Dunbar Village Terrace

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a comfortable and homelike environment for one (1) of (14) sampled residents (Resident #30) by failing to adequately accommodate the prolonged loss of a bathroom sink for approximately one (1) month.Findings include:A review of the facility's policy, Resident Rights, revised 1/2026, revealed, .Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the village .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .A record review of the admission Record revealed the facility admitted Resident #30 on 9/3/24 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed Resident #30 had a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a resident was free from a significant medication error when facility staff administered undiluted Sertraline Hydrochloride (Zoloft) Oral Solution to a resident for one (1) of six (6) residents reviewed for medication review. (Resident #62) Findings include:A review of the facility's policy, Medication Errors, Date Reviewed/Revised 9/2025, revealed, Policy Explanation and Procedure: 1. The village shall ensure medications will be administered as follows.b. Per manufacturer's specifications regarding the preparation, and administration of the drug. A record review of the admission Record revealed the facility admitted Resident #62 on 2/27/26 with diagnoses including Aftercare Following Joint Replacement Surgery.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/26 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility failed to comply with state nursing facility staffing requirements by failing to designate a charge nurse responsible for supervision of the total nursing activities in the facility during the 3:00 PM to 11:00 PM shift, separate from the medication/treatment nurse assignment for one (1) of three (3) shifts reviewed for charge nurse supervision. Findings include:A record review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility, revealed, .To be classified as a facility, the institution shall comply with the following staffing requirements.2. Each facility shall have the following licensed personnel as a minimum.D. A registered nurse or licensed practical nurse shall serve as a charge nurse and be responsible for supervision of the total nursing activities in the facility during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift. The nurse assigned to the unit for the 11:00 p.m. to 7:00 a.m. shift may serve as both the charge nurse and medication/treatment nurse.A record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure services were provided in accordance with professional standards of practice observed during medication administration when the nurse allowed Resident #11 to self-administer two (2) different prescribed nasal sprays without assessing whether he was capable of doing so safely for one (1) of four (4) residents observed. (Resident #11). Findings include:A review of the facility's policy titled Resident Self-Administration of Medication, with a reviewed/revised date of 5/2025, revealed, .It is the policy of this village to support each residents' right to self-administer medication. A resident may only self-administer medications after the village's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines.4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.On 7/30/25 at 8:32 AM, during a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and the facility's ServSafe (a food safety training and certification program) documentation review, the facility failed to ensure that food was stored in a safe and sanitary manner to prevent contamination and deterioration for one (1) of two (2) kitchen observations.Findings include:A review of the facility's ServSafe document The Flow of Food: Purchasing, Receiving and Storing, dated 2020, revealed, . Receiving and Inspecting.make sure enough trained staff are available to receive and inspect food items promptly . Food Quality.Appearance Reject food that is moldy or has an abnormal color . Do not overload coolers or freezer to prevent good air flow, use open shelving .On 7/28/25 at 10:15 AM, during an observation of the kitchen and an interview with the Dietary Manager (DM), seven (7) pints of strawberries with visible mold were observed on a cardboard flat between two (2) flats of grapes in the walk-in cooler. Additionally, eight (8) oranges with a dried appearance, mold, and soft texture, and two (2) lemons with green and black mold were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that all clinical records, including nurse practitioner (NP) visit notes, were readily accessible to licensed nursing staff responsible for resident care for one (1) of 15 sampled residents, Resident #5, with the potential to affect fifty-seven (57) residents who reside in the facility. Findings include:On 7/28/25 at 1:54 PM, during an observation and interview, Resident #5 was observed wearing a right wrist splint. The resident explained she fell at home and broke her femur and wrist. She stated she continued to have some pain but received pain medications as ordered and that the nurse practitioner recently changed how often she could receive them.On 7/29/25 at 1:10 PM, during an interview with Licensed Practical Nurse (LPN) #1 she stated Resident #5's pain medication frequency was recently changed from every four (4) hours to every six (6) hours. She explained she typically reviewed progress notes in the EHR for any changes related to residents and confirmed there were no progress notes from the NP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions related to a resident with full length bed rails (Resident #1) and a resident with an indwelling catheter (Resident #52) for two (2) of 17 sampled residents. Findings include: Review of the facility's policy, Comprehensive Care Plans, revised 7/29/2019, revealed, Policy Statement: An individual comprehensive care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident . Resident #1 During an observation on 01/17/24 at 12:08 PM, Resident #1 had full length bed rails on both sides of the bed. The resident explained she does not remember how long she had the bed rails. She stated she was not able to lower the rails on her own and asked staff to lower them for her at times, but there were times that she wanted to have the bed rails raised as well. She said she was unable to get up without assistance and she was unable to walk. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an indwelling catheter tubing was stabilized to prevent trauma and failed to provide incontinence care in a manner to prevent complications for two (2) of three (3) residents observed for incontinence and catheter care. Resident #29 and #52. Findings Include: A review of the facility's policy Perineal Care, dated 10/2023, revealed . Peri (Perineal) care helps prevent skin breakdown of perineal area, itching, burning, odor, and infections. Perineal care is very important in maintaining the resident's comfort . Policy . 8. Gently clean the skin of the perineal area moving from front to back. Do not move from back to front due to the risk of introducing germs . Males: Retract foreskin in uncircumcised male. Grasp penis, clean tip of penis using a circular motion, wash down shaft of the penis and wash testicles. Replace foreskin of uncircumcised male . A review of the facility's policy Indwelling Catheter Use and Removal, undated, revealed, Policy: It is the policy of this village…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to date and label a tube feeding bag for one (1) of (1) residents reviewed for tube feeding management. (Resident #4) Findings include: A review of the facility's policy Care and Treatment of Feeding Tubes, undated, revealed, Policy: It is a policy of this village to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . On 01/17/24 at 12:36 PM, during an observation, Resident #4 was lying in bed with the head of the bed elevated. There was a tube feeding running at 70 cc (cubic centimeters)/hour (hr). The tube feeding formula bag did not contain a date, time, or label indicating when the bag of tube feeding was started. The bag had a manufacturer's label indicating the type of feeding as Isosource. There was a bag of water that did not contain a date, time, or label indicating when the water flush was started. On 01/17/24 at 4:16 PM, during an observation and interview with Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews the facility failed to inform a resident or the Resident Representative (RR) of the risk and benefits of full length bed rails prior to bed rail installation for one (1) of 17 sampled residents. Resident #1 Findings include: Record review of the facility's statement, dated 1/19/2024, provided by the Administrator revealed, (Proper Name of Facility) does not have a policy on bed rails. On 01/17/24 at 12:08 PM, during an observation, Resident #1 had full length bed rails on both sides of the bed. The resident explained she does not remember how long she had the bed rails. She stated she was not able to lower the rails on her own and asked staff to lower them for her at times, but there were times that she wanted to have the bed rails raised as well. She said she was unable to get up without assistance and she was unable to walk. On 01/18/24 at 03:00 PM, during an observation and interview with Licensed Practical Nurse (LPN) #3, she confirmed Resident #1 had full length bed rails and has had them for as long as she could remember. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications were discontinued after 14 days or had a documented indication for continued use by the prescriber, with a designated time frame for one (1) of five (5) residents reviewed for unnecessary medications. Resident #44 Findings include: Review of the facility's policy, Use of Psychotropic Medication, undated, revealed, Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . Policy Explanation and Compliance Guidelines: 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e.14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.