Inspection visit

Health inspectionSeptember 1, 2022

DUNBAR HEALTH & REHAB CENTERCMS #3661576 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to timely report an alleged misappropriation of resident funds to the Administrator and the state agency. This affected one resident (#26) out of one reviewed for misappropriation. The facility census was 47. Findings include Review of the medical record for the Resident #26 revealed an admission date of 01/11/22. Diagnoses included leg amputation, end stage renal disease, heart failure, anxiety, hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 required extensive assistance of two staff for mobility. Interview on 08/29/22 at 11:22 A.M., with Resident #26 and State Tested Nursing Assistant (STNA) #36 revealed she had a missing $50 bill that had been in a bank envelope on her bed. Resident #26 requested STNA #36 to provide an update on the status of finding the missing money. Resident #26 said the night housekeeper who changed her linens, took the money. STNA #36 informed Resident #26 the housekeeping manager and the laundry staff were updated and keeping an eye out in case the money turned up in laundry. Interview on 08/30/22 at 2:01 P.M., with STNA #36 revealed she informed the Housekeeping Staff #48 of the missing money the morning of 08/29/22. The STNA #36 revealed she had not informed the Administrator or Director of Nursing (DON) of the potential for misappropriation of the residents' money. Interview on 08/30/22 at 4:35 P.M. with Housekeeper #48 revealed she was informed of the missing money and revealed she had not found the money in the laundry on 08/29/22 and revealed she had not reported to the Administrator or the Director of Nursing. Interview on 08/30/22 at 5:05 P.M. with the DON revealed she had been informed of the missing money on 08/30/22 and denied any staff informing her of the possible misappropriation on 08/29/22 when it was reported by Resident #26. The DON revealed the social worker had started an investigation and confirmed they were trying to get in touch with resident's sister to confirm she brought in the money as Resident #26 had reported. The DON revealed if the resident's sister in fact brought in the money a self-reported incident (SRI) would be initiated. The DON verified a SRI had not been initiated. Interview on 08/31/22 at 9:40 A.M., with Social Services #92 revealed she was informed by Resident #26 on 08/30/22 around 1:00 P.M. and informed the Administrator about an hour later of the missing (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 366157 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few money. Social Services #92 revealed the money had not been found as of 08/31/22. She revealed the resident's sister verified she had brought Resident #26 fifty dollars and Social Services #92 revealed the SRI was initiated 08/30/22 in the evening. A follow-up interview on 09/01/22 at 4:00 P.M., with the DON and the Regional Clinical Manager #98 acknowledged the missing money from Resident #26 was not reported by their direct care staff or housekeeping manager on 08/29/22. Review of the facility policy titled Ohio Resident Abuse Policy, dated 07/14/22 revealed it was the facilities policy to investigate all allegations, suspicions and incidents of misappropriation of resident property. The policy revealed facility staff are to immediately report all allegations to the Administrator/Abuse Coordinator and an investigation will begin to notify the applicable local and state agencies. The policy revealed initial reports should be reported immediately to the Administrator, the DON and the state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Self-Reported Incident (SRI), review of the facility investigation, and policy review, the facility failed to thoroughly investigate an alleged resident to resident abuse. This affected two residents (#18 and #33) out of three residents reviewed for abuse. The facility census was 47. Residents Affected - Few Findings include 1. Review of the medical record for the Resident #18 revealed an admission date of 03/03/22. Diagnoses included congestive heart failure, hypoglycemia, bradycardia, COVID-19, dementia with behaviors, restlessness and agitation and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had cognitive impairment. The resident was independent with mobility requiring supervision and cueing due to cognition. Review of the progress note dated 08/17/22 revealed Resident #18 had a physical altercation on 08/16/22 with another resident where he struck her hand. 2. Review of the medical record for the Resident #33 revealed an admission date of 03/23/21. Diagnoses included chronic respiratory failure, cerebral ataxia, anoxic brain injury and muscle weakness. Review of the MDS assessment dated [DATE] revealed Resident #33 had cognitive impairment and required extensive assistance of one to two staff for mobility. Review of the progress note dated 08/17/22 revealed Resident #33 had a physical altercation with another resident on 08/16/22 where her hand was struck. Review of the Self-reported incident number 225473 dated 08/17/22 revealed a physical altercation between Resident #18 and #33 occurred the previous day (08/16/22) when Resident #18 stuck Resident #33's hand. Staff responded immediately and separated the two residents and completed head to toe checks on both residents with no negative findings. The SRI investigation reported staff interviews were completed however, were not included in the investigation. No progress notes were written in either resident record detailing the incident or follow up steps and included only a head to toe assessment that flowed into a progress note until Social Services spoke with both residents the next day. Interview on 09/01/22 at 10:00 A.M. with the Director of Nursing (DON) and the Regional Clinical Director #98 revealed on 08/16/22 State Tested Nursing Assistant (STNA) #12 reported to the DON that Resident #33 reported to her while the smokers were being directed into the building from the courtyard. Resident #18 took his hand and tapped Resident #33 on the hand to direct her to come into the building. The DON revealed all contact between residents are investigated and an SRI was submitted. At this time staff interview documentation was requested. Review of the staff interview dated 09/01/22 revealed only one staff was interviewed regarding the incident. A follow-up interview on 09/01/22 at 4:00 P.M., with the DON and Regional Clinical Director #98 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 acknowledged the facility did not have staff interviews as part of the investigation packet provided. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Ohio Resident Abuse Policy, dated 07/14/22, revealed the facility failed to implement the policy regarding the allegation. The policy revealed it was the facilities policy to investigate all allegations, suspicions and incidents of misappropriation of resident property. The policy revealed facility staff are to immediately report all allegations to the Administrator/Abuse Coordinator and an investigation will begin to notify the applicable local and state agencies. The investigation should be initiated and be finalized within five working days from the alleged occurrence. The investigation should include interviews of all involved residents and all witnesses including employees who had worked closely with the reported victim or perpetrator. If no direct witnesses than interviews should be expanded to all residents and all employees on the unit. Facility should obtain written statements from all witness of residents and staff and document evidence of the steps of investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to provide a written discharge notice to a resident and resident representative timely. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admission date of 07/29/22 and was hospitalized on [DATE]. Diagnoses included acute respiratory failure, encephalopathy, seizures, tracheostomy, persistent vegetative state and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the social services #92 contacted Resident #38's representative via the telephone and did not want anything sent to her and wants her father to return when his hospital stay was completed. Interview on 08/31/22 at 10:18 A.M. with Social Services #92 revealed the facility had no evidence of the discharge notice being provided to the resident's family. Social Services #92 acknowledged the progress note written on 08/31/22 regarding discussion of the discharge notice. Review of facility policy titled Resident Discharge and Transfer Letter Policy, dated 10/05/17, revealed the letter would be given to resident and if applicable to the resident representative. The letter would be uploaded to the electronic medical record along with certified receipt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to ensure a bed hold notice was timely provided to a resident and resident representative upon discharge to the hospital. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admission date of 07/29/22 and was hospitalized on [DATE]. Diagnoses included acute respiratory failure, encephalopathy, seizures, tracheostomy, persistent vegetative state and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the Social Services #92 contacted resident representative by the phone and did not want anything sent to her and wanted her father to return to the facility when his hospital stay was completed. Interview on 08/31/22 at 10:18 A.M., with Social Services #92 revealed facility had no evidence of the bed hold notification being provided to resident's family. Social Services #92 verified the progress note written on 08/31/22 was the first discussion of bed hold notices with Resident #38's family. Review of facility policy titled Bed Hold Letter Policy, dated 09/26/20, revealed a copy would be sent certified mail or with return receipt requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, interview, and policy review, the facility failed to ensure residents received their medications as ordered. This affected one resident (#33) out of five residents reviewed for unnecessary medications. The facility census was 47. Findings Include: Review of the medical record for Resident #33 revealed admission date of 03/23/21. Diagnoses included acute respiratory failure, protein-calorie malnutrition, iron deficiency anemia cerebellar atoxia disease and anoxic brain damage. Review of the physician orders dated August 2022 revealed Resident #33 was ordered the following medications: Atenolol tablet 100 milligrams (mg) one tablet two times a day for hypertension (HTN). Amlodipine Besylate tablet 10 mg one tablet daily for HTN. Both medications for hypertension had parameters to follow. Gabapentin 300 mg one capsule three times a day for muscle pain. Baclofen tablet 20 mg one tablet four times a day for muscle spasms. Tylenol tablet 325 mg give 650 mg four times a day for pain. Review of the Medication Administration Record (MAR) dated from 08/01/22 to 08/31/22 revealed Resident #33 had not received the following medications on the specified dates: On 08/09/22 and 08/10/22 the 4:00 P.M. dose of Baclofen 20 mg was not documented as given. On 08/09/22 and 08/10/22 the 4:00 P.M. dose of Tylenol 325 mg was not documented as given. On 08/09/22 and 08/10/22 the 6:00 P.M. dose of Atenolol 100 mg was not documented as given and no blood pressure was recorded. On 08/09/22 and 08/10/22 the 6:00 P.M. dose of Gabapentin 300 mg was not documented as given. On 08/12/22 the 6:00 A.M. dose of Amlodipine Besylate 10 mg was not documented given and no blood pressure was recorded. Interview on 09/01/22 at 2:20 P.M., with the Director of Nursing and the Regional Clinical Director #98 verified Resident #33 had not received the medications. Review of the facility policy titled General Dose Preparation and Medication Administration, dated 01/01/22 revealed the nurse should record each time a medication is administered and the time that is was administered. If ordered obtain vital signs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, review of the pureed recipes, review of the pureed food resource guide, and policy review, the facility failed to ensure pureed foods were made according to a recipe and were the correct consistency. This affected one resident (#05) out of one resident who received a pureed diet. The facility identified no other residents received a pureed diet in the facility. The facility census was 47. Findings include: Review of the medical record for the Resident #05 revealed an admission date of 08/04/09. Diagnoses included kidney failure, schizoaffective disorder, dysphagia, diabetes, dementia, anoxic brain injury, depression, and cognitive communication deficit. Review of the physician order dated 03/07/22 revealed Resident #05 had a diet order for a large portion diet with pureed texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had an altered cognition and a mechanically altered diet. Observation and interview on 08/31/22 at 11:09 A.M. with Dietary Staff (DS) #44 of the pureed process of the fruit medley. The DS #44 revealed the medley contained banana, mango, pineapple, and papaya chunks. One half cup scoop of fruit was put in the blender with residual unmeasured juice estimated at about two to three tablespoons. The food was blended to a smoothie consistency and an unmeasured additional amount of juice was added. The mixture was again blended. The DS #44 revealed the mixture was at the right consistency for service. The mixture appeared liquid like similar to a watered-down smoothie and held no form. Observation and interview on 08/31/22 at 11:14 A.M. with Dietary Staff #40 of pureed process of a cabbage roll and a vegetable blend. The DS #44 placed one pre-made cabbage roll in the blender with an unmeasured amount of sauce (tomato sauce the rolls were sitting in). The DS #40 revealed the cabbage roll consisted of mainly rice and hamburger meat they are bought pre-made and staff just heat them. The DS #40 added two more scoops of unmeasured liquid sauce. The DS #40 revealed the food was the correct consistency and poured the mixture into the pan. The pureed food mixture held no form and was liquid like consistency similar to applesauce. The DS #40 then scooped a quarter cup of vegetable blend (green beans, yellow beans, lima beans, black beans, peas, and carrots) along with unmeasured juice. The mixture was blended and additional unmeasured juice was added. The mixture was poured into a pan and held no form. The vegetable blend was dripping from the mixer into the pan and was liquid like consistency. The DS #40 verified both the cabbage roll and the vegetable blend purees were at the correct consistency. Interview on 08/31/22 at 11:18 A.M., with the DS #40, DS #44, and Contracted Kitchen Manager #95 discussed the above observations and verified the pureed food should have had a mashed potato consistency that would hold a form of a mold or scoop. Observation on 08/31/22 at 12:33 P.M. revealed the pureed food on the test tray had a watery texture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the pureed recipes for the fruit cocktail, the vegetable blend, and the cabbage roll revealed no measurement amounts of liquid were listed for staff use. Review of the Resource-Pureed food preparation guide undated revealed in order to puree food, the final product should have a pudding-like consistency. The guide also revealed liquids should be added in small amounts at a time to avoid over thinning. Review of the facility policy titled Preparation of Altered Texture Food Policy, dated 04/2011, revealed staff will use recipes, menus, and spreadsheets to ensure residents receive safe palatable and nutritionally appropriate meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366157 If continuation sheet Page 9 of 9

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

FAQ · About this visit

Common questions about this visit

What happened during the September 1, 2022 survey of DUNBAR HEALTH & REHAB CENTER?

This was a inspection survey of DUNBAR HEALTH & REHAB CENTER on September 1, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at DUNBAR HEALTH & REHAB CENTER on September 1, 2022?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 1, 2022