Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dahlia Gardens Center For Nursing And Rehabilitati during CMS and state inspections, most recent first.
A resident with a new diagnosis of bipolar disorder and new psychotropic medication orders did not receive a required Level II PASRR evaluation. Staff interviews revealed that the MDS nurse, DON, and administrator each missed or misunderstood their roles in identifying and submitting the necessary PASRR request after the resident's mental health status changed.
A used, stained urine collection hat was found on the floor under a bathroom sink in a memory care resident's room, unlabeled and not stored in a bag. Staff were unaware of its presence and confirmed that such devices should be discarded after use or, if kept, properly cleaned, labeled, and bagged. This failure resulted in an environment that was not safe, clean, or homelike for the resident.
A resident with chronic pain and diabetes was prescribed methadone, but a card of the medication and its count sheet went missing. The issue was discovered when a refill request was denied for being too early, leading to an investigation that revealed the loss had been masked by missing documentation. The resident reported receiving all doses as ordered, and the incident was reported to law enforcement.
A resident with severe cognitive and physical impairments, fully dependent on staff for ADLs, was observed over several days with long, jagged fingernails and debris under one nail. Despite care plans requiring regular nail care and no documented refusals, staff failed to notice or address the resident's nail care needs, resulting in a deficiency.
The facility did not accurately post daily nurse staffing information, with incomplete and incorrect data regarding actual hours worked and staff numbers for both licensed and unlicensed personnel. Staff responsible for posting lacked access to necessary information and were unaware of requirements to include certain roles, resulting in discrepancies between posted and actual staffing levels.
A resident with moderately impaired cognition and a history of behavioral issues refused medications and care on several occasions, as documented in the MAR. However, the MDS assessment was not coded to reflect these refusals because the staff member responsible for this section only reviewed nurses' notes and was unsure where to find all relevant information in the medical record.
A resident with hemiplegia and other medical conditions was found to have their call light on the floor and out of reach, preventing them from requesting assistance. The resident expressed that this was a frequent issue, and a nursing assistant admitted to forgetting to check the call light's placement. The facility's administration confirmed that the call light should always be within reach.
A resident with a history of verbal aggression slapped his roommate, who was talking to himself, in a LTC facility. The incident was witnessed by a nursing assistant, who intervened and reported it to a nurse. The facility failed to protect the resident from abuse, as the altercation occurred despite existing care plans and interventions.
A nurse failed to report an incident where one resident slapped another, as she was unaware of the facility's abuse policy. The facility also delayed notifying APS due to the Administrator's unfamiliarity with local reporting requirements.
A resident with severe cognitive impairment and multiple health issues experienced significant decline, including a stage 3 pressure ulcer and notable weight loss. Despite these changes, the facility failed to complete a significant change MDS, as the MDS Nurse mistakenly completed a quarterly MDS instead. The DON and MD acknowledged the oversight and the resident's continuous decline.
An agency nurse at a LTC facility failed to report a resident-to-resident abuse incident due to a lack of prior abuse training. The nurse, who was on duty when one resident slapped another, did not notify administration as she was unaware of the facility's abuse policy. The nurse received orientation training, including the abuse policy, only after the incident occurred.
The facility failed to complete quarterly MDS assessments on time for five residents. The MDS nurse cited a high volume of admissions and discharges as the reason for the delay. The facility's Administrator and DON expected timely completion of these assessments.
The facility failed to maintain resident rooms in good repair, with observations revealing exposed sheetrock putty and a missing plank panel in some rooms. The Maintenance Director confirmed these issues but could not provide a timeline for repairs. The Administrator acknowledged the importance of a well-repaired environment and indicated that the Maintenance Director was responsible for addressing these concerns.
A facility failed to transmit an annual MDS assessment on time for a resident. The MDS nurse admitted to being behind due to a high volume of admissions and discharges, resulting in the assessment not being transmitted as required. The Administrator and DON confirmed the need for timely transmission.
A facility failed to complete a discharge MDS assessment within the required time frame for a resident. The MDS nurse admitted the delay was due to a high volume of admissions and discharges. The Administrator and DON confirmed the assessment should have been completed on time.
Two residents' MDS assessments were inaccurately coded, one for urinary status and another for upper extremity range of motion. A resident with a urinary catheter was incorrectly marked as incontinent, while another resident was mistakenly coded for limited range of motion based on a misinterpreted MD note. Staff interviews confirmed the inaccuracies.
Failure to Submit Level II PASRR Evaluation for Resident with New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was newly diagnosed with a serious mental illness. The resident was admitted with diagnoses of generalized anxiety disorder and unspecified depression, and a Level I PASRR was completed prior to admission. Subsequently, the resident was diagnosed with bipolar disorder by a psychiatrist, and new psychotropic medications were ordered and adjusted to address behaviors related to psychosis. Despite these changes, there was no evidence in the electronic medical record that a Level II PASRR screening was requested for the resident. Interviews with facility staff revealed gaps in communication and process oversight. The MDS nurse acknowledged noticing the new diagnosis and medication orders but did not recognize the need to notify the administrator for a Level II PASRR evaluation. The social worker did not have access to the state's PASRR submission system and indicated that the administrator was responsible for submitting requests. The DON believed the resident already had a Level II PASRR determination and maintained a list of residents needing screenings. The administrator confirmed she had not submitted a request for a Level II PASRR for this resident and relied on notifications from the DON and MDS nurse regarding changes in residents' conditions.
Improper Disposal and Storage of Used Urine Collection Device
Penalty
Summary
Surveyors observed a yellow-stained urine collection hat with a tissue inside lying on the floor underneath the sink in a resident's bathroom on two separate occasions. The device was not labeled with a resident's name nor stored in a bag. The resident, who resided in the memory care unit and was present in the room during both observations, was unable to confirm if the device belonged to him. Staff interviews revealed that nurse aides were unaware of the device's presence and stated that urine collection hats should be cleaned, labeled, and stored properly if intended for reuse, or disposed of after use. The unit manager and DON both confirmed that urine collection hats used for obtaining samples should be discarded after use and not left in resident bathrooms. The deficiency was identified as a failure to maintain a safe, clean, and comfortable environment for the resident by not properly disposing of or storing a used urine collection hat. The improper handling and storage of the device were attributed to staff inaction and lack of awareness, as well as a failure to follow established protocols for the disposal or storage of such items after use.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medication, specifically methadone prescribed for pain management. The resident, who was cognitively intact and had a history of diabetes with polyneuropathy and chronic pain, was admitted with an order for methadone 10 mg three times daily. During a leave of absence, the facility sent a supply of methadone with the responsible party, and medication counts were maintained on count sheets. However, upon reconciliation of medications after the resident's discharge, it was discovered that one card of methadone and its corresponding count sheet were missing. The discrepancy was identified when a refill request for methadone was denied by the pharmacy for being too soon, prompting the nurse practitioner to notify the DON of possible drug diversion. Investigation revealed that after the last documented administration from one card, the next card and its count sheet were missing, and staff had begun using a subsequent card. The end-of-shift narcotic count appeared correct because both the medication card and count sheet were absent, masking the loss. The nurse who last handled the medication stopped coming to work once the investigation began and was subsequently terminated. Interviews with the resident confirmed she received her medication as ordered and did not experience uncontrolled pain. The pharmacy and pharmacy supervisor confirmed the facility attempted to refill the medication prematurely and that no methadone had been returned. The incident was reported to law enforcement, and the facility initiated an internal investigation. The deficiency centers on the facility's failure to prevent the misappropriation of a resident's narcotic medication, as required by policy and regulation.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment, neurological disorder, contracture of the left arm, and vascular dementia was dependent on staff for all activities of daily living, including personal hygiene and nail care. The resident's care plan required staff to check, trim, and clean nails on bath days and as necessary, with no documented refusals of care. Despite this, multiple observations over several days revealed the resident's fingernails were long, jagged, and had a brown substance under one nail. The resident indicated a need for nail care, but there was no evidence that staff addressed this need. Interviews with direct care staff, including a nursing assistant, the DON, and a medication aide, confirmed that the resident's nails were in poor condition and that nail care was expected to be performed on shower days and as needed. Staff acknowledged they had not noticed or addressed the resident's nail care needs, and there were no documented refusals or reasons for the lack of care. The deficiency resulted from the facility's failure to provide necessary assistance with nail care for a resident who was fully dependent on staff.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information for a period of 32 consecutive days. Record review and staff interviews revealed that the posted staffing sheets were incomplete and inaccurate when compared to the actual daily staff schedules. Specifically, the total actual hours worked for each shift by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides were left blank. Additionally, the total number of licensed and unlicensed staff listed on the postings did not match the actual number of staff working on multiple dates and shifts. The discrepancies included both underreporting and omission of staff such as wound nurses, nurse supervisors, and medication aides from the posted totals. Interviews with facility staff indicated a lack of understanding and oversight regarding the completion of the staffing sheets. The receptionist responsible for posting the information stated she did not have access to the new time clock system to calculate total hours and was unaware of the requirement to include certain staff roles in the totals. The Director of Nursing (DON) confirmed the inaccuracies and incomplete postings, acknowledging that the sheets did not reflect actual hours or correct staff numbers. The Administrator was also unaware of the deficiencies, as the DON was responsible for overseeing the task.
Inaccurate MDS Coding for Rejection of Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of rejection of care. The resident, who had a diagnosis including anxiety disorder and moderately impaired cognition, was admitted with a care plan that addressed behavior problems such as noncompliance with tube feedings and ordered oral diet. Review of the medical record and Medication Administration Record (MAR) showed that the resident refused medications and care on multiple occasions within the seven-day look-back period for the MDS assessment. Despite these documented refusals, the MDS assessment was not coded to reflect any rejection of care. Interviews with facility staff revealed that the Social Worker (SW), who was responsible for completing the rejection of care section on the MDS, only reviewed nurses' notes and did not check the MAR for refusals. The SW admitted to being unsure where to find information about rejection of care in the medical records and confirmed that the resident's refusals should have been coded on the MDS. The administrator stated an expectation for accurate MDS coding.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to request staff assistance. This deficiency was identified during an observation of a resident who was admitted with diagnoses including hemiplegia affecting the left side, requiring assistance with personal care, and type 2 diabetes mellitus. The resident was cognitively intact but dependent on staff for various activities of daily living, including toileting hygiene, transfers, and dressing. The resident's care plan specifically included interventions for staff to ensure the call light was within reach due to the resident's risk of falls and need for prompt assistance. During a continuous observation, it was noted that the resident's call bell was on the floor and out of reach while the resident was in bed. The resident expressed that the call bell often falls to the floor and staff frequently forget to place it within reach, causing him to feel uneasy. A nursing assistant confirmed that the call bell was on the floor and admitted to forgetting to check its placement after assisting the resident with lunch. The facility's administrator and director of nursing acknowledged that the call bell should always be within the resident's reach.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident slapped another resident on the side of the head. The resident who committed the act had a history of verbal aggression and poor impulse control, as noted in his care plan. Despite interventions in place to manage his agitation, the resident became agitated and struck his roommate, who was talking to himself. The incident was witnessed by a nursing assistant, who intervened and reported the event to a nurse. The resident who was slapped had a history of cerebral palsy, depression, and bipolar disorder, and his care plan noted episodes of agitation and unclear speech. The facility's response included separating the residents and initiating an investigation. However, the report indicates that the facility did not adequately protect the resident from abuse, as the altercation occurred despite the existing care plans and interventions. The administrator acknowledged the incident and noted that the residents had been considered a good match for roommates prior to the event.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when a nurse did not report an incident where one resident slapped another. Nurse #2, who was on duty at the time, was informed by a nurse aide that Resident #19 slapped Resident #9 on the right hand/forearm. Despite separating the residents and ensuring Resident #9 was safe, Nurse #2 did not report the incident to the Administrator or other required agencies, as she was unaware of the facility's policy. The orientation training, which included the abuse policy, was signed by Nurse #2 after the incident occurred. Additionally, the facility did not notify Adult Protective Services (APS) in a timely manner regarding the abuse allegation. The Administrator submitted an initial report to the state regulatory agency but delayed notifying APS because she was unaware of the requirement to do so, having recently moved from a state with different reporting requirements. This oversight contributed to the facility's failure to adhere to its abuse policy and reporting procedures.
Failure to Complete Significant Change MDS for Resident with Decline
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) for a resident who experienced two areas of significant decline. The resident, who was admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and dementia, developed a stage 3 pressure ulcer and experienced a 9.36% weight loss over three months. Despite these changes, the MDS Nurse only completed a quarterly MDS instead of a significant change MDS, which was an oversight on her part. Interviews with the Medical Director and the Director of Nursing confirmed the resident's continuous decline and the expectation that a significant change MDS should have been completed. The Medical Director noted the resident's overall physical decline and the family's decision to opt for comfort care. The Director of Nursing acknowledged that the significant change MDS was expected due to the resident's condition, which had already been addressed in the care plan revisions.
Failure to Provide Abuse Training to Agency Nurse
Penalty
Summary
The facility failed to provide abuse training to an agency nurse, Nurse #2, before she began working at the facility. This deficiency was identified during a review of records and staff interviews. Nurse #2 was on duty during an incident of resident-to-resident abuse, where one resident slapped another. The Director of Nursing (DON) stated that Nurse #2 did not report the incident to the administration because she did not recognize it as abuse. The orientation training, which included the abuse policy, was signed by Nurse #2 after the incident occurred, indicating that she had not received the necessary training before starting her shift. Nurse #2 confirmed in a phone interview that she was unaware of the facility's abuse policy at the time of the incident. She had worked her first shift at the facility on the night of the incident and received orientation training, including the abuse policy, only after the incident had occurred. The Administrator also confirmed that Nurse #2 did not report the incident because she did not perceive it as abuse. The facility's goal was for agency staff to receive orientation before their first shift, but this was not achieved in Nurse #2's case.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for five residents. The residents involved were admitted to the facility on unspecified dates, and their most recent MDS assessments were dated in July 2024. However, these assessments were still in progress and had not been completed by the time of the survey. The residents affected by this deficiency were identified as Residents #17, #81, #24, #42, and #19. During an interview, the MDS nurse acknowledged that the quarterly MDS assessments for these residents had not been completed as required. She attributed the delay to a high volume of admissions and discharges, which caused her to fall behind in her duties. The facility's Administrator and Director of Nursing were also interviewed and expressed their expectation that MDS assessments should be completed within the required time frame.
Deficiency in Room Maintenance and Repair
Penalty
Summary
The facility failed to ensure that resident rooms were maintained in good repair, compromising the residents' right to a safe, clean, comfortable, and homelike environment. During an initial tour, it was observed that rooms had multiple areas of sheetrock putty exposed on the walls, indicating they were in preparation for painting. Additionally, one room had a missing plank panel on the wall behind the headboard, exposing a dried clear substance that appeared to be glue. These deficiencies were confirmed during a round with the Maintenance Director, who acknowledged the issues but could not provide a specific date or timeframe for when the repairs would be completed. The Administrator, who had been working at the facility since April, acknowledged the importance of maintaining a well-repaired environment and indicated that the Maintenance Director was responsible for addressing these concerns.
Failure to Transmit Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment within the required time frame for one resident. Resident #9 was admitted to the facility, and a review of their most recent MDS assessment revealed it was dated as an annual assessment but had not been transmitted. The MDS nurse acknowledged that the assessments had not been transmitted as required, citing a high volume of admissions and discharges as the reason for falling behind. The Administrator and Director of Nursing confirmed that the MDS assessments should be transmitted within the required time frame.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment within the required time frame for one of the residents reviewed. Resident #61 was admitted to the facility, and their most recent MDS assessment was dated as a discharge assessment. However, the assessment was still in progress and had not been transmitted to the State within the required 7-day period. During an interview, the MDS nurse acknowledged that the discharge MDS assessment for Resident #61 had not been completed as required, citing a high volume of admissions and discharges as the reason for the delay. The Administrator and Director of Nursing confirmed that the MDS assessment should have been completed within the required time frame.
Inaccurate MDS Coding for Urinary Status and Range of Motion
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of urinary status and upper extremity range of motion. For one resident, who was admitted with neuromuscular dysfunction of the bladder, the MDS assessment incorrectly indicated that the resident was always incontinent of bladder despite having an indwelling urinary catheter during the assessment's 7-day look-back period. This error was acknowledged by the MDS Nurse as an oversight. The facility's Administrator and Director of Nursing expected the MDS to be coded accurately. For another resident with a diagnosis of dementia and severe behavioral disturbance, the MDS assessment inaccurately coded a limited range of motion in the upper extremities. Observations and interviews with staff, including a Nursing Assistant and the Medical Director, revealed no evidence of a hand contracture or range of motion impairment. The MDS Nurse based her coding on a Medical Director's progress note, which was later clarified as a misinterpretation during a video visit. The Director of Nursing expected the MDS Nurse to question the MD's documentation if it appeared inaccurate.
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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.
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Nursing homes near Aberdeen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Penick Village | 3.6 mi | ★★★★★ | 3 | 0 |
| Pinehurst Healthcare & Rehabilitation Center | 4.1 mi | ★★★★★ | 7 | 0 |
| Inn At Quail Haven Village | 4.1 mi | ★★★★★ | 0 | 0 |
| Saint Joseph Of The Pines Health Center | 5 mi | ★★★★★ | 9 | 0 |
| The Greens At Pinehurst Rehabilitation & Living Ce | 6 mi | ★★★★★ | 11 | 0 |
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