Dahlia Gardens Center for Nursing and Rehabilitati

In the surveyor’s words

From the most serious findings on record at Dahlia Gardens Center for Nursing and Rehabilitati, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 6, 2023

  Based on staff and Wound Doctor interviews, record review and observations, the facility failed to safely position a resident in bed without injury when Resident #7 fell from a resident bed raised to the waist high position resulting in a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). This was for 1 (Resident #7) of 3 residents reviewed for accidents. The findings included: Resident #7 was admitted on [DATE] with a traumatic brain injury (TBI), seizure disorder, left side hemiplegia, muscle spasms and contractures to his left arm, elbow and leg. […]

• Actual harm, isolatedF688Sep 30, 2021

  Based on observations, facility staff, rehabilitation staff and Physician #1 interviews and record review, the facility failed to assess a resident for the worsening of bilateral hand contractures (Resident #24) and also failed to obtain Physician orders for splint management (Resident #32). This was for 2 of 6 residents reviewed for range of motion. The findings included: 1. Resident #24 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Admission/Re-Admission Screening dated 2/4/20 did not include any evidence that Resident #24 was admitted with bilateral hand contractures. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2023

  Based on observations and staff interviews the facility failed to ensure leftover food items were labeled and dated in 1 of 1 walk-in refrigerators and failed to ensure the low temperature dish machine a reached a minimum temperature of 120 degrees Fahrenheit during the wash cycle. This practice had the potential to affect food served to all residents. The findings included: 1. During the initial kitchen tour of the walk-in refrigerator on 05/01/23 at 10:00 AM the following concerns were observed: - a container of leftover spaghetti was sealed with plastic wrap, unlabeled, and undated - a container of chicken noodle soup was sealed with plastic wrap, unlabeled, and undated - a container of chili beans was sealed with plastic wrap, unlabeled, and undated - a container of cooked rice was… […]

• No harm, potential for more than minimal, patternF791Aug 9, 2023

  Based on observation, record review, staff interviews and interview with Nurse Practitioner (NP), Medical Director (MD), and Dental Office Customer Service Representative, the facility failed to refer a medically complex resident with multiple caries and broken teeth to an oral surgical center for recommended extractions in 1 of 1 resident (Resident #2) reviewed for dental care. The findings included: Resident #2 as admitted to the facility on [DATE] for diagnoses that included cerebral vascular accidents (stroke). The residents quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely or never understood and her cognitive skills for daily decision making were severely impaired. […]

• No harm, potential for more than minimal, patternF925Jun 20, 2023

  Based on observations, record reviews, and interviews with residents and staff, the facility failed to maintain an effective pest control program that was free of fly activity for 3 of 3 (Residents # 4, #8, and #11) residents reviewed for pest control. The findings included: A customer service report by the pest control complany dated 5/17/2023 indicated interior area floor drains in the kitchen were in need of cleaning. Recommended cleaning in and around drains frequently to prevent pest breeding sites. Spot applications of pest control were applied to interior dining, interior halls, interior kitchen, interior offices, and entry points. a. […]