fluid restrictions, which were no longer applicable as the dialysis provider had discontinued them. This discrepancy was not communicated effectively to the staff, resulting in confusion about the resident's current care needs. Another resident, who smoked cigarettes, was assessed as safe to smoke independently, but the care plan inaccurately indicated that he was not safe to smoke on his own. This inconsistency in the care plan could lead to inappropriate supervision and care. Additionally, a resident with a high risk of falls had a care plan that did not reflect the necessary interventions, such as positioning the bed low to the floor and using a fall mat at night, which were crucial for her safety. Furthermore, the care plans for two residents who were considered vulnerable adults due to their conditions were not updated to include new interventions for their safety. The facility's policy required care plans to be updated with any significant changes in the resident's condition, but this was not consistently done. The MDS/RN was responsible for ensuring the accuracy of the care plans, but the documentation did not support that the care plans were updated as required.
Expired Medications and Improper Storage in Facility
Penalty
Summary
The provider failed to ensure proper monitoring and removal of expired medications and personal care products in the facility. During an observation, it was found that PRN medications stored in blister pack cards for three residents were expired and had not been removed for destruction. Additionally, four medications for three residents lacked opened or expiration date stickers. The facility's policy requires that expiration dates be determined by the pharmacist at dispensing and that medications be marked with an opened date. However, these procedures were not followed, leading to expired medications remaining in the medication cart. In a separate observation, prescription personal care products in a resident tub room were not securely stored or discarded when expired. The tub room contained prescription products with expired dates, including Selsun Blue shampoo, anti-itch lotion, Desitin, and Nystatin powder. The MDS coordinator/RN confirmed that prescription items should have been stored in a locked medication cart or room and that expiration dates should have been monitored and expired items discarded. However, these practices were not adhered to, resulting in expired and improperly stored prescription products in the tub room.
Infection Control Deficiency During Dressing Changes
Penalty
Summary
The provider failed to adhere to acceptable infection control practices during dressing changes for two residents, both of whom were on enhanced barrier precautions (EBP). Registered Nurse (RN) N was observed performing dressing changes for these residents without following proper hand hygiene protocols. During the dressing change for the first resident, RN N donned gloves and a gown in the hallway, then proceeded to touch various surfaces and the resident's personal items without changing gloves or performing hand hygiene. She also touched the resident's wound area directly with gloved hands that had been in contact with potentially contaminated surfaces. After removing her gloves, she did not wash her hands before applying tape to the gauze and the resident's toe, which is considered hands-on care. In a similar incident with the second resident, RN N again failed to perform hand hygiene at critical points during the dressing change. She used the same pair of gloves to handle supplies, touch the resident's skin, and apply wound care products. After removing her gloves, she did not wash her hands before securing the dressing with tape, directly touching the resident's toe. These actions were contrary to the facility's hand hygiene and personal protective equipment policies, which require hand hygiene before and after resident care and the use of gloves. Interviews with RN N revealed a lack of awareness regarding the missed opportunities for hand hygiene and glove changes. Despite receiving ongoing training from her staffing agency, RN N did not follow the facility's infection control policies. The Minimum Data Set (MDS) coordinator confirmed that agency staff were expected to adhere to the facility's policies, although orientation did not cover handwashing or glove use. The facility's policies clearly outlined the need for hand hygiene and proper use of personal protective equipment, which were not followed in these instances.
Failure to Routinely Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as residents 8 and 9, were routinely assessed for the safe self-administration of medications. During an interview and observation, it was noted that resident 8 had a bottle of nasal spray on her bedside table, but the registered nurse (RN) was unsure if there was a physician order for self-administration, leading her to administer the medication herself. Resident 8's medical record indicated she had a BIMS score of 15, showing intact cognition, and had several medications she was allowed to self-administer, but there was no self-administration order for the nasal spray. Resident 9 also had a BIMS score of 15, indicating intact cognition, and had an order for unsupervised self-administration of a medication for constipation. However, her most recent self-administration assessment was completed over a year ago. The facility's policy required quarterly assessments for self-administration, which were not conducted for either resident. The minimum data set coordinator confirmed that these assessments should have been completed quarterly. The facility's policy on self-administration of medications outlined the need for an initial screening tool to evaluate residents' ability to self-administer medications, with quarterly evaluations thereafter. Despite this policy, the facility did not perform the required quarterly assessments for residents 8 and 9, leading to a deficiency in ensuring the safe self-administration of medications.
Inaccurate MDS Assessments for Pressure Ulcers and Catheter Use
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical conditions. For one resident with pressure ulcers, the MDS assessment completed on 5/11/2024 inaccurately indicated that the resident had no unhealed pressure ulcers, despite weekly wound documentation on 5/6/2024 showing two grade 2 coccyx pressure wounds. The MDS/registered nurse (RN) responsible for the assessment admitted to not reviewing the weekly wound documentation before completing the MDS, resulting in incorrect coding. In another case, a resident's MDS assessment on 5/4/2024 incorrectly noted the presence of an indwelling urinary catheter, although the resident had not had a catheter since admission. The MDS/RN responsible for this assessment was unaware that the section had been marked incorrectly. The RN's training included basic online resources, and she relied on the RAI manual for guidance when needed. These inaccuracies highlight a failure to adhere to the CMS Resident Assessment Instrument (RAI) Manual guidelines, which require thorough review and confirmation of medical records and resident conditions.
Failure to Monitor Dialysis Patient Post-Treatment
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment. Resident 16, who received dialysis twice a week, had a physician's order dated December 4, 2023, which required the assessment of vital signs and the fistula site for any abnormalities upon returning from dialysis. This assessment was to be documented, and any abnormal findings were to be reported to the primary care provider. However, there was no documentation of such monitoring for four out of sixteen opportunities between April 19, 2024, and June 10, 2024. The specific dates lacking documentation were April 19, May 13, May 20, and June 10, 2024. Interviews revealed that the charge nurse on duty was responsible for monitoring and documenting the resident's condition in the electronic medical record. The minimum data set coordinator/registered nurse indicated that LPN J was responsible for the documentation on three of the four days it was not completed. However, LPN J's documentation had been problematic, and she was no longer employed at the facility. The provider's dialysis policy, dated October 29, 2024, stated that nurses should monitor the dialysis catheter and/or AV fistula site every shift for signs of infection or malfunction, and report any concerns to the appropriate medical professionals.
Failure to Assess and Document Bed Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents using bed side rails were appropriately assessed, and the documentation accurately reflected the type of bed side rail in use. Resident 8 was observed using side rails on both sides of the upper half of her bed, which she had been using since 2023 to assist with turning in bed after a hip fracture. Her medical record indicated a physician's order for a 1/4 side rail/grab bar, but the Physical Device Evaluation noted the use of 1/2 side rails. No further evaluations were completed after April 2023, and her care plan mentioned the use of a 1/4 side rail/grab bar, indicating inconsistencies in documentation and assessment. Resident 2 was observed with a side rail on the right side of his bed, with a physician's order for a U-shaped grab or 1/4 side rail to assist with independence and repositioning. An Assistive Device Assessment and a Physical Device Assessment were completed in January 2024, but no further assessments were conducted. The facility's policy required quarterly assessments for side rail use, which were not completed for these residents. The MDS coordinator acknowledged the lack of current assessments and was unsure why they were not completed. The facility's restraint policy outlined the need for assessments and care plan reviews, which were not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Canistota | 10.7 mi | — | 11 | 0 |
| Oakview Terrace | 14.9 mi | — | 0 | 0 |
| Tieszen Memorial Home | 15.3 mi | — | 0 | 0 |
| Menno-olivet Care Center | 22.3 mi | — | 1 | 0 |
| Avera Bormann Manor | 26.8 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Diamond Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.