Dunbar Village Terrace

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 12, 2024

  Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk and had moderate cognitive impairment, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 was observed by a therapy staff member to be in the lobby of the facility at approximately 12:00 PM on 4/6/24. The therapy staff member left the facility to pick up lunch and as she returned to the facility, she observed Resident #1 near the side of the main road, approximately 100 feet from the facility grounds at approximately 12:08 PM. […]

• No harm, potential for more than minimal, isolatedF584May 28, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF760May 28, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF836May 28, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF658Jul 31, 2025

  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. […]