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 Dunbar Health & Rehab Center during CMS and state inspections, most recent first.
Two residents were affected by the facility's failure to maintain a pest-free environment, with one resident found with ants on her bed, body, and tracheostomy area, and another resident reporting gnats in her room. Staff and multiple observations confirmed the presence of ants and gnats throughout the facility, despite ongoing monthly pest control treatments.
Staff used incorrect scoop sizes when serving lunch, resulting in smaller portions of rice, carrots, and ground chicken than planned. This discrepancy was confirmed by both the staff member and the Dietary Manager, and affected meal service for multiple residents.
Surveyors observed that the kitchen steam table was not maintained in a clean and sanitary manner, with yellowish-brown liquid, debris, and sediment present in the water wells. Food was served from the unclean steam table, and staff confirmed that cleaning was performed weekly rather than daily as required by facility policy and equipment guidelines. This deficiency had the potential to affect the majority of residents.
The facility did not document or follow up on concerns raised by residents during council meetings, leaving issues such as activity requests, noise complaints, and snack options unresolved. Interviews with a resident, a staff member, and the administrator confirmed that no resolutions were provided or communicated, affecting all council participants and potentially all residents.
The facility did not conduct complete investigations into abuse and misappropriation allegations involving three residents. In one case, two residents were involved in a physical altercation, but the investigation lacked witness statements, documentation of who was present, and assessments of others involved. In another case, a resident reported a stolen iPad mini, but the investigation was missing key details, and law enforcement was not contacted as required by policy. The Administrator acknowledged gaps in documentation and investigative steps.
Two residents at high and moderate risk for falls experienced unwitnessed falls resulting in serious injuries, including a hip fracture and scalp laceration. In both cases, the facility did not complete thorough or timely fall investigations, with missing documentation on interventions in place and the circumstances leading up to the incidents. The DON confirmed that required investigative steps were not followed, and the facility lacked a set timeline for completing fall investigations.
A resident with cognitive impairment and multiple diagnoses was found unresponsive in bed holding a cup with three pills, after an LPN failed to observe the resident taking prescribed Olanzapine and Baclofen. Facility policy requires staff to observe medication consumption, but this was not followed, resulting in medications being left with the resident.
Two CNAs provided care to a resident on Enhanced Barrier Precautions (EBP) without wearing gloves or gowns and then delivered meal trays to other residents without sanitizing their hands, despite facility policies requiring EBP and hand hygiene for residents with indwelling devices and before meal delivery.
A resident who was fully dependent on staff for care and had multiple medical conditions was observed with excessively long fingernails, despite care plans and facility policy requiring regular nail care. An LPN confirmed the oversight during an interview.
A facility failed to monitor and address significant weight changes in a resident with epilepsy and other conditions, leading to a substantial weight increase over several months. Despite a care plan indicating increased nutrition/hydration risk, the facility did not implement timely interventions. The RD requested a re-weight but did not follow up, and the resident was not weighed again for over a month, resulting in further weight gain. The facility's policy required routine weight monitoring, which was not adhered to, leading to non-compliance.
A resident with moderate cognitive impairment did not receive prescribed Anbesol for thrush due to unavailability from January 13 to January 20. The facility was informed of the backorder and a substitution was suggested, but the NP was not notified. The DON confirmed the medication was not administered.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain an environment free from pests, as evidenced by the presence of ants and gnats affecting two residents. One resident, who was dependent for all activities of daily living and had a tracheostomy, was found with ants crawling on her bed, body, and tracheostomy area. Staff statements confirmed that ants were observed on the resident and her personal blanket, which was subsequently bagged. The presence of ants was also captured in a video provided by the resident's family, showing ants on and around the tracheostomy. Staff interviews revealed that the incident was not promptly reported to facility leadership, as the DON and Administrator were only made aware after being contacted by the resident's family. The facility's pest control policy required notification of the contractor for unscheduled visits if a pest situation was reported, but the initial staff response did not include such notification. Another resident reported the presence of gnats in her room, and facility observations confirmed gnats flying around the building, particularly in the ventilator unit. Multiple staff members, including an LPN and a housekeeper, acknowledged seeing ants and gnats in the facility at various times. Review of pest control invoices indicated that the facility received monthly pest control treatments, but pests were still present and observed by both residents and staff. The deficiency was substantiated through medical record review, staff and resident interviews, direct observations, and review of facility documentation and video evidence.
Failure to Serve Planned Meal Portion Sizes
Penalty
Summary
The facility failed to ensure that portion sizes for meals were served as planned, as required to meet residents' nutritional needs. During observation of lunch meal preparation, a staff member was seen using incorrect scoop sizes for serving rice, sliced carrots, and ground chicken, resulting in smaller portions than specified on the dietary spreadsheet. The staff member confirmed using a #12 scoop for sliced carrots, a #20 scoop for ground chicken, and a #16 scoop for rice, which did not match the planned serving sizes of 1/2 cup for rice and carrots and 3 ounces for ground chicken. The Dietary Manager also verified that the wrong scoop sizes were being used. The facility identified six residents who did not receive food from the kitchen, and the issue had the potential to affect 57 of 63 residents in the facility.
Failure to Maintain Steam Table in Sanitary Condition
Penalty
Summary
The facility failed to maintain the steam table in the kitchen in a clean and sanitary condition, as observed during a survey. On the morning of the observation, the water wells of the steam table contained a yellowish-brown liquid with floating debris and brown sediment around the bottom and edges. A staff member confirmed the presence of grime and attributed it to grease falling into the wells during use. The staff member also stated that the steam table was cleaned on a weekly basis, with plans to clean it the following day. Despite the unclean condition, food was served from the steam table during the lunch meal. Further interviews revealed that the Dietary Manager acknowledged the need for cleaning and confirmed that the last cleaning occurred six days prior, with a weekly cleaning schedule in place. However, the Senior Registered Dietitian stated that the expectation was for daily draining and cleaning, with deep cleaning weekly. Review of the steam table manual and the facility's daily task schedule both indicated that daily cleaning was required, but this was not being followed. Six residents did not receive food from the kitchen, and the unsanitary condition of the steam table had the potential to affect 57 of 63 residents in the facility.
Failure to Address and Document Resident Council Concerns
Penalty
Summary
The facility failed to document and follow up on concerns raised by residents during Resident Council meetings, as evidenced by a review of meeting minutes from August 2024 to March 2025. The minutes showed that resolutions to concerns from previous meetings were left blank, and specific issues such as requests for more outings, a higher activities budget, loud music in other residents' rooms, a pop-up facility store, bed linen changes, call lights, and snacks including fresh fruit were not addressed. Interviews with the Resident Council President, a staff member, and the administrator confirmed that these concerns had not been resolved or communicated back to the residents, and the resolution sheets remained unfilled. This affected all 10 regular members of the Resident Council and had the potential to impact all 63 residents in the facility.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and misappropriation involving three residents. In one incident, a resident with quadriplegia and moderately impaired cognition was struck in the face by another resident during a dining room altercation. The facility's investigation did not include documentation of who was present, witness statements from staff or other residents, or assessments of other residents for injury or psychosocial impact. The Administrator acknowledged that conversations with other residents were not documented and was unsure if staff were present at the time, despite facility policy requiring comprehensive interviews and written statements from all potential witnesses. In another case, a resident with multiple medical conditions, including hemiplegia and vascular dementia, was involved in the same altercation but the investigation again lacked critical details. The facility's self-reported incident documentation did not provide information about the events leading up to the altercation or any follow-up with other residents who may have been affected. The Administrator confirmed that no further investigation was conducted, as she believed the incident was straightforward, contrary to the facility's abuse policy. A third incident involved a cognitively intact resident who reported the theft of an iPad mini from her room. The investigation into the alleged misappropriation was incomplete, lacking details such as dates, times, and the content of staff interviews. The facility did not file a police report as required by policy, and the resident's daughter expressed dissatisfaction with the lack of follow-up and communication regarding the incident. The Administrator admitted that documentation of the investigation was insufficient and that required steps, such as contacting law enforcement, were not taken.
Failure to Thoroughly and Timely Investigate Resident Falls
Penalty
Summary
The facility failed to ensure that falls were thoroughly and timely investigated for two residents who were identified as being at risk for falls. One resident with chronic diastolic heart failure, vascular dementia, a history of left femur fracture, and osteoporosis experienced a fall while attempting to transfer herself from bed to chair. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was found on the floor by an LPN after calling for help. The post-fall evaluation was not completed, and the facility's fall investigation only included a brief statement from the LPN and hospital records, lacking details about interventions in place at the time of the fall or the circumstances leading up to the incident. Another resident, who had intact cognition and was moderately at risk for falls, was found on the floor after an unwitnessed fall from bed. The resident sustained a facial injury, scalp laceration, and abrasions, and was transferred to the hospital, where he later passed away. The facility's documentation did not include a progress note about the fall, and the fall investigation was not completed until over a month later. The investigation only included a brief statement from an LPN and did not provide information about interventions in place or the events leading up to the fall. Interviews with the DON confirmed that thorough investigations were not completed for either resident following their falls. The DON also stated that there was no established timeline for completing fall investigations and that immediate interventions were limited to sending the residents to the hospital. The facility's policy required interdisciplinary review and timely investigation of all falls, including assessment of interventions and environmental factors, but these steps were not documented or completed in these cases.
Failure to Observe Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a history of encephalopathy, malnutrition, psychotic disorder with hallucinations, major depression, and insomnia, and who was assessed as having moderately impaired cognition, was found in bed holding a medication cup containing three pills. The resident's eyes were closed and they could not be verbally aroused. Observation and staff interview confirmed that the LPN had not observed the resident consume the medications, which included Olanzapine and Baclofen. Facility policy requires staff to observe residents taking their medications, but this procedure was not followed in this instance, resulting in medications being left with the resident and not ensuring their consumption.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Certified Nurse Aides (CNAs) failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols while providing care to a resident with significant medical needs. Specifically, two CNAs repositioned a resident who was under EBP due to conditions including a feeding tube and severe cognitive impairment, without wearing the required gloves or gowns. After providing care, both CNAs exited the resident's room and delivered meal trays to other residents without sanitizing their hands, as observed during a morning shift. Interviews with the involved CNAs confirmed that they did not use the required personal protective equipment or perform hand hygiene after caring for the resident on EBP. The facility's policies require the use of EBP for residents with indwelling devices and handwashing before meal delivery, but these protocols were not followed. The administrator was present during the interviews and confirmed the observations.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was totally dependent on staff for all care was not provided with appropriate nail care as required by their care plan and facility policy. The resident, who had diagnoses including respiratory failure with ventilator dependence, diabetes, and anxiety, was observed to have long fingernails growing downward into the fingertips during a wound care observation. The resident's care plan specified weekly nail care with baths, and the facility's policy required daily nail care. Staff confirmed that the resident's nails were too long and had not been properly maintained.
Failure to Monitor Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes in a resident, identified as Resident #64, who was admitted with diagnoses including epilepsy, major depressive disorder, anxiety disorder, and cerebral infarction. The resident's care plan, dated January 14, 2025, indicated an increased risk for nutrition and hydration issues due to seizures, cerebral infarction, and weight gain over three months. Despite this, the facility did not implement timely interventions to manage the resident's weight. The weight records showed a significant increase from 193.4 pounds in June 2024 to 283.6 pounds by January 2025, with no weight recorded in December 2024. A progress note from September 11, 2024, highlighted a 12.3% weight gain in one month and a 25.3% increase over three months, prompting the Registered Dietician (RD) to request a re-weight to confirm accuracy. The RD, identified as RD #50, acknowledged not following up on the re-weight request and confirmed that the resident was not weighed again until October 21, 2024, resulting in a further 23.4-pound increase. The RD discontinued a dietary supplement, ProStat, as it was deemed unnecessary after a wound had healed, but did not request weekly weights to monitor the resident's weight gain more closely. The facility's policy required weights to be obtained routinely to monitor nutritional health, with specific guidelines for frequency based on admission and identified risks. The deficiency was investigated under Complaint Number OH00161977, indicating non-compliance with the facility's weight monitoring policy.
Medication Unavailability for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that medications were available and administered according to physician orders for Resident #65, who was admitted with diagnoses including congestive heart failure, cerebral infarction, and chronic obstructive pulmonary disease. The resident, who had moderate cognitive impairment, was ordered Anbesol liquid for thrush, to be used twice daily. However, the medication was not administered from January 13 to January 20, 2025, due to its unavailability. Interviews revealed that the facility was responsible for obtaining the medication as it was considered an over-the-counter prescription. The pharmacy had informed the facility on January 13, 2025, that Anbesol was on backorder and suggested a substitution with Nystatin, which was communicated to an LPN. However, the Nurse Practitioner was not informed about the backorder situation. The Director of Nursing confirmed that the resident did not receive the prescribed Anbesol during the specified period.
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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 Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gem City Healthcare And Rehabilitation Center | 1.6 mi | ★★★★★ | 9 | 0 |
| Grafton Oaks Nursing Center | 1.6 mi | ★★★★★ | 16 | 0 |
| Sanctuary At Wilmington Place | 2.3 mi | ★★★★★ | 1 | 0 |
| Widows Home Of Dayton | 2.7 mi | ★★★★★ | 4 | 0 |
| Oaks Of West Kettering The | 2.7 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.