Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Dunlap Specialty Care during CMS and state inspections, most recent first.
Surveyors identified multiple instances of improper food storage and handling, including undated and expired food items in refrigerators and dry storage, as well as staff using bare hands and tongs interchangeably during meal service. The Certified Dietary Manager and Registered Dietitian confirmed that these practices did not meet facility expectations or policy requirements.
Multiple residents and family members reported that rooms and common areas were not cleaned regularly, with dead insects observed in several locations. Housekeeping staff and supervisors confirmed significant understaffing, lack of proper orientation, and inability to complete required cleaning tasks, resulting in missed areas and unaddressed grievances about cleanliness. Facility policy required regular cleaning, but these standards were not consistently met.
Two residents did not receive ordered medications as prescribed, with staff documenting administration on the MAR despite the medications not being given. One resident missed a scheduled nebulizer treatment for pneumonia, and another did not receive a prescribed dose of Lasix, as confirmed by both staff and medication packaging. Staff interviews revealed a lack of clarity on procedures for missed medications and failure to notify supervisors, resulting in noncompliance with professional standards for medication administration.
A resident who was fully dependent on staff developed a new deep tissue injury on the heel, which was not identified by staff until discovered by a provider. Despite care plan instructions to use a pressure-relieving boot, staff did not consistently implement this intervention, and the resident was repeatedly observed without the required device in place. Documentation failed to reflect the presence of the skin issue, and staff interviews revealed gaps in awareness and follow-through with prescribed care.
A resident with significant cognitive and physical impairments, including a PEG tube and Foley catheter, did not receive scheduled morning medications until the afternoon, contrary to facility policy. Documentation also lacked evidence that a physician was notified of the late administration.
Three residents with complex medical needs, including those on dialysis and with indwelling catheters, had incomplete or delayed documentation in their medical records. Nursing notes and assessments were entered days after care was provided, and some referenced vital signs or procedures that were not actually completed or recorded at the indicated times. Staff confirmed that documentation was sometimes based on assumptions rather than direct observation, in violation of facility policy requiring accurate and timely recordkeeping.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices and wounds, including not wearing gowns or gloves during wound care and feeding tube procedures, despite facility policy requiring EBP for such conditions.
A resident with an indwelling catheter did not have documented orders for regular catheter changes, leading to a deficiency in care. Despite a care plan and a standard order for monthly changes, the facility failed to document or perform consistent catheter changes, resulting in the resident's hospitalization for sepsis. Staff interviews revealed confusion about the frequency of catheter changes, and the Director of Nursing admitted the policy had not been updated in the QAPI meeting.
The facility failed to maintain sanitary conditions in the kitchen and during meal service. Observations revealed unsanitary conditions such as grease and food debris on the stove, scattered food debris on a dish cart, and accumulated debris on the floor. The Dietary Manager and another staff member failed to perform hand hygiene during meal service, and food was placed on unsanitized surfaces. The facility's sanitation policy required clean and sanitary conditions, which were not met.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving disrespectful remarks by staff. An LPN made derogatory comments towards residents, including telling a CNA to let a resident sit in waste to 'teach him a lesson.' Another resident experiencing chest pain was dismissed by the same LPN as attention-seeking. An RN was reported for rude behavior towards a resident with paraplegia, who filed a grievance. These incidents highlight a failure to uphold residents' rights to dignity and respect.
A resident with heart failure, COPD, and respiratory failure did not have their oxygen tubing changed weekly as ordered by the physician. The tubing, last changed on 6/12/24, was observed unchanged until 7/1/24, when the Activity Coordinator, not typically responsible for this task, replaced it. The care plan lacked specific instructions for tubing changes, and the facility's policy required weekly changes, which were not adhered to.
A facility failed to accurately document the changing of oxygen tubing for a resident with heart failure, COPD, and respiratory failure. Despite physician orders to change the tubing weekly and as needed, observations showed the tubing had not been changed as documented. The care plan lacked specific instructions for tubing changes, and the facility's policy required detailed documentation of respiratory therapy, which was not followed.
A facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling catheter and a history of MRSA. A CNA did not wear a gown as required, despite the facility's policy and CDC guidelines emphasizing the need for PPE during high-contact care activities. The DON confirmed the expectation for proper PPE use.
A resident was unable to access personal funds after business hours due to the facility's lack of a policy and availability of funds. Staff confirmed that funds were only accessible when the business office was open, and the DON was initially mistaken about the availability of funds at the nurse's station.
Improper Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple instances where food was not stored in accordance with professional standards. During a kitchen tour, open bags of lettuce with expired dates, undated open bags of hard-boiled eggs, and expired yogurt containers were found in refrigerators. Additionally, cheese was found in a container with an outdated open date. In dry storage, several open bags of food items, including gravy mix, lemonade mix, gluten free flour, egg noodles, tri-colored noodles, and cake mix, were found undated. Staff interviews confirmed that the facility's expectation was for all open food items to be dated and expired food to be discarded, which was not followed in these instances. Further observations during meal service revealed improper food handling practices. A Certified Dietary Manager (CDM) was seen using metal tongs to serve bread and then using bare hands to replace the lid, touching both the tongs and the lid handle throughout the service. Another CDM was observed handling sandwiches with bare hands after performing hand hygiene, removing them from the refrigerator, and placing them on a plate for a resident. The Registered Dietitian (RD) acknowledged witnessing bare hand contact with food and expressed concerns about cross-contamination due to improper use of tongs and bare hands. Facility policy required all foods to be covered, labeled, and dated, which was not consistently followed.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several residents and family members reported that rooms and common areas, such as the chapel and hallways, were not cleaned in a timely manner. Dead insects, including spiders, were observed in resident rooms, the chapel, and around the nurses' station. One resident's family member reported seeing a spider in the dining room for about a week and noted that her mother's room also had spiders at times. Another resident stated that housekeeping rarely cleaned her room, less than twice a month, and that she had reported this to nursing staff. A third resident reported having to clean his own room due to lack of housekeeping and had filed grievances about the cleanliness of his room and bathroom, which he felt were not addressed adequately. Staff interviews revealed significant understaffing in the housekeeping department, with only one housekeeping aide responsible for cleaning all resident rooms and common areas. The aide reported being unable to complete all required cleaning tasks due to time constraints and lack of support, missing areas such as the chapel, hallways, and nurses' station. The aide also stated that he had not received proper orientation for his role and that requests for additional staff or overtime were not fulfilled until surveyors arrived. The temporary housekeeping supervisor and maintenance supervisor confirmed that the facility was short-staffed, with two full-time housekeeping positions and laundry staff unfilled, and that cleaning schedules were not being followed due to limited hours and competing priorities. Documentation review showed that grievances regarding unclean rooms and bathrooms had been submitted over the past three months, with residents expressing dissatisfaction with the cleanliness and the lack of timely response from housekeeping. The facility's policy required regular cleaning and disinfection of resident rooms and personal use items, but observations and staff statements indicated that these standards were not consistently met. The administrator acknowledged that additional housekeeping staff were only brought in from other facilities during the survey, and that insects should have been cleaned up promptly.
Failure to Follow Physician Orders and Accurate Medication Administration Documentation
Penalty
Summary
The facility failed to follow physician orders and ensure proper medication administration for two residents. For one resident with severe cognitive impairment and a recent diagnosis of pneumonia, there was a physician's order for a sodium chloride inhalation nebulization solution to be administered in the morning. On the specified date, the Medication Administration Record (MAR) was signed by a registered nurse indicating the treatment was given, but both the Director of Nursing (DON) and the resident's daughter confirmed that the treatment was not administered. The nurse admitted to not providing the treatment and acknowledged signing the MAR in error, with the medication still in her possession at the time. The resident's daughter discovered the omission later in the day and reported it to staff. For another resident with lymphedema and no cognitive impairment, there was a physician's order for a daily mid-morning dose of Lasix. The MAR indicated the medication was administered, but the resident reported not receiving it, and observation of the medication bubble pack confirmed the dose was still present. The certified medication aide and the DON both acknowledged the missed dose, and the nurse responsible stated that it was not uncommon for medications to be missed without explanation. The nurse also admitted to not notifying anyone about the missed dose and was unclear about the process for handling such situations. Policy review revealed that medication administration must be documented immediately after it is given, and not before, with proper signatures. In both cases, staff documented administration of medications that were not actually given, and there was a lack of communication and follow-up regarding the missed doses. These actions and inactions resulted in the facility failing to meet professional standards of quality in medication administration for the residents involved.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and did not ensure that appropriate interventions were consistently in place for a resident at risk. A resident, who was totally dependent on staff for mobility and care, developed a new deep tissue injury on the right heel that was discovered by the primary care provider during rounds. Prior to this, staff documentation indicated no new skin issues, and the resident had reported heel pain to the provider but not to other staff. The resident had multiple diagnoses, including anemia, heart failure, renal insufficiency, malnutrition, and asthma, and was identified as being at risk for skin impairment and pressure ulcers. The care plan was updated to include the use of a pressure-relieving boot for the resident's right heel after the ulcer was discovered. However, observations showed that staff did not consistently implement this intervention. On several occasions, the resident was observed in bed with his heels resting directly on the bed surface and the protective boot not in use, despite care plan instructions. Staff interviews revealed a lack of awareness regarding the resident's pain and the development of the sore, and there was uncertainty about whether staff should have identified the issue sooner. Documentation and policy review indicated that while the facility had protocols for assessing risk and providing wound care, there was a lack of clear guidance on staff responsibility for following through with prescribed interventions. The resident's electronic chart showed no documentation of skin issues in the period leading up to the discovery of the ulcer, and staff were not consistently monitoring or documenting the use of pressure-relieving devices as required by the care plan.
Failure to Administer Medications Timely for Dependent Resident
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for one resident. Specifically, a resident with moderate cognitive deficits, total dependence on staff for care, a terminal diagnosis of progressive multifocal leukoencephalopathy, a Foley catheter, and a PEG tube for feeding did not receive her scheduled morning medications until the afternoon. The Medication Administration Audit Report showed that ten morning medications, scheduled between 7 am and 9 am, were not given until 12:20 PM, and two additional medications scheduled for 11:00 AM were administered at 3:37 PM. There was no documentation in the clinical record that the physician had been notified of these late administrations. Facility policy required that morning medications be administered between 7 am and 9 am, and later morning medications between 11 am and 1 pm, with immediate documentation after administration. The failure to follow these policies was confirmed by staff interviews and record review. The resident was observed to be in bed, receiving continuous tube feeding, and unable to respond to questions at the time of observation. The lack of timely medication administration and absence of physician notification constituted the deficiency identified during the survey.
Failure to Maintain Accurate and Timely Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and timely medical records for three residents, resulting in incomplete or delayed documentation of care and assessments. For one resident with moderate cognitive deficits, an indwelling urinary catheter, and a feeding tube, the care plan required catheter care every shift. However, the Medication Administration Record indicated that a catheter flush was not completed as scheduled, and a late nursing note was entered stating the flush was done with normal saline after the fact, based on an assumption rather than direct observation or confirmation. The Director of Nursing confirmed that the documentation was entered the next day without certainty that the procedure had been performed. Two other residents receiving dialysis also had deficiencies in their medical records. For both, Dialysis Evaluation forms were completed and entered into the system up to 12 days after the actual assessment dates. Additionally, the documentation referenced vital signs that were either missing or not recorded at the times indicated. For example, one resident's evaluation referenced vital signs that were not present in the record for the specified date and time, and another had only partial vital sign documentation that did not match the times noted in the assessment. Staff interviews and record reviews confirmed that the facility's documentation practices did not align with its own policy, which requires objective, complete, and accurate records of care, including the date and time procedures and treatments are provided. The lack of timely and accurate documentation for these residents, particularly those with complex medical needs such as dialysis and indwelling catheters, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling medical devices and wounds. For one resident with a stage 2 pressure ulcer not present on admission, staff were observed performing transfers and wound care without donning gowns, despite completing hand hygiene and glove use. Both the RN/ADON and DON provided conflicting statements regarding the necessity of EBP for this resident, with the DON stating EBP should be used for residents with draining wounds or external devices, but ultimately EBP was not applied during care. Another resident with a Foley catheter and a feeding tube, who was totally dependent on staff for care, also did not receive EBP during high-contact activities. During a procedure involving the disconnection and flushing of the feeding tube, the RN failed to wear gloves or a gown, and interacted directly with the resident. Facility policy required EBP for residents with wounds or indwelling medical devices, regardless of known infection or colonization with multidrug-resistant organisms, but this was not followed during the observed care activities.
Failure to Ensure Regular Catheter Changes for Resident
Penalty
Summary
The facility failed to ensure that a resident had orders to change his catheter, which led to a deficiency in the care provided. The resident, who had no cognitive impairment, was admitted with an indwelling catheter and various diagnoses, including renal failure and depression. Despite having a care plan that included monitoring for urinary tract infection symptoms and catheter care, the facility did not have documented orders for regular catheter changes in the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs). The resident's catheter was reportedly not changed since his admission until he was hospitalized in December for acute encephalopathy and sepsis, which was believed to be due to the catheter not being changed. Although there was a standard order dated December to change the catheter monthly, there were no other catheter orders completed or documented in the electronic health record. Staff interviews revealed inconsistencies in the understanding of catheter change frequency, with some staff believing it should be every 30 days and others every 60 days. The Director of Nursing acknowledged that the catheter change policy had not been updated in the Quality Assurance and Performance Improvement (QAPI) meeting, and there were no progress notes indicating catheter changes. The lack of documentation and clear orders led to the deficiency, as the facility did not ensure the catheter was changed according to any consistent schedule, resulting in potential harm to the resident.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and during meal service, as observed during a survey. The initial kitchen walk-through revealed several unsanitary conditions, including a stove top with a thick layer of grease and food debris, a clean dish cart with scattered food debris, and a floor with accumulated food debris and dried liquid. Additionally, all refrigerator and freezer systems had dried liquid and debris at the bottom, and there was ice build-up in the freezers and milk cooler. The microwave was splattered with food and dried liquid, the toaster was covered in grime, and dead gnats were found along the window sills. The Dietary Manager acknowledged these issues and indicated a problem with a staff member who worked over the weekend. During lunch service, further deficiencies were noted. The Dietary Manager failed to perform hand hygiene after serving a resident and handling food items. The manager also placed a slice of bread directly on the bread bag and a spatula on the counter before using it to make a grilled cheese sandwich. Another staff member, identified as Staff B, also failed to perform hand hygiene while entering and exiting the kitchen and accessing the refrigerator multiple times. The Dietician observed these failures and reported that staff did not use hand hygiene appropriately and expected food and utensils to be placed on sanitized surfaces. The facility's sanitation policy, last revised in October 2008, required the food service area to be maintained in a clean and sanitary manner, with all equipment and surfaces washed and sanitized properly.
Disrespectful Treatment of Residents by Staff
Penalty
Summary
The facility failed to treat all residents with dignity and respect, as evidenced by multiple incidents involving disrespectful remarks made by staff members. Staff G, an LPN, was reported to have made derogatory comments towards several residents, including telling a CNA to let a resident sit in their own waste to 'teach him a lesson.' This resident, who had an intact cognitive ability and required substantial assistance for toileting due to multiple health conditions, was subjected to disrespectful treatment. Other staff members corroborated these incidents, noting that Staff G often spoke loudly and disrespectfully to residents. Another incident involved Resident #25, who had a moderate cognitive deficit and was experiencing chest pain. Staff G dismissed the resident's concerns, loudly accusing him of seeking attention and medication. This resident had a history of serious health issues, including hypertension and respiratory failure, and was later taken to the hospital for treatment. Staff members reported that Staff G made similar dismissive comments to emergency personnel, further demonstrating a lack of respect and dignity towards the resident. Additionally, Resident #81, who had intact cognitive ability and required assistance due to paraplegia and pressure ulcers, reported being treated rudely by Staff J, an RN. The resident filed a grievance after being embarrassed and blamed for her medical condition in front of others. A family member and other staff confirmed the RN's rude behavior. The facility's policy emphasizes the residents' right to be free from abuse and neglect, yet these incidents highlight a failure to uphold these standards, as acknowledged by the DON.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not adhering to the physician's order to change and label oxygen tubing weekly and as needed. Resident #15, who had diagnoses of heart failure, COPD, and respiratory failure, was observed with oxygen tubing that had not been changed since 6/12/24, despite the physician's order dated 4/7/24 requiring weekly changes. The care plan for Resident #15 did not specify when the oxygen tubing should be changed, contributing to the oversight. On 7/1/24, the tubing was observed to be changed and labeled with a new date, but this was done by the Activity Coordinator, who stated it was not typically her responsibility. The Director of Nursing confirmed that the expectation was for oxygen tubing to be changed every Sunday, which was not followed in this case. The facility's policy, last revised in November 2011, also required weekly changes of oxygen tubing, indicating a lapse in following established protocols.
Inaccurate Documentation of Oxygen Tubing Changes
Penalty
Summary
The facility failed to accurately document the changing of oxygen tubing for a resident diagnosed with heart failure, COPD, and respiratory failure. The resident, who had no cognitive impairment, was prescribed oxygen therapy with specific instructions to change the tubing every Sunday night and as needed, with the new tubing dated accordingly. However, the care plan did not specify when the tubing should be changed, leading to discrepancies in documentation. Observations revealed that the oxygen tubing for the resident had not been changed since a specific date, despite records inaccurately indicating changes on subsequent dates. The facility's policy required weekly changes and detailed documentation of respiratory therapy, including the date, time, type of therapy, and the name and title of the individual performing it. The Director of Nursing confirmed the expectation for accurate documentation, highlighting the deficiency in maintaining proper records for the resident's oxygen therapy.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during catheter care for a resident with renal insufficiency, neurogenic bladder, and multiple sclerosis, who utilized an indwelling catheter. The resident had a history of MRSA, and the physician's orders required enhanced barrier precautions every shift. During an observation, a Certified Nursing Assistant (CNA) performed catheter care without wearing a gown, which is required under EBP for high-contact care activities involving urinary catheters. The CNA acknowledged the oversight in an interview, confirming that a gown should have been worn. The Director of Nursing (DON) also stated that the expectation was for gowns and proper personal protective equipment (PPE) to be used during such procedures. The facility's policy on Enhanced Barrier Precautions, as well as guidelines from the Centers for Disease Control and Prevention, emphasize the necessity of PPE during high-contact activities to prevent the spread of multidrug-resistant organisms (MDROs).
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide ready and reasonable access to personal funds for a resident, as required by regulations. A resident reported that they could only access their personal funds when the business office person was present. Staff interviews confirmed that no personal funds were available to residents after normal business hours. The Business Office Manager acknowledged the lack of a policy related to personal funds and confirmed that funds were not accessible after hours without prior notice. The Director of Nursing initially stated that a small amount of money was kept at the nurse's station for resident requests, but later admitted to being mistaken about the availability of funds after hours.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Dunlap
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azria Health Rose Vista | 9.5 mi | ★★★★★ | 12 | 0 |
| Gracewell, An Eventide Community | 17 mi | ★★★★★ | 1 | 0 |
| Denison Care Center | 18.1 mi | ★★★★★ | 2 | 0 |
| Elm Crest Retirement Community | 19.3 mi | ★★★★★ | 8 | 0 |
| Maple Heights | 24.3 mi | ★★★★★ | 17 | 0 |
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