ABERDEEN, NC- DAHLIA GARDENS CENTER FOR NURSING AND REHABILIATION

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Reasonably accommodate the needs and preferences of each resident.

Based on observation, record review, resident and staff interviews, the facility failed to place a resident’s (Resident #83) call light within reach to allow for the resident to request staff assistance this was for 1 of 7 residents reviewed for accommodation of needs.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations and staff interviews the facility failed to ensure resident rooms were in good repair. Rooms #304 and #308 had several patched areas of sheetrock putty exposed on walls and room [ROOM NUMBER] had a missing plank panel on wall behind the headboard. This was for 3 of 8 rooms reviewed for comfortable, clean, and homelike environment.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review, resident and staff interviews, the facility failed to protect 1 of 4 residents (Resident #19), for his right to be free from physical abuse as evidence by another resident (Resident #9) slapping him with an open hand to the side of his head.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on record review and staff interviews, Nurse #2 failed to implement the reporting portion of the abuse policy after Nurse Aide #3 (NA #3) told her Resident #19 slapped Resident #9 on the right hand/forearm. The facility also failed to notify Adult Protective Services (APS) regarding an allegation of abuse. This was for 1 of 4 Residents (Resident #9) reviewed for abuse.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Based on record reviews and staff interviews, the facility failed to complete an annual Minimum Data Set (MDS) assessment within the required time frame for 1 of 19 residents reviewed for MDS assessments (Residents #9).

Assess the resident when there is a significant change in condition

Based on staff, Medical Director (MD) interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after 2 areas of significant decline. This was for 1 of 19 residents reviewed for MDS accuracy (Resident #24).

Assure that each resident’s assessment is updated at least once every 3 months

Based on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for 5 of 19 resident MDS assessments reviewed (Residents #17, #81, #24, #42 and #19).

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Based on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within the required time frame for 1 of 4 residents reviewed for MDS assessments (Residents #61).

Ensure each resident receives an accurate assessment.

Based on record review, observation, physician and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of urinary status, and upper extremity range of motion. This was for 2 of 19 MDS assessments reviewed (Resident #37 and Resident #49).

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Based on record review and staff interviews, the facility failed to provide abuse training to Nurse #2 prior to her working at the facility. This was for 1 of 5 employees reviewed for abuse training.