Dunbar Village Terrace
DUNBAR VILLAGE TERRACE in BAY SAINT LOUIS, MS — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the medication error.
The RR reported she and her brother gathered Resident #62's belongings,
Nurse (RN) #1/RN Supervisor, she reported the facility completed an incident report and medication
nurse administering medications gave the resident liquid Zoloft that should have been diluted and Resident #62 complained that her mouth was burning afterward. RN #1 reported the family arrived at the facility and was informed of the error. RN #1 stated Resident #62 complained of discomfort and was provided water, ice cream, and pudding. RN #1 reported the facility's Nurse Practitioner was notified.On 5/27/26 at 1:10 PM, during an interview with the Nurse Practitioner (NP), she stated she recalled being notified regarding Resident #62 receiving liquid Zoloft without dilution.
The NP explained she contacted the pharmacy and was informed the medication should be diluted with at least four (4) ounces of liquid.
The NP reported administration of undiluted liquid Zoloft could cause numbness, tingling, mouth soreness, throat soreness, and a burning sensation.
The NP stated the recommendation was to continue fluids to help alleviate the symptoms.On 5/28/26 at 2:34 PM, during an interview with the Director of Nursing (DON), she recalled the incident involving administration of undiluted liquid Zoloft to Resident #62.
The DON reported the family was upset regarding the medication error.
The DON stated the medication arrived from the pharmacy without dilution instructions on the pharmacy label.
The DON reported she contacted the pharmacist following the medication error and discussed the need for administration instructions to accompany medications.
The DON stated nurses should look up administration instructions and obtain additional information when administering medications that are unfamiliar to them.On 5/28/26 at 2:54 PM, during a phone interview, Licensed Practical Nurse (LPN) #1 reported she recalled administering the medication to Resident #62. LPN #1 stated this was the first time she had administered liquid Zoloft. LPN #1 reported the medication packaging she reviewed contained dosing information, but she did not recall instructions regarding dilution before administration. LPN #1 stated she was later advised by her supervisor to look up administration instructions when administering a medication that was unfamiliar to her.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.