Dunbar Health & Rehab Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF803May 1, 2025

  Based on observation, staff interview, and record review, the facility failed to ensure portion sizes were served as planned. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Review of the dietary spreadsheet for the lunch meal on 04/30/25 revealed the serving size for the rice was 1/2 cup, sliced carrots was 1/2 cup, and ground chicken was 3 ounces. Observation on 04/30/25 at 11:04 A.M. revealed [NAME] #735 making plates for the lunch meal. [NAME] #735 utilized a #12 scoop (1/3 cup) for the sliced carrots, a #20 scoop (1 5/8 ounces) for the ground chicken, and a #16 scoop (1/4 cup) for the rice. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on observation, staff interview, and record review, the facility failed to ensure the steam table was maintained in a clean and sanitary manner. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Observation on 04/30/25 at 10:26 A.M. revealed the water wells of the steam table in the kitchen contained a yellowish-brown liquid with debris floating at the top and brown sediment around the bottom and edges of each well. […]

• No harm, potential for more than minimal, patternF565May 1, 2025

  Based on the review of Resident Council meeting minutes, resident interview, and staff interviews, the facility failed to document and follow up on resident concerns from the resident council meetings. This affected 10 out of 10 members of Resident council who regularly attended the meetings and had the potential to affect all residents residing at the facility. The facility census is 63. Findings include: Review of Resident Council meetings minutes from August 2024 to March 2025 revealed the facility did not follow up on concerns brought forward at the Resident Council meetings. Review of the meeting minutes revealed the resolutions from the last meeting concerns were left blank. […]

• No harm, potential for more than minimal, patternF636Aug 22, 2023

  Based on record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents comprehensive Minimum Data Set (MDS) assessments were completed timely. This affected four (#10, #16, #110, and #118) out of the four residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE] with medical diagnoses of convulsions cerebral infarction, and psychotic disorder. Review of the medical record for Resident #10 revealed an admission MDS with assessment reference date (ARD) of 05/21/23 revealed the MDS had a completion date of 06/23/23. 2. […]

• No harm, potential for more than minimal, patternF638Aug 22, 2023

  Based on record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents quarterly Minimum Data Set (MDS) assessments were completed timely. This affected five (#8, #18, #78, #108, and #124) residents out of the six residents reviewed for quarterly MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with medical diagnoses of congestive heart failure (CHF), atrial fibrillation, anxiety, and obesity. Review of the medical record revealed a quarterly MDS assessment with Assessment Reference Date (ARD) of 05/20/23 revealed the MDS had a completion date of 07/09/23. 2. […]