Pennsylvania Department of Health
DUBOIS NURSING HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

DUBOIS NURSING HOME
Inspection Results For:

There are 106 surveys for this facility. Please select a date to view the survey results.

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DUBOIS NURSING HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a complaint survey completed on March 3, 2026, it was determined that Dubois Nursing Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations: Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of seven residents reviewed (Resident 5). Findings include: Review of facility policy for oxygen administration by nasal cannula or mask dated February 27, 2026, indicated that residents who require oxygen will have a physician's order which includes the oxygen flow rate. An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 5 dated January 22, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, had diagnoses that included heart failure, and was receiving supplemental oxygen. Physician's orders for Resident 5 dated February 13, 2024, indicated that the resident was to receive oxygen at three Liters per minute (L/min) via nasal cannula (a lightweight, flexible tube with two small prongs that sits in the nostrils to deliver supplemental oxygen). Observation of Resident 5 on March 3, 2026, at 11:25 a.m. revealed the resident sitting in her wheelchair in her room, with a nasal cannula in place attached to a portable oxygen tank that was empty. Interview with Licensed Practical Nurse 1 on March 3, 2026, at 11:25 a.m. confirmed that Resident 5's portable oxygen tank was empty, and she replaced it with a full one. Observation of Resident 5 on March 3, 2026, at 12:04 p.m. revealed the resident sitting in her wheelchair in the dining room with a nasal cannula in place attached to a portable oxygen tank that had the oxygen flow rate set at 2 L/min. Interview with Licensed Practical Nurse 2 on March 3, 2026, at 12:04 p.m. confirmed that Resident 5's oxygen flow rate was set at 2 L/min and the physician's orders indicated that it should be set at 3 L/min. Interview with the Director of Nursing on March 3, 2026, at 12:56 p.m. confirmed that oxygen should have been administered to Resident 5 according to her physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/07/2026

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state laws. This statement of applies to all observances below and throughout the entire 2567, Statement of Deficiencies document.

Resident 5's oxygen was adjusted according to the physician order at the time identified during survey.

An audit will be conducted by the Director of Nursing/Designee of current residents that utilize oxygen to ensure that residents are receiving oxygen per physician orders.

Current nursing staff will be educated by the Director of Nursing/Designee on the facility's policies and procedures on oxygen usage.

The Director of Nursing/Designee will audit all residents utilizing oxygen for proper administration per physician orders 5 days a week for 2 weeks and weekly for 2 weeks. The audit findings will be reviewed at the facility's monthly quality assurance committee meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations: Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of seven residents reviewed (Resident 7). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility policy for transmission-based precautions dated February 27, 2026, indicated that transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact precautions staff will wear gloves and disposable gown upon entering the room and remove them before leaving the room. An Admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 24, 2026, revealed that the resident was cognitively intact, required assistance for daily care needs, and medical diagnosis that includes urinary tract infection. A physician order for Resident 7, dated February 21 ,2026, included an order for the resident to be on contact isolation for diagnosis of MDRO. Observations on March 3, 2026, at 11:01 a.m. revealed that Nurse Aide 3 was assisting Resident 7 into the bathroom. She did not have a gown per contact isolation policy. Interview with Nurse Aide 3 on March 3, 2026, at 11:01 a.m. confirmed that she did not have an isolation gown on while providing care to Resident 7 and should have. Interview with Licensed Practical Nurse 4 on March 3, 2026, at 11:10 a.m. confirmed that Resident 7 had orders for contact isolation for MDRO. Interview with the Director of Nursing on March 3, 2026, at 12:57 p.m. confirmed that Nurse Aide 3 should have had a gown on when providing care to Resident 7. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 04/07/2026

Resident 7 remains on contact isolation for Multi Drug Resistant Organism (MDRO).

An audit will be conducted by the Director of Nursing/Designee of all current residents that are utilizing isolation precautions to ensure that staff are utilizing proper personal protective equipment per physician order and facility policies.

Current nursing staff will be educated by the Director of Nursing/Designee on the facility's policies and procedures related to isolation guidelines and the personal protective equipment required for each level of isolation.

The Director of Nursing/Designee will audit all residents that utilize isolation precautions based on the physician's order 5 days a week for 2 weeks and weekly for 2 weeks. The audit findings will be reviewed at the facility's monthly quality assurance committee meeting.

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