Dunbar Center

In the surveyor’s words

From the most serious findings on record at Dunbar Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 2, 2026

  Based on record review, resident and family interviews, and staff interviews, the facility failed to ensure residents received timely assessment, intervention, and treatment for acute changes in condition. Specifically, the facility failed to ensure a resident exhibiting signs and symptoms consistent with sepsis, respiratory distress, hypoxia, hypotension, tachycardia, and acute clinical deterioration received timely emergency medical evaluation and transfer to the hospital; failed to follow physician orders for skin and wound care; and failed to provide pain management as ordered. […]

• Actual harm, isolatedF600Aug 26, 2026

  Based on record review, staff interview, and Adult Protective Services (APS) interviews, the facility failed to protect a vulnerable resident from neglect when a facility staff member witnessed Resident #117 being removed from the premises by an unknown individual. The resident appeared to be exhibiting signs of distress but the staff member failed to take action or report the incident. The facility was unaware of the resident's whereabouts and well-being for approximately three hours, exposing the resident to an unsupervised, unsafe environment. Resident identifier: #117. Facility census: 116.The State Agency (SA) determined that harm was caused to Resident #117 when the witnessed removal from the premises, was not immediately reported. […]

• Actual harm, isolatedF692Jul 28, 2025

  Based on observation, record review, caregiver interview and staff interview, the facility failed to ensure each resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible. This was true for four (4) of four (4) residents reviewed. This failed practice resulted in actual harm for Resident #64 who since the time of her admission has lost a severe amount of weight. The facility failed to track her consumption of meals, provide assistance at mealtimes and failed to implement the dietician's recommendation for a house supplement and the resident continued to lose weight. […]

• Actual harm, isolatedF600May 8, 2025

  Based on record review and staff interview, the facility failed to protect the resident's right to be free from neglect. The facility failed to care for the resident's skin conditions and percutaneous endoscopic gastrostomy (PEG). The facility also failed to ensure the resident received bathing activities. The resident was hospitalized for a wound infection. The resident's PEG tube was adhered to her skin. This caused actual harm to the resident. Resident Identifiers: #110. Facility census: 109. a) Resident #110 Resident #110 was discharged from the hospital and returned to the facility on [DATE]. On 03/25/25, Resident #110 was transferred back to the hospital. Hospital records stated upon admission to the hospital, the resident was generally soiled with dirt and feces in her skin folds. […]

• Actual harm, isolatedF686May 8, 2025

  Based on record review and staff interview, the facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for pressure ulcers. Pressure ulcers were not assessed weekly for Residents #110, #58, and #90. Additionally, Resident #110's pressure ulcers were not treated as ordered. This deficient practice caused actual harm to Resident #110, who was admitted to the hospital with a pressure ulcer infection. The hospital physician also diagnosed the resident with septic shock, believed to be caused by a combination of pneumonia and sacral pressure ulcer wound infection. Resident identifiers: #110, #58, #90. Facility census: 109. […]