Inspection Reports for Dunbar Center

An unannounced revisit was conducted at Dunbar Center on June 18, 2025 for the annual recertification, relicensure, facility reported incident (FRI), and complaint investigation surveys concluding on May 8, 2025.

The facility was found to be in compliance with all previously cited tags as reflected on the CMS-2567b.

An unannounced complaint and Facility Reported Incident (FRI) survey was conducted at Dunbar Center from 05/05/25 through 05/08/25 to investigate multiple substantiated complaints and one unsubstantiated FRI.

The facility was found deficient in infection prevention and control, privacy/confidentiality of records, resident rights and dignity, safe and comfortable environment, nutritive value and food temperature, quality of care including skin and wound management, sufficient nursing staff, accuracy of assessments, and PEG tube care. Deficiencies included failure to follow infection precautions, improper handling of resident information, failure to honor resident preferences, inadequate food temperatures, incomplete wound care and assessments, insufficient staffing, inaccurate Minimum Data Set (MDS) reporting, and lack of PEG tube care orders and cleaning.

Multiple complaints (#38643, #38482, #38276, #38039, #37907, #37985) were substantiated. Facility Reported Incident #38726 was unsubstantiated.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Dunbar Center, was found to be in substantial compliance with the applicable federal and state regulations, with previously cited deficient practices addressed through accepted plans of correction.

An unannounced annual re-certification and annual re-licensure survey was conducted at Dunbar Center from 03/31/25 through 04/03/25, including complaint investigations and follow-up on prior deficiencies.

The facility was found deficient in multiple areas including failure to follow physician orders for wound care and immunizations, improper storage of controlled medications, failure to coordinate PASARR assessments, incomplete COVID-19 immunization consent, incomplete transfer/discharge notifications to the Ombudsman, failure to provide showers as scheduled, failure to provide appropriate assistive eating devices, improper disposal of garbage, inaccurate medication administration routes, lack of individualized activity programming, failure to provide bed hold notices, incomplete influenza and pneumococcal immunizations, failure to honor resident food preferences, and infection control lapses such as touching medication pills with bare hands.

Multiple complaints were investigated during the survey period. Complaint #36186 was substantiated; all others were unsubstantiated.

The inspection was conducted to assess compliance with regulatory requirements, including maintenance and testing of the automatic sprinkler and standpipe systems in accordance with NFPA 25 standards.

The facility failed to ensure that automatic sprinkler and standpipe systems were maintained according to NFPA 25 standards, with corrosion observed on multiple sprinkler heads in various areas of the facility. Immediate repairs were initiated and a plan of correction was implemented.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual recertification and complaint investigation survey was conducted at Dunbar Center from 03/17/24 through 03/21/24.

The survey identified multiple deficiencies including incomplete dialysis communication documentation, failure to provide dignified care, missing nurse aide performance reviews, incomplete care plan revisions, inaccessible call lights, incomplete medical records, failure to address resident grievances, inappropriate use of psychotropic medications, unsafe medication storage, inaccurate posted menus, infection control breaches, inadequate pressure ulcer care, serving food at improper temperatures, unsafe water temperatures for showers, and late medication administration.

Complaint #30498 Unsubstantiated; Complaint #31440 Unsubstantiated; Complaint #31498 Unsubstantiated; Complaint #31481 Substantiated.

The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with regulatory requirements for long term care facilities.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence.

The inspection visit was conducted to evaluate the facility's compliance with fire safety regulations, specifically regarding the protection and enclosure of hazardous areas as required by NFPA 101.

The facility was found to have a large hole in the firewall above the dining room, which compromised the fire barrier and could affect all residents, staff, and visitors. The Director of Maintenance secured the hole and implemented monitoring and re-education plans to prevent recurrence.

An unannounced complaint investigation survey was conducted at Dunbar Center from July 5-6, 2023, based on complaint #28049 which was substantiated.

The facility was found to be in substantial compliance overall but had deficiencies including failure to follow physician orders for blood pressure checks and failure to provide an accurate care plan regarding transmission-based precautions for residents. Specifically, Resident #113 did not have vital signs checked as ordered, and Resident #12's care plan listed conflicting transmission-based precautions with no appropriate PPE available.

Complaint #28049 was substantiated with a citation at F684 related to quality of care issues including failure to follow physician orders for vital signs.

The inspection was conducted as a complaint investigation survey and a Focused Infection Control survey.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The plans of correction and credible evidence were accepted in lieu of an onsite revisit.

The complaint investigation survey concluded on 07/06/2023 with the facility found in substantial compliance with previously cited deficient practices.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual recertification, annual relicensure, complaint investigation survey was conducted at Dunbar Center from February 13-15, 2023.

The facility had multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to document rationale for medication changes, failure to provide required notices, inadequate foot care, unsafe medication storage, infection control lapses, incomplete care plans, incomplete POST forms, failure to administer medications as ordered, and failure to provide scheduled showers.

Complaint #27416 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27947 and #27308 were substantiated with related deficiencies cited at F657.

The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

Dunbar Center was found to be in substantial compliance with the applicable federal and state regulations, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence in lieu of an onsite revisit.

The inspection was conducted as a routine survey to assess compliance with National Fire Protection Association (NFPA) codes and other regulatory requirements.

The facility was found deficient in maintaining delayed-egress locking systems and electrical receptacles according to NFPA standards. Specifically, a delayed egress exit door did not alarm or release as required, and a receptacle behind a water cooler lacked a ground fault circuit interrupting receptacle.

The inspection was conducted as a complaint investigation survey concluding on August 3, 2022, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Dunbar Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

The complaint investigation survey concluded on August 3, 2022, and the facility was found in substantial compliance with previously cited deficient practices.

An unannounced complaint investigation survey was conducted at Dunbar Center from August 1-3, 2022, based on complaints #26968, #26980, and #27059.

The facility was found to have deficiencies related to resident dignity during wound care, timely medication administration, and proper documentation and orders for catheter and urostomy care. Complaint #26980 was substantiated with past non-compliance deficiencies, and complaint #27059 was substantiated with related and unrelated deficiencies.

Complaint #26968 was unsubstantiated with no related or unrelated deficiencies. Complaint #26980 was substantiated with past non-compliance deficiencies cited at F658. Complaint #27059 was substantiated with a related deficiency cited at F684 and unrelated deficiencies cited at F550 and F657.

An unannounced complaint investigation survey was conducted at Dunbar Center from April 4-5, 2022.

The complaint #26241 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #26241 was unsubstantiated with no related or unrelated deficiencies cited.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted to assess compliance with fire safety regulations, specifically the inspection, testing, and maintenance of fire-rated door assemblies in accordance with NFPA 101 standards.

The facility failed to ensure that fire-rated door assemblies in the means of egress were properly inspected, tested, and maintained, with multiple deficiencies observed including gaps exceeding allowed limits, unapproved astragals, penetrations around door frames, and malfunctioning door operations. Corrective actions were planned and partially completed by contracted vendors and facility staff.

The visit was the annual survey of Dunbar Center to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the applicable federal and state regulations, with plans of correction and credible evidence accepted in lieu of an onsite revisit.

Routine inspection to assess compliance with fire safety, electrical systems, HVAC, smoke barriers, emergency preparedness, and maintenance of patient care equipment and fire doors.

The facility was found deficient in multiple areas including smoke barrier penetrations, electrical wiring and equipment not meeting NFPA standards, lack of testing for fire dampers and emergency generator, and fire doors not properly maintained or installed. The facility submitted plans of correction for all deficiencies.

An unannounced annual re-certification and annual re-licensure survey was conducted at Dunbar Center from 11/01/21 to 11/03/21 to assess compliance with federal and state regulations.

The survey identified multiple deficiencies including failure to provide dignity in meal service, failure to notify physicians of significant changes in resident condition, failure to secure medication administration records, failure to report alleged violations timely, inaccurate resident assessments regarding oxygen use, failure to follow physician orders for insulin management and follow-up treatments, failure to provide appropriate contracture care, failure to maintain a safe environment free of hazards, and failure to post nurse staffing information in a prominent location.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 09/13/2021 and 09/19/2021, which has the potential to cause more than minimal harm to all residents.

An unannounced complaint investigation was conducted at Dunbar Center on March 30-31, 2021.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #24792 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was a Focused Infection Control survey to assess compliance with infection control regulations and COVID-19 preparedness.

The facility was found to be in substantial compliance with infection control regulations, CMS and CDC recommended practices for COVID-19, and previously cited deficient practices based on review of plans of correction and credible evidence without an onsite revisit.

The visit was a Focused Infection Control survey to assess compliance with infection control regulations and COVID-19 related practices.

The facility, Dunbar Center, was found to be in substantial compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency to assess compliance with infection control regulations and CDC recommended practices related to COVID-19.

The facility failed to maintain and implement an infection control program to prevent the spread of COVID-19 when a staff member neglected to perform appropriate hand hygiene during COVID-19 testing. This was observed during specimen collection for two surveyors and had the potential to affect multiple residents.

An unannounced revisit was conducted at Dunbar Center on 11/11/20 for the complaint investigation survey concluding on 08/20/20.

The facility was found to have corrected the previously cited deficient practices from the complaint investigation.

Complaint reference: #24038. The previously cited deficient practices were corrected as of the revisit.

An unannounced revisit was conducted at Dunbar Center on 11/10/20 - 11/11/20 for the complaint investigation survey.

The facility was found to have corrected the previously cited deficient practices, as reflected on the CMS-2567B.

Complaint reference: #24449. The revisit was related to a complaint investigation.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency to assess compliance with infection control regulations and CMS/CDC recommended practices related to COVID-19.

The facility failed to maintain an infection prevention and control program in the laundry area, specifically failing to keep the door between soiled and clean laundry closed, resulting in potential cross-contamination. Dirty linens were uncovered, trash cans were uncovered and overflowing, and debris was present on the floor, posing a risk for infection transmission.

An unannounced complaint survey was conducted at Dunbar Center from 09/21/2020 to 09/25/2020 based on complaint #24449 which was substantiated with related deficiencies cited.

The facility failed to ensure residents were free from neglect and failed to properly secure controlled medications, resulting in a resident (Resident #100) ingesting other residents' narcotic medications, causing actual harm and hospitalization. The facility also failed to complete required controlled substance shift counts consistently, leading to missing narcotics and unsafe medication practices.

Complaint #24449 was substantiated. The complaint involved missing narcotic medications that were accessed by Resident #100, leading to an overdose and hospitalization. The facility was found negligent in securing medications and completing required controlled substance counts.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on September 9, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

An unannounced complaint survey was conducted at Dunbar Center on August 17-20, 2020, triggered by complaint #24038 which was substantiated with a related deficiency cited.

The facility failed to provide adequate pain management for Resident #5 following a fall on 04/17/20, resulting in physical and psychosocial harm. The resident's pain was not treated timely or effectively, pain assessments and documentation were inadequate, and the facility failed to follow physician orders including immobilization of the injured limb.

Complaint #24038 was substantiated with a related deficiency cited.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 29, 2020.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 22, 2020.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint investigation survey concluding on 02/19/2020, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint reference number #23434; the facility was in substantial compliance with previously cited deficient practices.

An unannounced complaint survey was conducted at Dunbar Center on 02/18/20 to 02/19/20 based on multiple complaints, some substantiated and others unsubstantiated.

The survey identified deficiencies related to failure to notify responsible parties of significant medication changes, failure to provide written discharge notices, failure to revise care plans, late medication administration, failure to complete neurological assessments after falls, unsafe environment hazards including unsecured razors and medication tablets on the floor, and failure to ensure residents receive treatment and care according to professional standards.

Multiple complaints were investigated; complaints #23360, #23635, #23873, #23567, and #23707 were unsubstantiated with no deficiencies cited. Complaint #23434 was substantiated with related deficiencies cited at F580, F657, F684, and F689. One unrelated deficiency was cited at F623.

An unannounced revisit was conducted at Dunbar Center from 11/05/19 to 11/07/19 for the annual recertification and relicensure survey concluding on 07/02/19.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced revisit was conducted at Dunbar Center from 09/16/19 to 09/18/19 for the annual survey conducted on 07/02/19 to verify correction of previously cited deficiencies.

The facility remained out of compliance with multiple tags including F600, F636, F660, F684, F756, F757, F761, F842, F867, and F880. Deficiencies included late medication administration, incomplete care area assessments, inadequate discharge planning, medication regimen irregularities, improper medication storage and labeling, incomplete medical record documentation, and failure to follow infection control protocols.

An unannounced annual re-certification and annual re-licensure survey was conducted at Dunbar Center from 06/24/19 through 07/02/19. The survey included complaint investigations and review of facility documentation.

The facility was cited for multiple deficiencies including failure to provide dignified dining experiences, failure to honor resident bathing and religious preferences, failure to notify responsible parties of falls, inadequate environmental cleanliness, failure to provide timely medication administration, incomplete care plans, failure to report abuse allegations to appropriate agencies, incomplete transfer documentation, inaccurate assessments, insufficient staffing, and failure to maintain proper food temperatures and sanitation.

Complaint #22778, #22506, and #22666 were substantiated with related deficiencies cited.

The inspection was conducted as a routine facility inspection to assess compliance with National Fire Protection Association (NFPA) standards related to electrical wiring and safety.

The facility failed to maintain electrical wiring in accordance with NFPA 101 and 70 standards, with multiple observations of electrical junction boxes missing cover plates or punch outs, spliced wiring without junction boxes, and dead-ending wiring in attic areas. Immediate corrective actions were taken by the Center Maintenance Director.

The inspection was conducted as a complaint investigation survey based on complaint references #21555 and #21558, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigation survey concluding on 12/06/2018 with complaint references #21555 and #21558; facility found in substantial compliance with previously cited deficiencies.

An unannounced complaint survey was conducted at Dunbar Center from 12/03/18 to 12/06/18 based on complaints #21555 and #21558, which were substantiated with related and unrelated deficiencies cited.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach, failure to complete neurological checks after falls, failure to monitor blood pressures and medication administration according to physician orders, failure to document pain medication effectiveness, improper labeling of IV medications, serving food at unsafe temperatures, and incomplete or inaccurate resident medical records and assessments.

Complaint #21555 and #21558 were substantiated with related and unrelated deficiencies cited during the unannounced complaint survey conducted from 12/03/18 to 12/06/18.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced revisit was conducted for the annual recertification, relicensure, and complaint investigation surveys concluding on May 17, 2018.

The facility was found to remain out of compliance with food safety requirements related to storage, preparation, and serving of food. Issues included undated opened food items, unclean kitchen equipment, and improper sanitary techniques during dishwashing, potentially affecting all residents.

The revisit included a complaint investigation survey concluding on May 17, 2018. The facility remained out of compliance with F812 related to food safety.

Desk Review of credible evidence submitted was made to verify correction of previously cited deficiencies.

All deficiencies were corrected as of 6/4/18. The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

Unannounced annual Long Term Care Survey Process and State Licensure Surveys, and four complaint investigations were conducted at Dunbar Center from May 14, 2018 through May 17, 2018.

The facility was found deficient in multiple areas including failure to provide appropriate beneficiary protection notifications, failure to verify background checks for agency staff, incomplete care plans addressing resident preferences and dietary needs, medication administration errors, unsafe smoking practices by a cognitively impaired resident, failure to provide medically-related social services when residents refused care, failure to serve food in a form meeting individual needs, failure to serve therapeutic diets as prescribed, and food safety violations in the dietary department.

Four complaints were investigated during the survey period. Complaint #14525 was unsubstantiated with no deficiencies cited. Complaint #14656 and #19318 were substantiated with related deficiencies cited. Complaint #18869 was unsubstantiated with no citations.

The inspection was conducted to assess compliance with fire safety sprinkler system installation and essential electrical system maintenance, including generator load bank testing, as part of routine regulatory oversight.

The facility failed to ensure sprinkler heads were unobstructed in two dining halls and did not perform an annual generator load bank test as required by NFPA standards. Corrective actions were planned and implemented, including replacing obstructive light fixtures and scheduling the required load bank test.

The visit was conducted as a complaint investigation following allegations, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The previously cited deficient practices were corrected.

Complaint investigation concluded on 07/24/17 with facility found in substantial compliance and previously cited deficiencies corrected.

An unannounced complaint survey was conducted at Dunbar Center from July 18, 2017 to July 24, 2017, related to complaint #17457 (not substantiated) and complaint #17261 (substantiated with related and unrelated deficiencies cited).

The facility was found deficient in honoring resident bathing preferences, completing comprehensive assessments after significant changes, conducting neurological assessments after falls, providing adequate assistance with meals, maintaining nutritional status, and documenting care accurately. Resident #63's preferred bathing schedule was not consistently honored or documented. Resident #11 experienced significant weight loss and lack of assistance with meals. Neurological assessments were incomplete for residents with falls. Documentation of refusals and care was incomplete.

Complaint #17457 was not substantiated. Complaint #17261 was substantiated with related and unrelated deficiencies cited.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for Dunbar Center, accepted in lieu of an onsite revisit.

Dunbar Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

An unannounced six-month Special Focus Facility Quality Indicator Survey was conducted at Dunbar Center from 03/20/17 through 03/22/17 to assess compliance with federal regulations based on observations, record reviews, and interviews.

The facility was found deficient in multiple areas including failure to inform residents about risks and benefits of psychotropic medications, failure to follow physician orders for insulin administration, failure to provide therapeutic diets as ordered, and failure to prepare pureed diets according to recipes. These deficiencies placed residents at risk for uninformed consent, improper medication administration, inadequate nutrition, and inconsistent diet preparation.

The inspection was conducted to assess compliance with NFPA 101 emergency lighting, corridor door maintenance, and gas equipment training requirements.

The facility failed to document emergency lighting testing, maintain corridor doors to resist smoke passage, and provide training on handling medical gas cylinders as required by NFPA standards. Corrective actions and staff reeducation plans were implemented.

The inspection was conducted as a complaint investigation concluding on 11/11/16, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint Reference: 16321. The complaint investigation concluded on 11/11/16 with the facility in substantial compliance and no onsite revisit required.

An unannounced complaint survey was conducted at Dunbar Center from 11/09/16 to 11/11/16 based on Complaint #16321, which was substantiated with unrelated deficiencies cited.

The facility failed to accurately maintain medical records for meal intake percentages and bedtime snack acceptance for five of eight residents reviewed. Documentation gaps were found in the ADL flow records for residents #1, #2, #4, #7, and #8, with missing entries for meal percentages and snack acceptance across multiple dates.

Complaint #16321 was substantiated with unrelated deficiencies cited. The complaint sample consisted of 11 residents.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for Dunbar Center, accepted in lieu of an onsite revisit.

Dunbar Center was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

Unannounced annual Quality Indicator and State Licensure surveys were conducted at Dunbar Center from July 11, 2016 through July 19, 2016.

The facility was found deficient in multiple areas including failure to notify residents about personal funds nearing SSI limits, failure to ensure privacy during care, unresolved complaints about missing personal items, inadequate housekeeping and maintenance, inaccurate comprehensive assessments, incomplete abuse policies, dignity issues during dining, incomplete care plans, failure to provide necessary care for dependent residents, improper catheter use, accident hazards, unnecessary medications, incomplete infection control data, and inaccurate clinical records. Facility administration failed to ensure continued compliance and effective oversight by the Quality Improvement Committee.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on smoke barriers and automatic sprinkler systems.

The facility failed to ensure smoke barriers provided the required one half hour fire resistance rating due to multiple penetrations in smoke walls. Additionally, the automatic sprinkler system was compromised by HVAC ducts, communication wires, and cables laying across sprinkler heads, potentially affecting all residents, staff, and visitors.

The inspection was conducted as a complaint investigation, with the facility's plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation concluding on 2016-04-05.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule, with previously cited deficient practices corrected.

Complaint Reference: #15472. The complaint investigation concluded on 2016-04-05 with the facility in substantial compliance and no onsite revisit required.

An unannounced complaint survey was conducted at Dunbar Center from March 31, 2016 to April 5, 2016, based on complaint #15472 which was substantiated with related deficiencies cited.

The facility failed to implement the care plan for one diabetic resident (#2) by not providing the prescribed consistent carbohydrate diet, instead providing a regular liberalized diet. This failure was confirmed through observations, medical record reviews, and staff interviews. The resident received insulin coverage as ordered, and no negative outcomes were reported. The facility initiated corrective actions including audits, staff re-education, and monitoring to ensure compliance with therapeutic diet orders.

Complaint #15472 was substantiated with related deficiencies cited based on observations, clinical record reviews, resident, family, and staff interviews, and other facility documentation.

The inspection was conducted as a complaint investigation, reviewing plans of correction and credible evidence in lieu of an onsite revisit.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices corrected.

Complaint Reference: 14725. The complaint investigation concluded on 2016-02-12 with the facility in substantial compliance.

An unannounced complaint survey was conducted at Dunbar Center from February 8 to February 10, 2016, triggered by complaint #14725 which was substantiated with an unrelated deficiency cited.

The facility failed to ensure that two of five residents reviewed for written bed-hold notice were provided the necessary bed-hold information at the time of transfer to an acute care hospital. Specifically, Residents #120 and #121 did not have documented evidence of receiving the required written bed-hold notice at transfer.

Complaint #14725 was substantiated with an unrelated deficiency cited. The complaint investigation included review of residents' clinical records, interviews with residents, family, and staff, and review of facility documentation.

An unannounced revisit was conducted at Dunbar Center from 01/11/16 to 01/12/16 for the Quality Indicator Survey concluding on 10/20/15.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was a routine survey to assess compliance with Life Safety Code standards and other regulatory requirements at the Dunbar Center nursing facility.

The facility was found deficient in maintaining ceiling tiles properly to prevent smoke and heat penetration, ensuring exit discharge paths were accessible for persons with severe mobility impairments, covering electrical junction boxes, and proper installation of alcohol-based hand rub dispensers away from ignition sources.

An unannounced annual Quality Indicator Survey was conducted at Dunbar Center from October 12, 2015 through October 20, 2015, including an off-hours survey. An extended survey was conducted due to substandard quality of care identified.

The survey identified multiple deficiencies including failure to promptly resolve grievances, ineffective housekeeping, inaccurate resident assessments, incomplete criminal background checks, failure to report abuse allegations timely, dignity violations, inaccurate care plans, failure to implement bowel and pain protocols, incomplete dialysis communication, delayed dental services, inaccurate nurse staffing postings, and ineffective quality assurance processes.

The facility failed to report and/or investigate allegations of abuse and neglect to State agencies as required for five (5) of twenty-five (25) resident complaints filed with the facility, and for one (1) of five (5) residents reviewed for dignity during Stage 2 of the Quality Indicator Survey. Residents #41, #170, #107, #212, #4, and #98. Some allegations were substantiated and the alleged perpetrator was no longer employed.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation concluding on 2015-05-20.

The facility, Dunbar Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint Reference: 13278. The complaint investigation concluded with the facility in substantial compliance and no onsite revisit was required.

An unannounced complaint survey was conducted at Dunbar Center from May 18, 2015 through May 20, 2015, triggered by complaint #13278 which was unsubstantiated.

The facility failed to accurately and completely assess residents' dental status and revise care plans accordingly. Multiple residents had conflicting or inaccurate documentation regarding dental conditions across nursing assessments, oral assessments, dental consults, care plans, and MDS assessments.

Complaint #13278 was unsubstantiated with unrelated deficiencies cited. The complaint sample consisted of six residents.

The document is a plan of correction submitted in response to previously cited deficiencies during a Quality Indicator and Licensure Survey.

The facility, Dunbar Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with acceptance of plans of correction and credible evidence in lieu of an onsite revisit.

The inspection was conducted to evaluate the facility's compliance with NFPA 101 Life Safety Code standards, including fire drills, sprinkler system maintenance, and emergency generator maintenance.

The facility failed to conduct fire drills at varied times as required, failed to continuously maintain the sprinkler system in reliable operating condition due to cables draped on sprinkler piping, and failed to maintain the emergency generator properly by not testing and recording the specific gravity of electrolyte fluid in the generator's batteries weekly.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Dunbar Center from March 23, 2015 through March 27, 2015 to assess compliance with regulatory requirements.

The survey identified multiple deficiencies including failure to promptly resolve resident grievances, inadequate reasonable accommodations, failure to notify residents of roommate changes, housekeeping and maintenance issues, failure to conduct significant change assessments, undignified staff conduct, failure to revise care plans after falls, unsafe environmental hazards, improper food handling, failure to assist with dental services, and malfunctioning resident call systems.

The document is a plan of correction submitted in response to previously cited deficiencies during the Quality Indicator and Licensure Surveys concluding on 09/04/14.

The facility, Dunbar Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Unannounced annual Quality Indicator and State Licensure Surveys, and a Complaint investigation were conducted concurrently at Dunbar Center from 08/25/14 through 09/04/14.

The facility was found deficient in housekeeping and maintenance services, comprehensive resident assessments, and food procurement and storage practices. Specific issues included unclean sit to stand lift bases, a soiled blanket left on the floor, inaccurate dental assessments for residents, and improper food storage and labeling in the kitchen.

Complaint #11892 was investigated concurrently with the annual survey and was not substantiated; no related deficiencies were found.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards related to smoke barriers, means of egress, and medical gas storage in the facility.

The facility failed to maintain smoke barrier walls with the required fire resistance rating, had malfunctioning delayed-egress locks that did not release as required, and did not store oxygen cylinders in accordance with NFPA 99 standards, including lack of proper signage and unsecured cylinders.

An unannounced complaint investigation was conducted at Dunbar Center for Complaint References 9969 and 10616.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable federal and state nursing home regulations.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the Dunbar Center nursing facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation based on complaint reference numbers 13262 / 9071.

The complaint was found to be unsubstantiated with no citations issued.

Complaint reference 13262 / 9071 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a substantiated complaint investigation from 11/05/13 to 11/08/13 regarding allegations of abuse, neglect, and failure to report incidents appropriately.

The facility failed to report allegations of abuse to appropriate State agencies timely, failed to conduct thorough investigations of injuries of unknown origin, failed to provide necessary care and services to residents including medication administration errors, failed to maintain infection control by not isolating a resident with C-diff promptly, and failed to maintain complete and accurate medical records for several residents.

Substantiated complaint record with citations related to failure to report abuse allegations, failure to investigate injuries of unknown origin, and failure to report identified nurse aide perpetrator to the nurse aide registry.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the Dunbar Center nursing facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).

Follow-up visit to verify correction of previous deficiencies related to resident rights, advance directives, care planning, pain management, medication use, and medical record accuracy.

The facility failed to ensure residents' wishes regarding advance directives were accurately documented and honored, failed to revise care plans to reflect current resident needs, failed to adequately assess and manage pain in a cognitively impaired resident, administered unnecessary medications, and had conflicting documentation regarding resuscitation orders. These deficiencies persisted from a prior survey and were not fully corrected at the time of this follow-up.

The inspection was a routine survey to assess compliance with federal regulations related to resident rights, abuse/neglect, medication administration, care planning, infection control, and other quality of care standards.

The facility was cited for multiple deficiencies including failure to display Medicaid/Medicare application instructions, failure to identify and report neglect related to a medication error causing harm to a resident, failure to accurately assess and care plan for urinary incontinence and falls, failure to update care plans for nutrition and dental status, failure to administer medications as ordered including insulin omission, failure to secure medications and medication carts, failure to maintain sanitary conditions for equipment, failure to monitor and document catheter use, failure to maintain accurate medical records, failure to serve hot food at proper temperatures, and failure to maintain a functional QAA committee.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to facility safety and resident rights.

The facility was found deficient in multiple areas including corridor doors not latching properly to resist smoke passage, lack of visible exit signage, sprinkler system maintenance issues including oversized ceiling penetrations and storage too close to sprinkler heads, trash receptacles exceeding allowed capacity in unprotected areas, and inadequate documentation and procedures for fire watch during sprinkler system shutdown.

The inspection was conducted in response to a complaint referenced as 12252 / 7405.

The complaint was investigated and found to be unsubstantiated.

Complaint Reference: 12252 / 7405. The complaint was unsubstantiated following investigation conducted on 12/27/12 from 4:00 a.m. to 9:30 a.m.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the Dunbar Center nursing facility.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulation.

The inspection was conducted as a complaint investigation based on substantiated complaints with citations related to facility conditions and care.

The facility was found deficient in multiple areas including housekeeping and maintenance services, comprehensive assessments, care planning, provision of care, medication administration, infection control, and sanitation. Specific issues included unsanitary resident rooms and equipment, failure to address hoarding behavior, incomplete assessments for pressure ulcers, inadequate care plans, failure to monitor fluid intake, grooming neglect, medication errors, and improper handling of soiled linens and dirty ice carts.

The visit was complaint-related with substantiated complaints referenced as 12078 / 7054 and 12169 / 7230, both resulting in citations.

The inspection was conducted in response to substantiated complaints regarding resident care and facility compliance, including allegations of neglect and failure to follow proper procedures.

The facility was found to have substantiated deficiencies including failure to promptly resolve grievances, failure to complete required transfer/discharge notices with reasons, failure to revise care plans to reflect changes in care, and incomplete and inaccurate medical record documentation related to resident incidents.

Complaint references #11171, #11178, and #11185 were substantiated with deficiencies cited related to resident care and documentation.

Complaint investigation related to substantiated allegations of abuse and failure to protect a resident from harm due to roommate's abusive behavior.

The facility failed to protect Resident #95 from physical harm caused by her roommate, Resident #119, who exhibited physically and verbally abusive behaviors. Despite staff awareness and family complaints, the facility did not take adequate measures to prevent harm, resulting in Resident #95 sustaining a laceration requiring emergency room treatment. Additionally, Resident #119's care plan was not revised to address her aggressive behaviors. The facility also had issues with leaking air conditioning units in multiple resident rooms, creating potential hazards.

Complaint reference #11157. Substantiated complaint record with deficiencies cited. Resident #95's family reported roommate abuse including choking and throwing objects. Facility staff failed to take prompt action to protect Resident #95 despite awareness of Resident #119's abusive behaviors.

The inspection was conducted concurrently with a complaint investigation and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was found to have multiple deficiencies including failure to provide private telephone access, inadequate investigation and reporting of neglect allegations, failure to ensure call light accessibility, failure to notify residents before room changes, maintenance issues, incomplete care plans, failure to revise care plans, inadequate infection control practices, and failure to act on pharmacist medication irregularity reports.

Complaint reference #11092 was unsubstantiated with unrelated deficiencies cited. The complaint investigation was conducted concurrently with the annual inspection.

The inspection was conducted as an annual survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements for the facility.

The facility was found deficient in several areas related to fire safety and life safety code compliance, including failure to maintain self-closing devices on hazardous room doors, inadequate corridor exit width due to obstructions, failure to maintain readily accessible exits, missing monthly inspections and missing parts on the rangehood wet chemical extinguishing system, and improper storage of oxygen cylinders not secured from unauthorized entry.

The inspection was conducted in response to complaint reference #11012.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #11012 was unsubstantiated with no deficiencies cited.

Complaint investigation related to allegations of failure to obtain informed consent and failure to notify physician and family prior to an invasive procedure on Resident #118.

The facility's certified nurse practitioner performed an incision and drainage of a large hematoma on Resident #118 without notifying the attending physician or obtaining informed consent from the resident or her medical power of attorney (MPOA). This resulted in harm to the resident, including increased pain, bleeding, and transfer to the hospital emergency room. The facility failed to notify the physician of the acute change and did not properly investigate or report the incident initially.

Complaint reference #10360 was substantiated with deficiencies cited related to failure to obtain informed consent, failure to notify physician and family, and failure to provide appropriate care resulting in harm to Resident #118.

Complaint investigation related to substantiated deficiencies involving failure to notify physician of treatment refusals, failure to conduct background checks, and failure to provide proper care and monitoring for a resident with respiratory issues.

The facility failed to notify the physician of a resident refusing inhalation treatments, failed to conduct a required criminal background check for a nurse practitioner, failed to follow professional standards in respiratory care and monitoring, and failed to provide timely medical intervention for a resident who experienced an acute decline and subsequently died. Documentation was incomplete and late entries were recorded days after the resident's death.

Complaint reference #10314. Substantiated complaint record with deficiencies cited.

The inspection was conducted as a complaint investigation based on complaint reference #10261 which was substantiated with deficiencies cited, and complaint reference #10267 which was unsubstantiated with no related deficiencies.

The facility was found deficient in several areas including failure to treat residents with dignity and respect, failure to honor residents' food preferences, failure to revise care plans after significant changes in resident status, and failure to post accurate nurse staffing information. Specific incidents involved Resident #71 being ignored by staff and not being informed of staff names, Resident #78 being served disliked food, Resident #50's care plan not reflecting her total dependence for eating, and inaccurate nurse staffing postings.

Complaint reference #10261 was substantiated with deficiencies cited. Complaint reference #10267 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a complaint investigation related to complaint reference #10208.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint reference #10208 was substantiated with no deficiencies cited.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Dunbar Center.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the Dunbar Center nursing facility.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation based on complaint reference #10156, which was substantiated with deficiencies cited related to neglect and improper medical treatment by nursing assistants.

The facility failed to thoroughly investigate allegations of neglect involving nursing assistants providing medical treatments reserved for licensed nurses, including the use of another resident's antifungal medication. Additionally, the facility failed to ensure ordered treatments were provided and did not assist dependent residents with hand hygiene prior to meals.

Complaint reference #10156 was substantiated. The complaint involved neglect allegations including improper medical treatment by nursing assistants and failure to investigate thoroughly.

Complaint investigation triggered by complaint references #10135, #10140, and #10141 regarding failure to provide proper discharge notices, bedhold policy notices, readmission, care planning, staffing, and safeguarding clinical records.

The facility failed to provide written discharge and bedhold notices to Resident #118's responsible party, refused to re-admit Resident #118 after hospitalization despite stabilization, failed to develop a comprehensive care plan addressing Resident #118's challenging behaviors, failed to provide sufficient nursing staff on the 3-11 shift especially on weekends to meet resident care needs, and failed to safeguard clinical record information for Resident #118.

Complaint references #10135, #10140, and #10141 were substantiated with deficiencies cited related to Resident #118's discharge notices, bedhold policy, readmission, care planning, staffing, and clinical record safeguarding.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding exit access and storage of soiled linen or trash receptacles.

The facility failed to maintain all means of egress readily accessible due to building supplies obstructing the egress path. Additionally, mobile soiled linen receptacles exceeding 32 gallons were found unattended in corridors and not stored in a protected hazardous area.

The inspection was conducted concurrently with complaint investigations #9284 and #9306, the facility's annual Federal Medicare/Medicaid certification resurvey, and State licensure inspection.

The facility was found deficient in multiple areas including failure to provide individualized Medicare non-coverage notices, improper management of resident personal funds, failure to maintain resident dignity and respect, inadequate accommodation of resident needs, incomplete care plans, delayed treatment of pressure ulcers, use of defective lift equipment and insufficient staff assistance during transfers, unnecessary drug use without proper documentation, and illegible or inaccurate medical records.

Complaint references #9284 and #9306 were unsubstantiated with no deficiencies cited. These complaint investigations occurred concurrently with the annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.