Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dunbar Center during CMS and state inspections, most recent first.
The facility failed to timely escalate a resident with signs of sepsis, respiratory distress, hypoxia, hypotension, and acute decline for hospital transfer despite NP and telehealth recommendations for immediate ED evaluation; the resident was later admitted with sepsis, obstructing kidney stone, and hypoxic respiratory failure. The facility also missed documentation for ordered wound care for one resident and administered PRN hydrocodone-acetaminophen to another resident without documenting the required pain level.
Failure to designate a qualified Infection Preventionist for the facility’s Infection Prevention and Control Program. The Administrator stated there was no official IP, and although an RN in the Clinical Reimbursement Coordinator role had IP certification, she was only completing weekly NHSN reporting. The DON and other clinical managers were handling infection prevention and control duties, but they had not completed the required specialized IP training.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Food was not consistently temped before leaving the kitchen, and a test tray showed both hot and cold items served at improper temperatures. The DAM could not produce food temp logs, dietary staff only recorded four item temps before tray line, and a tray sent to a hall had a ham & cheese sandwich, coleslaw, lettuce and tomato, and mixed fruit all outside expected temp ranges. Residents also reported that room trays were often hot when they should be cold and cold when they should be hot.
Food storage and kitchen sanitation failures were observed throughout the kitchen, dry storage, and refrigeration areas. Surveyors found soiled cloths, debris on food contact surfaces and equipment, improper cutting board use, unlabeled and outdated food items, chemicals stored near food, ice buildup and refrozen ice cream, and multiple sanitation issues in the dish room and food prep areas, including improperly stored dishware, wet meal trays, and unlabeled spray bottles.
Improper storage and disposal of garbage and refuse was observed in the dish room and food service area. A box full of garbage was sitting on the wet floor under the three-compartment sink, a trash receptacle beside the handwashing sink had no liner but contained trash, and another blue-lidded trash receptacle was soiled on the outside. The HCSG Director of Operations acknowledged the soiled receptacle during interview.
An RN failed to maintain infection control during medication administration for multiple residents. Hand hygiene was not performed before preparing or after administering medications, the nurse touched multiple items and surfaces with bare hands, and a Spiriva inhaler box was placed on a resident’s over-the-bed table without a barrier. The RN later confirmed hand hygiene was not completed throughout the process, and a corporate RN confirmed hand hygiene should be completed throughout medication administration and a barrier used on resident surfaces.
The facility failed to maintain an effective pest control program. During a kitchen survey, a State Agency Surveyor found four packages of hamburger buns in dry storage with bite marks, chewing damage, and droppings consistent with rodent activity, and later observed ceiling spots consistent with drain flies. An HCSG Regional Chef confirmed the rodent damage, and an HCSG Dietary Account Manager observed the ceiling findings.
Failure to obtain informed consent for a psychotropic medication. A resident with medical decision-making capacity was prescribed Cymbalta, but the consent form had not been completed. A Corporate RN confirmed the missing consent during the survey review.
The facility failed to provide required SNF-ABN and/or NOMNC forms to two residents reviewed for beneficiary protection notification practices. One resident was discharged home after the last covered day of Medicare Part A services without evidence of a NOMNC, and another resident remained in the facility after the last covered day without evidence of either a SNF-ABN or NOMNC. The BOM stated the facility could not produce evidence that the required notices had been given.
The facility did not document that required transfer information was sent to the hospital for two residents who were transferred out for acute care. One resident was sent for SOB related to bronchitis and pneumonia, and another was sent after a fall with hematoma. The Interim DON said the facility’s process is to send the face sheet, advance directives, physician orders, and MAR, but the chart did not show what information was actually transmitted.
A resident with PTSD had an inaccurate PASARR because the diagnosis was not documented on the screening. The NHA confirmed the resident’s PTSD diagnosis and acknowledged it was missing from the PASARR.
Incomplete Baseline Care Plans for Resident Assistance Needs: Surveyors found that baseline care plans for two residents were left incomplete, with blanks in required instructions for assistance with eating, toileting, dressing, grooming, and ambulation. The Interim DON acknowledged the care plans did not specify the level of help each resident needed, despite one resident having multiple complex diagnoses including dementia, Parkinson's disease, dysphagia, and malnutrition, and the other having Parkinson's disease, seizures, COPD, and malnutrition.
A resident’s care plan was not developed for the diagnosis of depression or for the use of the antidepressant Cymbalta. During record review, the chart showed no care plan addressing the resident’s depression or psychotropic medication, and the Corporate RN confirmed the omission.
Failure to Follow Monthly Pharmacy Recommendation: A resident’s monthly pharmacy review included a recommendation to change overactive bladder treatment from an anticholinergic to vibegron, and the MD agreed to the switch. The pharmacy recommendation and MD order were not followed as ordered, and a corporate RN later confirmed the recommendation had been missed.
A resident who took meds crushed in applesauce received Cardizem CD 120 mg crushed during a med pass by an RN. The RN did not review the facility’s Do Not Crush list and acknowledged forgetting about it. The facility policy required staff to check the list before crushing meds, and Cardizem CD was listed as a medication that should not be crushed.
A resident with an order and care plan for an Advanced Dysphagia texture diet was served a regular texture lunch tray instead of the ordered consistency. A unit clerk identified the dietary error before the resident ate, and the DO verified the tray was incorrect.
Incomplete Quarterly Smoking Safety Assessment: The facility failed to complete a quarterly smoking safety assessment for a resident who wished to smoke. The assessment was started but left unfinished and unsigned, and the IDON confirmed it had not been completed in accordance with the facility’s smoking policy.
Hydration was not available at bedside for four residents on the 300 and 400 halls. Residents stated they had no water or ice water, and staff observations confirmed no water was present for some residents. An NA said she had started passing water but had not finished because she was doing showers, an RN said the residents had not told her they needed water, and an LPN confirmed the residents did not have water available. The Corporate Nurse stated the residents should have been given water on their drink pass that morning.
Improper handling of beverages during meal service. A red liquid and a pitcher of koolaid were observed on meal carts without ice, and one pitcher was not labeled or dated. An LPN confirmed the drinks were not kept cold during tray service, and a resident stated the koolaid was room temperature.
A resident could not reach a broken or short pull cord to turn on the light, and another resident’s call light was draped over the nightstand and out of reach. An LPN confirmed both residents could not access the devices, and a corporate nurse stated the call light should be in reach at all times.
A resident did not have the required Beneficiary Notification and NOMNC available before discharge. The admin confirmed the paperwork could not be located after the BOM left the facility, and although an email showed the clinical reimbursement coordinator had related discharge paperwork, a signed copy of the notices was not found or provided to surveyors.
Failure to report allegations of abuse involving two residents and an NA. One resident reported another resident constantly threatened and intimidated her, while also describing increased anxiety tied to that resident’s behavior. The same resident also alleged an NA grabbed her by the pants and threw her back into bed, and both she and her roommate described ongoing fear and the NA being present on the hallway despite prior restrictions. The DON and Administrator acknowledged the allegations had not been reported.
A resident was observed smoking with staff present, but the Annual MDS incorrectly coded current tobacco use as 0, indicating the resident did not smoke. The CRC confirmed the MDS error during interview.
A resident’s care plan had multiple blank intervention fields for ADL assistance, including bed mobility, eating, toileting, dressing, personal hygiene, and bathing, and the fall-risk goal was incomplete because the number of days was left blank. The care plan also called for turning and repositioning every 2-3 hrs for skin breakdown risk, but task records were missing for several shifts, and the DON confirmed the blank care plan areas and the lack of implementation.
A resident’s comprehensive care plan was not revised after the discharge plan changed from a short-term skilled stay to LTC. The care plan continued to reflect discharge potential and community referral planning, and the DON confirmed it had not been updated for LTC placement. A later revised care plan stated the resident and RP had chosen LTC due to health and physical needs that could no longer be safely managed in the community.
A resident at risk for skin breakdown had a care plan intervention for turning and repositioning every 2-3 hrs, but staff did not document the required repositioning on multiple shifts. The DON confirmed the intervention was not implemented, and the Corporate Nurse stated there should be three documented times for each date.
A resident’s fall risk evaluation was incomplete, with blank sections for gait/balance, medication use, recent medication changes, the fall risk score, and several intervention selections under falls, discharge planning, visual impairment, and clinical suggestions. The record review showed the missing entries on the assessment, and the Corporate Regional Manager confirmed the document was not complete.
Improper Disposal of Soiled Brief and Linen: A soiled brief and soiled wash cloth were observed on the floor at the foot of a resident's bed. An NA then picked up the items, and an LPN confirmed they should have been disposed of correctly. The DON later confirmed the items should have been disposed of properly.
A deficiency occurred when a medication cart computer screen in a hallway was left unattended while displaying a resident’s medication administration list. The cart was positioned in a common corridor without staff present, allowing resident-specific medication information to remain visible until an LPN later confirmed the issue and secured the screen. No additional clinical details about the resident were documented.
A resident with DM had physician orders for twice-daily fingerstick blood glucose checks, multiple scheduled insulin glargine doses, a daily HumaLOG dose, and a hypoglycemia protocol. On one day, there was no documentation of blood glucose monitoring in the vitals, MAR, or progress notes, and no evidence that any insulin was administered. In an interview, the DON and Administrator confirmed the resident did not receive the ordered fingersticks or insulin, resulting in a failure to provide medications in a timely manner as ordered.
Surveyors observed a container of Clorox wipes left on the bathroom sink in a resident room during a facility tour, indicating that hazardous cleaning supplies were not properly stored. An LPN confirmed that such wipes should not be kept in a resident bathroom, and facility leadership acknowledged that this storage practice was not appropriate.
A bedpan in a resident bathroom was found placed on top of a trash can without being bagged or labeled, contrary to infection control standards. An LPN confirmed that the bedpan was not properly labeled or stored, and facility leadership acknowledged that it should have been kept in a storage bag with appropriate labeling.
The facility failed to maintain adequate nutritional status for multiple residents by not consistently tracking meal intake, providing necessary feeding assistance, or implementing dietary recommendations. One resident experienced severe weight loss due to lack of meal assistance and failure to receive ordered supplements, while others had incomplete meal documentation, preventing accurate nutritional assessments.
Multiple residents were not treated with dignity or respect, as evidenced by delays in meal service, lack of assistance with eating, inappropriate staff responses to hunger, and failure to recognize dietary restrictions. Residents were left waiting for food, offered items they could not have, or left to feed themselves in unsafe or undignified ways until staff intervened.
Two residents were found in unclean conditions, sitting in geri-chairs with dried food and debris, disheveled appearance, dirty clothing, and foul body odor. Their rooms had strong urine odors, sticky floors, and leftover food. Bathing records showed that both received significantly fewer showers than scheduled, with no refusals documented. Staff acknowledged the poor care and environment, confirming a failure to provide scheduled hygiene and maintain a clean living space.
Several residents did not receive required interventions for wound care, turning and repositioning, or meal assistance as outlined in their care plans. Residents with pressure ulcers were not turned or repositioned as ordered, wound care treatments were not administered per physician orders, and a resident needing meal assistance was left without support until a DON intervened. These deficiencies were confirmed by facility leadership.
Several dependent residents did not receive scheduled showers or bed baths, with some going extended periods without bathing and lacking proper documentation for missed care. Observations found residents in disheveled states with poor hygiene, and staff confirmed the failure to provide required ADL assistance.
The facility did not complete physician-ordered wound treatments for three residents, resulting in multiple missed wound care interventions such as cleansing, dressing changes, and use of specialized wound care products. These omissions were confirmed through record review and staff interviews, affecting residents with pressure ulcers, diabetic ulcers, and other wounds requiring ongoing care.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective prevention measures to avoid the development of new ulcers. Observations and record reviews showed lapses in assessment, monitoring, and intervention for pressure ulcer management.
Two nurse aides were found to have completed only basic competency check-offs for hand hygiene and PPE use, with no evidence of other required skill assessments for the year. This lack of comprehensive competency documentation was confirmed by the NHA, indicating a failure to ensure all nursing staff had the necessary skills to meet resident needs.
The facility did not provide annual performance evaluations for five nurse aides, as confirmed by record review and staff interview. This deficiency was identified during a review of employee records and affects a facility with a census of 115.
A resident was admitted and discharged on the same day, during which time a nurse aide retrieved meal trays for the resident, who refused both breakfast and lunch. The refusals were not documented in the medical record, resulting in incomplete documentation of meal intake.
Two residents were found in unclean, foul-smelling rooms, sitting in geri-chairs with dried food and debris, facing the wall without any stimulation. Both appeared disheveled, with dirty clothing, unkempt hair, and noticeable body odor. Staff and a regional nurse confirmed the poor condition of the residents and their environment, including sticky floors, damaged equipment, and a strong urine odor.
A resident who had a history of falls experienced another fall, but the care plan was not updated to include a focus statement, goals, or interventions related to fall risk. Although fall precautions were mentioned in follow-up documentation, the care plan itself did not reflect the resident's ongoing risk or history of falls, as confirmed by facility staff.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of accidents for residents.
A resident receiving enteral nutrition was observed to have their feeding pump set at 60 mL/hr instead of the physician-ordered 70 mL/hr. This discrepancy was identified during a review and confirmed by both a Corporate Resource Nurse and an LPN, who then corrected the rate to comply with the medical order.
A resident was not provided with required wound care, PEG tube site care, or adequate hygiene, as documented wound treatments and dressing changes were not performed or recorded, and no PEG tube care orders were present. The resident was found at the hospital with soiled skin, old dressings, and an infected pressure ulcer, resulting in actual harm and hospitalization.
The facility did not perform weekly pressure ulcer assessments or administer wound care treatments as ordered for three residents, resulting in incomplete documentation and unaddressed wounds. One resident was hospitalized with a pressure ulcer infection and septic shock, while two others had pressure ulcers that were not properly assessed or documented according to facility policy.
The facility did not ensure that two residents were treated with dignity and respect for their personal preferences. One resident was not consistently provided with her glasses and was observed in public with her legs uncovered, despite her religious beliefs and requests from her legal representative. Another resident was not given the opportunity to vote, even though this was documented as important in her care plan. These actions reflect a failure to honor residents' rights to dignity and self-determination.
Delayed Transfer, Missed Wound Care, and Incomplete Pain Documentation
Penalty
Summary
The facility failed to ensure timely assessment, intervention, and transfer for a resident who developed acute clinical deterioration consistent with sepsis. Resident #123 was noted during an acute visit to be more lethargic than normal, responsive only to verbal stimuli, cool and clammy, tachypneic, with oxygen saturation of 86-89% on room air, heart rate up to 125 beats per minute, and hypotension. The nurse practitioner assessed septicemia, tachypnea, tachycardia, and acute hypotension and ordered labs, IV fluids, ceftriaxone, and close monitoring. Later the same day, after-hours telehealth review documented that the resident appeared acutely ill with respiratory distress, increased work of breathing, oxygen saturation fluctuating between 80% and 92% despite oxygen, fever, acute kidney injury, suspected infection/sepsis, leukocytosis, anemia, and thrombocytopenia. The telehealth consultant directed that the resident be transferred immediately to the ED. The resident was not transferred until later that evening and was subsequently admitted to the hospital with sepsis, an obstructing kidney stone, and hypoxic respiratory failure. Interviews with the nurse practitioner, RN, family members, and other staff described delays in sending the resident out and disagreement from the DON about hospital transfer. The facility also failed to follow ordered treatment for another resident’s skin and wound care. For Resident #129, the TAR showed multiple dates when skin tear treatment, stage 2 pressure ulcer treatment, and left lower limb wound care were not signed off as completed or refused. In addition, the facility failed to provide pain management as ordered for Resident #4. The physician ordered hydrocodone-acetaminophen 5/325 mg, 2 tablets every 4 hours as needed for pain level 4-6, but the MAR showed the medication was administered on multiple days without a documented pain level of 4-6 before administration.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate one or more qualified Infection Preventionists responsible for the Infection Prevention and Control Program in accordance with regulatory requirements. During the entrance conference, the Administrator stated the facility did not have an official Infection Preventionist and noted that the Clinical Reimbursement Coordinator held Infection Preventionist certification. Record review showed RN #139, the Clinical Reimbursement Coordinator, had completed Infection Preventionist certification, but she was not functioning as the facility’s designated Infection Preventionist. During interview, RN #139 stated her only infection prevention responsibility was completing weekly NHSN reporting. The Administrator later stated the DON and other clinical managers were performing the facility’s infection prevention and control responsibilities, and that those staff members had not completed the specialized Infection Preventionist training required for the role.
Excessive Ambient Temperatures at Nurses' Stations
Penalty
Summary
The facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. During direct observation, the wall-mounted thermostat at the 100/200 Nurses' Station displayed 83 F. The surveyor then requested that the Facility Maintenance Director obtain ambient temperature readings using the facility's temperature monitoring device, and the readings were verified by the surveyor as they were obtained. At that time, the Facility Maintenance Director measured 82.2 F at the 100/200 Nurses' Station and 83.0 F at the 300/400 Nurses' Station. The surveyor also observed residents seated in common areas close to both nurses' stations while the temperatures were above the recommended comfort range. The facility census was 118.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and served at safe, appetizing temperatures. The facility failed to ensure all food was temped before leaving the kitchen and failed to ensure hot foods were served hot and cold foods were served cold. Healthcare Services Group policies cited in the report stated that food should be prepared to conserve nutritive value, flavor, and appearance, and that food should be served at proper safe and appetizing temperatures. The report also states that all foods are to be prepared in accordance with the FDA Food Code. On 06/29/26 at 11:01 AM, the Dietary Account Manager could not produce the June 2026 food temperature logs and stated she could not find them. When the surveyor asked for any food temperature logs for 2026, the DAM stated she had checked the trash and everywhere but still could not find them. Later that day, before tray line started, dietary staff only recorded temperatures for four regular consistency food items: BBQ Chicken, Coleslaw, [NAME] Beans, and a Ham & Cheese Sandwich. A regular consistency test tray sent to Dogwood Hall at 12:51 PM was checked at 1:02 PM, and the recorded temperatures were 67.5 F for the Ham & Cheese Sandwich, 68 F for Coleslaw, 79.3 F for Lettuce and Tomato, and 55.2 F for Mixed Fruit. During Resident Council on 07/01/26, residents stated that when they ate in their rooms, cold food was hot and hot food was cold, and that the food was the correct temperature only when they ate in the dining room.
Food Storage and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and failed to follow proper sanitation practices in the kitchen. During the initial walkthrough of the kitchen, surveyors observed a soiled cleaning cloth in the handwashing sink near the toaster, debris on the knife rack, and one cutting board being used for green bell peppers, onions, and strawberries. Additional observations included a soiled drip pan under the stove, a stove top and convection oven with built-up food debris, an opened container of quick oats without a use-by date, an employee Pepsi soda placed beside vinegar and spices, and a meat slicer and microwave with food debris on them. Surveyors also found multiple storage and labeling problems in refrigeration and freezer areas. These included water pooling in the bottom of a reach-in refrigerator with opened Mighty Shakes sitting in the water, opened or outdated items without labels or use-by dates such as bacon, blueberries, sliced potatoes, sandwiches, bread, and milk, as well as outdated yogurt, onions, tomatoes, hotdog buns, and flour tortillas. In the walk-in freezer, there was ice buildup and six cases of ice cream cups that had been thawed and refrozen. The ice machine in the service hall had a black substance inside near the top, and the dry storage room contained a brown liquid on the floor, bleach stored beside food thickener, hotdog buns with a green substance on them, and outdated flour tortillas. On follow-up observation, surveyors found additional sanitation and storage concerns, including a soiled cloth near the meat slicer, dishware on the clean side of the dish room not stored upside down and containing lint and particles, a soiled tray on a clean cup rack, a soiled black cart beside the griddle, grease and cobwebs on the exhaust vent grease trap, an unlabeled spray bottle at the three-compartment sink, a dirty kitchen ceiling with lint and pest particles, a hole in the ceiling with a cleaning cloth sticking out, a steam table pan on the floor, wet resident meal trays, soiled gloves beside the toaster, crumbs in the toaster tray, wall damage above an electrical box, debris on the floor behind cooking equipment, an unlabeled chemical bottle on the floor behind the steamer, dried coffee grounds in a drawer, and clean serving utensils stored with handles in different directions.
Improper Storage and Disposal of Garbage and Refuse in Food Service Area
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly in the food service area. During observation, a box full of garbage was found sitting on the wet floor under the three-compartment sink. The trash receptacle beside the handwashing sink in the dish room did not have a liner but contained trash. Another trash receptacle in the dish room with a blue lid was soiled on the outside and needed cleaning. During interview, the HCSG Director of Operations acknowledged that the trash receptacle was soiled on the outside and needed cleaning.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program during medication administration. During observation of RN #154 administering medications to Residents #90, #105, and #29, hand hygiene was not completed prior to preparing medication for Resident #90, and hand hygiene was not completed before entering the resident’s room after the medication was prepared. The Spiriva inhaler box was placed on the over-the-bed table without using a barrier. After administering medication to Resident #90, hand hygiene was not completed before preparing Resident #105’s medication, and hand hygiene was not completed after preparing or administering that medication. The RN then left the medication cart to obtain medicated cream from the treatment cart and, upon returning, did not complete hand hygiene before or after administering medication to Resident #29. During the medication preparation process, the RN touched multiple items and surfaces with bare hands, and hand hygiene was not completed at any time during this process. RN #154 later confirmed hand hygiene was not completed throughout the medication administration process, and Corporate RN #175 confirmed hand hygiene should be completed throughout medication administration and a barrier used when placing medication and/or boxes on resident surfaces.
Pest Control Program Not Effectively Maintained
Penalty
Summary
The facility failed to ensure an effective pest control program was in place. During the kitchen pathway of the survey, the State Agency Surveyor observed four packages of hamburger buns on the bread rack in the dry storage room with multiple bite markings, chewing marks, and droppings consistent with rodent activity. The facility’s pest control policy stated that a program would be established for control of insects and rodents in the Dining Services Department and that food preparation, service, and storage areas would be monitored regularly for signs of pests. At a later follow-up visit to the kitchen, the State Agency Surveyor observed multiple tiny dark spots on the ceiling consistent with digested organic waste left behind by drain flies. The HCSG Regional Chef confirmed the surveyor’s observation that a rodent had damaged the hamburger buns, and the HCSG Dietary Account Manager also observed the ceiling spots consistent with drain flies.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for a psychotropic medication for Resident #1, who was prescribed Cymbalta, an antidepressant. During record review, it was found that the resident had been admitted to the facility and had medical decision-making capacity, yet the consent for the medication had not been completed. The deficiency was identified during survey review of unnecessary medications and involved 1 of 5 residents reviewed in that area. A Corporate RN later confirmed that the consent for Cymbalta had not been completed.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) and/or Notice of Medicare Non-Coverage (NOMNC) forms to two of three residents reviewed for the facility's beneficiary protection notification practice. Resident #128 was discharged home after her last covered day of Medicare Part A services, and there was no evidence in the electronic medical record that a NOMNC had been issued before discharge. Resident #29 remained in the facility after his last covered day of Medicare Part A services, and there was no evidence in the electronic medical record that either a SNF-ABN or a NOMNC had been issued before discharge from skilled care. During interview, the Business Office Manager stated the facility was unable to produce evidence that the appropriate beneficiary notification forms had been given to either resident.
Missing Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to provide evidence that it conveyed required transfer information to the hospital when two residents were sent out for acute care. For Resident #98, the electronic record showed the resident was transferred to the hospital for shortness of breath related to bronchitis and pneumonia, but the record did not document that the receiving health care institution received, at a minimum, the resident’s advance directives, physician orders, and comprehensive care plan. For Resident #115, the electronic record showed transfer to the hospital after a fall with hematoma, and the record likewise did not show documented evidence that the receiving institution received those required transfer documents. During interview, the Interim DON stated that the facility’s process when a resident is sent to the hospital is to send documents such as the face sheet, advance directives, physician orders, and the MAR. However, the Interim DON also stated that there was no documentation in the medical records to accurately reflect what information had been sent for either resident. The deficiency was identified for two of two residents reviewed under the hospitalization pathway.
Inaccurate PASARR Screening for Resident With PTSD
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) was maintained for a resident with a diagnosed serious mental illness. Record review showed the resident had a diagnosis of Post-Traumatic Stress Disorder (PTSD) documented on 02/26/2026, but the PASARR dated 03/05/2026 did not identify or document PTSD. During an interview on 06/30/2026 at approximately 10:10 AM, the Nursing Home Administrator confirmed the resident had PTSD and acknowledged that the diagnosis was not reflected on the PASARR screening.
Incomplete Baseline Care Plans for Resident Assistance Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care within 48 hours of admission. During the Hospitalization and Discharge pathways, surveyors identified incomplete baseline care plans for Resident #115 and Resident #119, with blanks left in key areas that were supposed to specify the level of assistance needed for care and mobility. Resident #115 had diagnoses including metabolic encephalopathy, hypokalemia, dehydration, acute kidney failure, hypothyroidism, hypernatremia, neurocognitive disorder with Lewy bodies, dementia, Parkinson's disease, pulmonary hypertension, dysphagia, and protein-calorie malnutrition. The baseline care plan contained incomplete interventions for eating, toileting, dressing, and personal hygiene, with blanks where the type and amount of assistance should have been documented. Resident #119 had diagnoses including Parkinson's disease, seizures, COPD, hypertension, altered mental status, hallucinations, tremor, and protein-calorie malnutrition. The baseline care plan contained an incomplete intervention for ambulation, with blanks for the level of assistance, the device to be used, and the number of times per day. The Interim DON acknowledged that the care plans were not thoroughly completed and failed to specify the level of assistance required for both residents.
Care Plan Not Developed for Depression and Antidepressant Use
Penalty
Summary
The facility failed to develop a care plan for Resident #1 regarding the diagnosis of depression and the use of the antidepressant Cymbalta. During record review on 07/01/26, the resident’s chart showed that a care plan had not been developed for the resident’s depression diagnosis or for the psychotropic medication. On 07/02/26, the Corporate RN confirmed that the care plan had not been developed for the diagnosis of depression and the use of Cymbalta.
Failure to Follow Monthly Pharmacy Recommendation
Penalty
Summary
The facility failed to follow the physician’s order for a monthly pharmacy recommendation for Resident #1 related to unnecessary medications. During monthly pharmacy review, the pharmacist made two recommendations, including a second recommendation to switch treatment for overactive bladder from an anticholinergic medication to the beta-3 agonist vibegron. The facility physician agreed to the change, but the pharmacy recommendation and physician’s order were not followed as ordered. Corporate RN #175 later confirmed that the second recommendation and the physician’s order had been missed, and stated that the nurse practitioner had reviewed it.
Medication Error Involving Crushing an Extended-Release Medication
Penalty
Summary
The facility failed to ensure freedom from significant medication errors during medication administration for Resident #105, who takes medications crushed in applesauce. During an observed medication pass, RN #154 prepared and administered Cardizem CD 120 mg by mouth daily to the resident even though it is an extended-release medication that cannot be crushed because of its time-release mechanism. After the medication was prepared, RN #154 did not review the facility’s Do Not Crush list and stated, “Oh, I forgot about that.” The facility’s policy, Medication Administration General Guidelines, states that medications should be crushed only after referring to the Medications Not To Be Crushed List, and the facility’s list identified Cardizem CD as a medication that should not be crushed.
Incorrect Diet Texture Served to Resident with Dysphagia Order
Penalty
Summary
The facility failed to prepare food in the form ordered to meet Resident #62’s individual needs. Resident #62 had a physician order for an Advanced Dysphagia texture diet and was care planned for that diet after the order was initiated on 05/28/26. During the lunch meal on 06/29/26 at 12:26 PM, the resident was served a regular texture lunch tray instead of the ordered dysphagia diet. A unit clerk identified the dietary error before the resident could consume the meal, and the HCSG Director of Operations verified that the tray consistency was incorrect.
Incomplete Quarterly Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure that quarterly smoking safety assessments were completed in accordance with its smoking policy for Resident #38. The policy stated that residents who wish to smoke must have a smoking assessment completed upon admission, readmission, and with any change in condition, and that if they remain in the facility, the assessment is to be completed quarterly without missing documentation and matched to the clinical admission assessment. Record review showed that the December 2025 quarterly smoking assessment for Resident #38 was initiated but was not completed or signed. During interview, the Interim Director of Nursing confirmed that the quarterly smoking assessment had not been completed.
Hydration Not Available at Bedside for Multiple Residents
Penalty
Summary
The facility failed to ensure hydration was available at bedside for four residents on the 300 and 400 halls. On the 400 hall, Resident #11 stated that no ice water was available, and no water was observed at the bedside for Resident #31. A nurse aide stated she had passed some water but had not been able to finish because she had been doing showers, and an RN stated the residents had not told her they needed water. On the 300 hall, Resident #88 stated that there was no water available, and the roommate agreed. Resident #108 also stated that no water was being given and said he or she would drink it if available. An LPN confirmed that the residents did not have water available to them. The Corporate Nurse was notified and stated that the residents should have been given water on their drink pass that morning.
Improper Handling of Beverages During Meal Service
Penalty
Summary
The facility failed to ensure liquids were distributed and served in accordance with professional standards for food service safety. During lunch service, a red liquid in a pitcher was observed on a cart at the beginning of Hall 300 before drinks had been passed; the pitcher was not iced, not placed in ice, and was not labeled or dated. An LPN confirmed the pitcher was not labeled, dated, or on ice. Later, on Hall 400, a pitcher labeled "koolaid" was observed sitting on the cart and not in ice, and an LPN confirmed the drink served to a resident did not contain ice and the pitcher was not on ice during tray service. The resident stated the koolaid was room temperature, which was how she drank it. The facility policy stated cold foods must be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination, and meal distribution must maintain proper temperature and protect against contamination.
Call Lights and Light Cord Not Within Reach
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not ensured when two residents did not have accessible means to summon assistance or turn on a light. Resident #58 was heard crying repeatedly during an early morning hall observation and told the surveyor, "Turn my light on, honey." The resident could not reach the pull cord for the light, which appeared broken, short, and approximately three feet away from the resident. An LPN confirmed the resident could not reach the light cord and stated, "We usually have to help her." Resident #75 was observed with the call light cord draped over the nightstand and could not reach it. An LPN confirmed the call light was out of reach and stated, "let me fix this." A corporate nurse later confirmed the call light should be in reach at all times.
Missing Medicare Discharge Notices
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered was not ensured prior to discharge for Resident #47. On 05/27/26, a Beneficiary Notification and a Notice of Medicare Non-Coverage (NOMNC) were requested for the resident, but at 1:41 PM the administrator confirmed the documentation was not available. The Business Office Manager had kept signed and dated copies of discharge paperwork in a binder in her office, but she was no longer employed by the facility, and the administrator stated the binder could not be located. An email provided to the state surveyor indicated the clinical reimbursement coordinator had paperwork, including an exhaust letter to be signed by the resident, but a signed copy of the notifications was not found or provided to the surveyor. The facility policy for Discharge and Transfer stated that if a patient's Medicare coverage will be ending, the center must comply with the requirements at 483.10(g)(17) and (18).
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving Resident #62 and Resident #113. Resident #62 stated that Resident #113 constantly threatened and intimidated her, made offensive comments when no one else was around, and caused her fear. Record review showed a telehealth physician note from 02/27/26 documenting that the resident requested Vistaril for increased anxiety because of behaviors from another resident, and a psychiatric follow-up note from 03/04/26 stating the resident was frustrated with another resident who was verbally offensive and instigating conflict, with staff aware of the situation. During the interview with surveyors, the Administrator stated the allegations would be reported and did not know why they had not been reported earlier. The facility also failed to report allegations involving Resident #62, Resident #13, and Nurse Aide (NA) #3. Resident #62 reported that NA #3 grabbed her by the pants and threw her back into bed when she was sliding to the edge of the bed after yelling for help. She stated she told staff the aide was rough and later said she did not feel safe because NA #3 continued to come onto the hallway and speak to her. The Facility Scheduler stated NA #3 was not to work on the hallway where Resident #62 resided, but the resident reported seeing the aide there again. Resident #13, the roommate, corroborated the event and stated she did not feel safe and believed staff, including nurses, were laughing and threatening to call 911 while the resident was yelling and cursing at NA #3. The Administrator again stated the allegations would be reported.
Incorrect Tobacco Use Coding on Annual MDS
Penalty
Summary
The facility failed to ensure an accurate Annual MDS for Resident #23 regarding tobacco use. During observation, Resident #23 was seen smoking with staff present, but a record review showed the Annual MDS section J1300, current tobacco user, was coded as 0, indicating the resident does not smoke. In an interview, the Clinical Reimbursement Coordinator confirmed the MDS was incorrect regarding tobacco use and stated it would be corrected with a modified MDS.
Incomplete Care Plan and Missed Turning/Repositioning Documentation
Penalty
Summary
Resident #69’s care plan contained multiple blank intervention fields under the focus area for risk for decreased ability to perform ADLs related to limited mobility. The blank areas included the level and amount of assistance to be provided for bed mobility, eating, toileting, dressing, personal hygiene/grooming, and bathing. The care plan also included a fall-risk focus area for impaired mobility, but the goal statement, “Resident will have no falls with injury x days,” was left incomplete because the number of days was blank. In addition, the care plan intervention for risk for skin breakdown, “Assist resident in turning and repositioning every 2-3 hrs.,” was not being implemented. A task review showed missing documentation for turning and repositioning on several shifts, including night shift on 04/18/26, night shift on 04/20/26, evening shift and night shift on 05/01/26, night shift on 05/05/26, and night shift on 05/11/26. The DON confirmed both the blank care plan areas and that the turning and repositioning intervention was not implemented, and the Corporate Nurse stated there should be three documented times for each date.
Care Plan Not Revised for LTC Placement
Penalty
Summary
The facility failed to revise and review a comprehensive care plan for Resident #47 after the resident’s discharge plan changed from a short-term skilled stay to long-term care. The resident was admitted on 12/17/25, and the care plan still reflected focus and goals for a short-term stay, including that the resident had potential for discharge and referrals to community-based agencies, providers, and services. The Director of Nursing confirmed the resident’s care plan was not revised for long-term care placement. An updated care plan was later provided to the state surveyor, and the revised care plan initiated on 05/27/26 stated that the resident and representative had chosen to transition to long-term care due to health and physical needs that could no longer be safely managed in the community. A progress note completed on 03/04/26 by the Social Worker confirmed the resident’s discharge plan was for long-term care.
Failure to Implement Turning and Repositioning for Skin Breakdown Risk
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident #69. The care plan for risk for skin breakdown included an intervention to assist the resident in turning and repositioning every 2-3 hours, but record review showed this intervention was not being implemented. Documentation in the tasks tab was missing for turning and repositioning on multiple shifts, including night shift on 04/18/26, night shift on 04/20/26, evening and night shifts on 05/01/26, night shift on 05/05/26, and night shift on 05/11/26. During interview on 06/01/26, the DON confirmed the care plan intervention was not implemented, and the Corporate Nurse stated there should be three documented times for each date.
Incomplete Fall Risk Evaluation Documentation
Penalty
Summary
The facility failed to ensure an accurate and complete medical record for Resident #111 in the fall risk evaluation dated 03/31/26. During record review, several required sections were left blank, including gait/balance, medications, whether there had been any medication or dosage change in the past 5 days, the fall risk score, and multiple intervention selections under the risk for falls, discharge planning, sensory/perception alterations: visual, and clinical suggestions sections. The report states that the gait/balance section did not indicate any choice was made from the listed options, the medications section did not show whether the resident was taking any of the listed medication classes, and the section asking about medication changes in the past 5 days was also not completed. The fall risk score was not documented anywhere on the evaluation. On 06/01/26 at 3:30 PM, Corporate Regional Manager #159 confirmed the document was not complete and that several sections did not indicate which choice was made.
Improper Disposal of Soiled Brief and Linen
Penalty
Summary
The facility failed to maintain an infection control program regarding the disposal of a soiled brief and linen for Resident #69. On 06/02/26 at 4:23 AM, a soiled brief and soiled wash cloth were observed lying on the floor at the foot of the resident's bed. At 4:25 AM, NA #160 approached the room and removed the soiled brief and wash cloth, stating, "let me take care of this." LPN #18 observed the NA picking up the items and confirmed the soiled brief and wash cloth should have been disposed of correctly. At approximately 5:00 AM, the DON was notified and confirmed the items should have been disposed of properly.
Unattended Medication Cart Screen Displaying Resident Information
Penalty
Summary
The facility failed to ensure confidentiality of medical records when a medication cart computer screen in the 300 hallway was left unattended while displaying resident information. On 01/28/26 at 11:13 AM, the computer screen on the hallway medication cart showed a resident’s list of medications to be administered, and the cart was positioned midway down the hallway with no staff present. At 11:16 AM, an LPN confirmed that the computer screen was displaying resident medication information. No additional resident-specific clinical details or conditions were documented in the report. This incident was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents. The report did not provide further information beyond the observation of the exposed medication list and the staff confirmation that protected health information was visible on the unattended screen.
Failure to Administer Ordered Blood Glucose Monitoring and Insulin
Penalty
Summary
Surveyors identified a deficiency in which a resident with diabetes mellitus did not receive ordered blood glucose monitoring and insulin administration on a specific date. The resident had physician orders for fingerstick blood glucose checks twice daily with instructions to notify the MD if blood sugar was greater than 400 and to initiate a hypoglycemic protocol if blood glucose was below 70, with a start date of 02/17/2025. Record review showed no blood sugar values documented in the vitals section (blood sugar summary), the MAR, or the progress notes for that date, indicating the ordered fingerstick monitoring was not performed. The same resident also had multiple active physician orders for insulin therapy, including insulin glargine-yfgn 24 units subcutaneously in the evening, insulin glargine-yfgn 46 units subcutaneously in the morning, and HumaLOG (insulin lispro) 4 units subcutaneously once daily, as well as an order for a hypoglycemia protocol to be followed if blood glucose was less than 70 mg/dL or at an ordered low parameter. On the date in question, there was no documentation that any of these insulin doses were administered. In an interview, the DON and the Administrator confirmed that the resident did not receive the ordered fingerstick blood glucose checks or any insulin on that date, and the report notes this had the potential to harm the resident due to not knowing if blood sugar levels were within an appropriate range.
Improper Storage of Clorox Wipes in Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to safely store a container of Clorox wipes in a resident room. During the initial tour on 01/28/26 at 11:55 AM, surveyors observed a container of Clorox wipes sitting on the bathroom sink in room [ROOM NUMBER]. At 11:58 AM, an LPN (identified as LPN #21) confirmed that the Clorox wipes should not be in the resident’s bathroom. At 12:20 PM the same day, the Administrator was notified and confirmed that Clorox wipes should not be stored in a resident’s bathroom. The report does not provide additional clinical or medical details about the resident(s) assigned to that room. This was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents at the time of the observation.
Improper Storage of Bedpan in Resident Bathroom
Penalty
Summary
Surveyors observed that in room [ROOM NUMBER], a bedpan was laying on top of a trash can in the bathroom during the initial facility tour on 01/28/26 at 11:55 AM. The bedpan was not placed in a storage bag and was not labeled as required for proper storage. At 11:58 AM on the same day, LPN #21 confirmed that the bedpan was not labeled or stored in a storage bag. At 12:20 PM, the Administrator was notified and confirmed that the bedpan should have been labeled and stored in a storage bag, indicating that the observed condition did not meet the facility’s infection control standards.
Failure to Ensure Adequate Nutrition and Accurate Meal Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including body weight and meal intake, as required. For four residents reviewed, there were significant lapses in tracking meal consumption, providing necessary assistance during mealtimes, and implementing dietary recommendations. One resident experienced severe weight loss since admission, with documented weights showing a decline from 117.8 lbs to 102 lbs over a period of less than two months. Despite orders for weekly weights and house supplements, the facility did not ensure these interventions were carried out, and documentation was inconsistent or inaccurate. Observations revealed that the resident who suffered severe weight loss did not consistently receive assistance with meals, despite being blind and deaf and requiring such support. Staff failed to provide ordered supplements, yet documented in the medication administration record that the supplements were given and fully consumed. Meal intake documentation was incomplete, with only 76 out of 147 meals tracked over a 49-day period. During direct observation, the resident was left waiting for her meal, did not receive timely assistance, and staff inaccurately recorded that she consumed 100% of her meal when she did not. For three additional residents, meal intake documentation was also incomplete, with many meals missing from the records. This lack of documentation prevented accurate nutritional assessments and timely identification of potential nutrition problems. Staff and management interviews confirmed that all meals should be documented, and that the lack of accurate records hindered the ability of the dietician and physician to evaluate and address residents' nutritional needs.
Failure to Ensure Resident Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by multiple observed incidents involving five residents. One resident, who was visually impaired and dependent on staff for assistance, was left without her meal while her roommate was served, and was not assisted in finding or consuming her juice until prompted by a nurse. She expressed hunger and frustration at the delay, and indicated she was accustomed to eating with her fingers due to lack of assistance. Another resident, who was NPO and receiving tube feeding, was found with a cup containing urine at his bedside, which staff initially mistook for broth or water. Despite being NPO, the nurse offered to bring him ice water and discussed breakfast, which he could not have, demonstrating a lack of awareness of his dietary restrictions and needs. A third resident was dismissed by a receptionist when expressing hunger, with the staff member stating the resident could not be hungry after lunch. The resident was left in the hallway until a nurse aide intervened to check her meal intake and offer a snack. In another case, a resident with difficulty self-feeding was left without assistance for over 20 minutes, during which she attempted to eat with her fingers, sucked on her clothing protector, and tried to pick up food from the tablecloth. Assistance was only provided when the interim DON arrived and helped her eat. Additionally, a resident was observed feeding herself with a butter knife, and only received redirection and appropriate assistance after more than 20 minutes. These incidents collectively demonstrate a pattern of staff inaction, lack of timely assistance, and failure to recognize or respond to residents' needs, resulting in compromised dignity and respect for the affected individuals.
Failure to Provide Adequate Hygiene and Environmental Care
Penalty
Summary
Surveyors observed two residents in their rooms sitting in geri-chairs with dried food and debris present, facing the wall without any television or music. Both residents appeared disheveled, with dirty clothing, unkempt hair, and foul body odor. The rooms had a strong odor of urine, sticky floors, leftover food, and other debris. One resident's fall mat was torn, and the other had a wet area under the fall mat and a broken nightstand handle. Staff present, including nurse aides and a regional corporate nurse, acknowledged the poor condition of the residents and their environment. A review of bathing records for both residents revealed that each had only received two or three showers over a 30-day period, despite being scheduled for showers twice weekly. There were no documented refusals for showers, indicating that the scheduled care was not provided. The regional corporate nurse confirmed that the residents should have received additional showers as per the schedule. These findings demonstrate a failure to provide adequate hygiene and environmental care, resulting in neglect.
Failure to Implement and Develop Care Plans for Wound Care, Repositioning, and Meal Assistance
Penalty
Summary
The facility failed to develop and/or implement complete care plans to meet the needs of several residents, as evidenced by direct observations, record reviews, and staff interviews. Multiple residents with pressure ulcers did not receive the required interventions for turning and repositioning as outlined in their care plans. For example, one resident with multiple pressure ulcers and a Braden Scale score indicating risk was not turned or repositioned every 1-2 hours as required, despite being dependent or requiring substantial assistance for bed mobility. This lack of implementation was confirmed by the Corporate Resource Nurse. Several residents with physician-ordered wound care did not receive treatments as specified in their care plans and treatment administration records. Orders for wound care to various body sites, including heels, elbows, coccyx, and ankles, were not carried out as documented. The care plans for these residents included instructions to provide wound care as ordered, but these interventions were not implemented, as confirmed by staff interviews and record reviews. Additionally, a resident requiring meal assistance and cueing was observed attempting to feed herself without any staff assistance for an extended period, despite her care plan indicating the need for set-up, supervision, and cueing during meals. The resident was unable to effectively feed herself and was not provided the necessary support until a DON intervened. The lack of appropriate meal assistance and cueing was acknowledged by facility leadership. Across all cases, the deficiencies were confirmed by the Corporate Resource Nurse during interviews.
Failure to Provide Scheduled ADL Care and Bathing to Dependent Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically bathing and personal hygiene, to several dependent residents as scheduled. Multiple residents who required assistance with bathing did not receive showers or bed baths according to their care plans and facility schedules. Documentation revealed missed showers on numerous scheduled days, with some residents going extended periods without any form of bathing. In several cases, there was no documentation to explain the missed care, and refusals were not consistently recorded. Observations and interviews confirmed the lack of care. One resident was overheard expressing concern about body odor due to missed showers, and another was found in a disheveled state with dirty clothing, foul body odor, and a room with a strong urine smell. Staff, including nurse aides and a corporate nurse, acknowledged the poor condition of these residents and the failure to provide scheduled showers. The corporate nurse confirmed that the residents should have received more frequent bathing and agreed with the surveyors' findings regarding the lack of care. The records and direct observations indicated that the affected residents were dependent on staff for bathing and personal hygiene. Despite being scheduled for regular showers, these residents received significantly fewer than required, with some receiving only a few showers over a 30- to 60-day period. The lack of proper documentation and the physical state of the residents at the time of survey further substantiated the deficiency in providing necessary ADL care.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to perform wound treatments as ordered by the physician for three out of five residents reviewed for wound care. Record reviews and staff interviews revealed that multiple wound care orders were not completed as prescribed for these residents. Specific missed treatments included failure to cleanse and dress various wounds, such as skin tears, pressure ulcers, diabetic ulcers, and venous wounds, on several occasions. Orders for specific wound care products and procedures, such as hydrating foam cleanser, Sureprep, MediHoney, Vashe soaked gauze, calcium alginate, and negative pressure wound therapy, were not carried out according to the prescribed schedule. These deficiencies were confirmed through review of the Treatment Administration Records (TAR) for the affected residents and corroborated by staff interviews, including confirmation from the Corporate Resource Nurse. The missed treatments spanned multiple dates and shifts, affecting residents with complex wound care needs, including those with pressure ulcers, diabetic ulcers, and wounds requiring specialized dressings and monitoring. The lack of adherence to physician orders for wound care was consistently documented across the reviewed cases.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not ensure consistent assessment, monitoring, or intervention for residents at risk for or with existing pressure ulcers.
Incomplete Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets required to provide safe and appropriate care to residents, as evidenced by a review of personnel records and staff interviews. Specifically, two nurse aides had only completed competency check-offs for hand hygiene and the use of personal protective equipment for the calendar year, with no documentation of other required competencies. This was confirmed by the Nursing Home Administrator during interviews, indicating that the aides had not completed additional competency assessments needed to meet residents' needs and promote their well-being.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aides received an annual performance evaluation. During a review of five employee personnel records, it was found that none of the records contained documentation of a yearly performance evaluation for the nurse aides in question. This was confirmed during an interview with the Corporate Resource Nurse, who stated that the facility did not have any of the requested performance evaluations available. The facility census at the time was 115 residents.
Failure to Document Meal Refusals in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted and discharged on the same day. Review of the resident's tray cards indicated that meal trays were scheduled for the day of admission, but the task documentation for meal intake was left blank for that day. According to an interview with a nurse aide, the resident was admitted, became upset due to a disagreement with family and delays in meal tray delivery, and ultimately refused both breakfast and lunch. The nurse aide retrieved the trays for the resident, but the refusals were not documented in the medical record as required.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors observed that two residents were found in their rooms sitting in geri-chairs with dried food and other debris present on the chairs. Both residents were facing the wall, with no television or music playing, and appeared disheveled. Their rooms had a foul odor of urine, sticky floors, leftover food and utensils on the floor, and damaged equipment such as a torn fall mat and a broken nightstand handle. The residents' clothing was dirty, they had a noticeable body odor, and their hair was unkempt. These conditions were confirmed by staff present at the time of the survey, including nurse aides and a regional corporate nurse, who acknowledged the poor state of the residents and their environment. The staff interviewed on-site agreed that the residents appeared disheveled and that the rooms were not clean or homelike. The regional corporate nurse and the facility administrator both confirmed that the residents should have been showered, dressed in clean clothes, and that the rooms should have been cleaned. The observations and staff confirmations indicate a failure to provide a safe, clean, and comfortable environment for the residents, as required.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect the resident's history of falls. Specifically, after a resident experienced a fall, the facility's five-day follow-up report noted that fall precautions were in place and that the resident's bed would be placed against the wall to prevent further falls. However, a review of the resident's current care plan showed there was no focus statement, goals, or interventions related to being at risk for falls or a history of falls. The care plan had previously included a focus on fall risk, but this was resolved and removed several months prior, and no new interventions or goals were added after the most recent fall. This deficiency was confirmed during an interview with the Corporate Resource Nurse, who acknowledged that the care plan did not reflect the resident's fall history.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via feeding tube was provided with the appropriate treatment and services to prevent complications. Specifically, a review of the resident's medical record showed a physician's order for Glucerna 1.5 cal to be administered at 70 mL per hour for 20 hours daily. During an observation, it was found that the feeding pump was set to deliver only 60 mL per hour, which was not in accordance with the physician's order. This discrepancy was confirmed by both the Corporate Resource Nurse and an LPN, who reviewed the electronic medical record and acknowledged the correct rate should have been 70 mL per hour. The feeding rate was then corrected to match the order.
Failure to Provide Wound, PEG Tube, and Hygiene Care Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate care for multiple skin conditions, a percutaneous endoscopic gastrostomy (PEG) tube, and personal hygiene. After returning from a hospital stay, the resident had documented pressure ulcers and skin tears, with specific wound care orders written in the Treatment Administration Record (TAR). However, there was no documentation that these wound treatments were performed, as the TARs were not signed off for any of the days the orders were active. The resident's care plan noted a history of resistance to care, but there was no indication in the TAR that the resident refused any treatments during this period. The resident was also not provided with proper bathing activities, as there were no showers documented and only two bed baths recorded during the relevant timeframe. Upon transfer to the hospital, the resident was found to be generally soiled with dirt and feces in skin folds, and had yeast-like exudate. Hospital records also noted that the resident had heart monitor lead stickers from a previous hospitalization still attached, and a PEG tube dressing adhered to the skin by drainage, with no facility documentation of PEG tube site care or cleaning orders. The hospital identified an infected sacral pressure ulcer, which, along with pneumonia, led to a diagnosis of septic shock. Additionally, the hospital found dressings on the resident's skin that were dated from a previous hospitalization, indicating that dressing changes had not been performed as required. The Center Nurse Executive confirmed that there was no documentation of wound care or dressing changes in the facility's records, and the facility was unaware of the hospital's findings regarding the lack of dressing changes. These failures resulted in actual harm to the resident, including wound infection and hospitalization.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice, as evidenced by the lack of weekly assessments and failure to administer wound treatments as ordered for three residents. Facility policy required weekly wound evaluations, but documentation showed that pressure ulcers for the affected residents were not assessed at the required intervals. For one resident, pressure ulcer assessments were not documented between two specific dates, and for another, prior assessments could not be located in the electronic health record for a recurring pressure ulcer. One resident returned from the hospital with pressure ulcers to the sacrum and left lateral foot. Nursing notes indicated issues with the facility's wound photo application, resulting in incomplete documentation of wound measurements and assessments. The Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as performed for multiple days, and there was no documentation of resident refusal for these treatments, despite the care plan noting a history of resistive behavior. The Center Nurse Executive confirmed that there was no evidence the required dressing changes or assessments were completed or documented. Another resident had a pressure ulcer to the left elbow that had healed and reoccurred, but no prior assessments were found in the medical record for the most recent occurrence. A third resident developed a sacral pressure ulcer, which was not assessed for a period of nearly two weeks. The lack of timely and complete assessments and failure to document or perform ordered treatments resulted in actual harm to one resident, who was hospitalized with a pressure ulcer infection and diagnosed with septic shock believed to be related to the infected wound.
Failure to Maintain Resident Dignity and Honor Rights to Personal Preferences
Penalty
Summary
The facility failed to uphold residents' rights to dignity, respect, and self-determination in several instances. One resident was not consistently provided with her glasses, which were kept locked in the medication cart for safekeeping. Despite being care planned for refusals to wear her glasses, there was no documentation that staff offered the glasses or reapproached the resident throughout the day, nor was there evidence that the legal representative was contacted as claimed by staff. Observations over multiple days confirmed the resident was not wearing her glasses until after surveyor intervention. Additionally, the same resident was observed sitting in a public area with her legs uncovered, contrary to her known religious preferences and the requests of her legal representative, with staff confirming her legs were exposed in a public setting. Another resident's right to participate in preferred activities, specifically voting, was not honored. Documentation in the resident's care plan and recreation progress notes indicated the importance of voting to the resident. However, the facility was unable to provide evidence that the resident was offered the opportunity to vote in a recent election, as confirmed by the Director of Recreation. These findings demonstrate failures in maintaining residents' dignity and honoring their individual rights and preferences.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 147 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dunbar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Center | 2.4 mi | ★★★★★ | 25 | 0 |
| Riverside Valley Of Journey | 2.9 mi | ★★★★★ | 2 | 0 |
| Arthur B Hodges Center, The | 4.3 mi | ★★★★★ | 0 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 4.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Oak Ridge Llc | 5.8 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.