Pennsylvania Department of Health
DUBOIS NURSING HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 55 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 12, 2024, at Dubois Nursing Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #560402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 12, 2024, it was determined that Dubois Nursing Home had deficiencies that have the potential for minimal harm, as related to the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire resistive building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm system testing and maintenance requirements for two of two building components.

Findings include:

Document review on June 12, 2024, at 9:41 a.m., revealed the facility was unable to provide documentation for the fire alarm system semi-annual visual inspection. The last documented inspection provided occurred on February 14, 2023.

Interview with the administrator and maintenance director on June 12, 2024, at 9:41 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 07/12/2024

1. Smith Meyers completes the semi-annual fire system inspections. Last function inspection was September of 2023. Smith Meyer's is scheduled to complete a visual inspection on July 11th, 2024 with report.
2. Smith Meyer's will continue to complete the visual and functional tests on a semi-annual basis and provide facility of the report with results.
3. Maintenance Director will audit the Smith Meyer reports for completion and verify the inspections were done.
4. Maintenance Director will report to Quality Assurance Performance Improvement meeting on a quarterly basis any findings from the visual and functional fire alarm systems tests.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, the facility failed to maintain sprinkler system testing and maintenance requirements for one of two building components.

Findings include:

Document review on June 12, 2024, at 10:00 a.m., revealed the quarterly report, completed May 21, 2024, listed under general deficiencies, "No sprinkler head inventory list on site." The facility was unable to provide corrective documentation for the deficiency.

Interview with the administrator and maintenance director on June 12, 2024, at 10:00 a.m., confirmed the facility lacked the corrective documentation at the time of the survey.

Plan of Correction - To be completed: 07/12/2024

1. Maintenance Director will correct the deficiency noted in the report from Johnson Controls for sprinkler system. A new sprinkler head inventory list was created to correct the deficiency.
2. Maintenance director will audit one year's worth of quarterly reports from Johnson Controls to ensure no other deficiencies were documented and not corrected.
3. Maintenance Director will audit all future reports from Johnson Controls on sprinkler system to verify and correct any noted deficiencies.
4. Results of the audited reports will be brought to quarterly Quality Assurance Performance Improvement meetings for discussion.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on document review and interview, the facility failed to maintain fire ceiling smoke dampers, per NFPA 80 19.3.4, for two of two building components.

Findings include:

Document review on June 12, 2024, at 9:52 a.m., revealed the facility's fire damper inspection sheet lacked inspector preforming the testing signature, and if any deficiencies were discovered during the inspection.

Interview with the administrator and maintenance director on June 12, 2024, at 9:52 a.m., confirmed the inspection sheet did not include the required items listed.

Plan of Correction - To be completed: 07/12/2024

1. Maintenance Director will re-inspect fire dampers and document the inspection to include signatures and if any deficiencies were found.
2. A new inspection sheet was created to properly document all future fire damper inspections.
3. Maintenance director will educate the maintenance staff on fire damper inspection procedure and properly documenting the inspection.
4. Maintenance Director will audit the fire damper inspections and bring any findings to quarterly Quality Assurance Performance Improvement meeting

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one emergency generator.

Findings include:

Document review on June 12, 2024, between 9:33 a.m. and 9:40 a.m., revealed the following generator deficiencies:
A. (9:33 a.m.) The facility failed to provide documentation for annual fuel quality testing;
B. (9:40 a.m.) The facility failed to provide documentation for monthly conductance testing.

Interview with the administrator and maintenance director on June 12, 2024, at 9:40 a.m., confirmed the facility lacked documentation for conductance and fuel quality testing at the time of the survey.

Plan of Correction - To be completed: 07/12/2024

1. The Maintenance director will schedule a fuel sample quality test through Cleveland brothers and log the results. Maintenance Director will complete a new generator battery conductivity test and document it properly.
2. Cleveland Brothers will complete an annual fuel quality test and provide the results in its reports to the facility. A new monthly generator battery conductivity test sheet was developed to properly document the test.
3. Director of Maintenance will educate maintenance staff on the testing of generator battery conductivity and using the new sheet to properly document the test.
4. Maintenance Director will audit the monthly generator battery tests for completeness and the yearly fuel quality reports. The findings will be reported to the quarterly Quality Assurance Performance Improvement meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #560402
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on June 12, 2024, it was determined that Dubois Nursing Home was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm system testing and maintenance requirements for two of two building components.

Findings include:

Document review on June 12, 2024, at 9:41 a.m., revealed the facility was unable to provide documentation for the fire alarm system semi-annual visual inspection. The last documented inspection provided occurred on February 14, 2023.

Interview with the administrator and maintenance director on June 12, 2024, at 9:41 a.m., confirmed the deficiency at the time of the survey.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0372

Based on document review and interview, the facility failed to maintain fire ceiling smoke dampers, per NFPA 80 19.3.4, for two of two building components.

Findings include:

Document review on June 12, 2024, at 9:52 a.m., revealed the facility fire damper inspection sheet lacked lacked inspector preforming the testing signature, and if any deficiencies were discovered during the inspection.

Interview with the administrator and maintenance director on June 12, 2024, at 9:52 a.m., confirmed the inspection sheet did not include the required items listed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one emergency generator.

Findings include:

Document review on June 12, 2024, between 9:33 a.m. and 9:40 a.m., revealed the following generator deficiencies:
A. (9:33 a.m.) The facility failed to provide documentation for annual fuel quality testing;
B. (9:40 a.m.) The facility failed to provide documentation for monthly conductance testing.

Interview with the administrator and maintenance director on June 12, 2024, at 9:40 a.m., confirmed the facility lacked documentation for conductance and fuel quality testing at the time of the survey.

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