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 57 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:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 20, 2025, 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 May 20, 2025, 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 Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain two of over ten self-closing doors.

Observation and interview on May 20, 2025, between 12:30 p.m. and 12:52 p.m., revealed the following deficiencies:
A. The second-floor 2N corridor storage room self-closing door failed to latch in the frame;
B. The main dining room to multi-purpose room self-closing door failed to latch in the frame.

Interview with the maintenance supervisor on May 20, 2025, at 12:52 p.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 07/07/2025

Adjustments and repairs have been made to the following doors. A. The second floor north corridor storage room and B. The main dining room to multi-purpose room. Random audits will be completed monthly X3 on self-closing doors. Maintenance staff will be educated on the importance of the latching of self-closing doors. Results will be reported at the monthly Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 observation and interview, the facility failed to maintain the sprinkler system for one of over six sprinkler heads.

Findings include:

Observation on May 20, 2025, at 1:06 p.m., revealed the kitchen dishwashing area ceiling sprinkler head was covered with a layer of dust/lint and was also corroded. A build-up of material can insulate the sprinkler thermal element, affecting the temperature activation and response time of the sprinkler and/or causing inadequate spray coverage.

Interview with the maintenance supervisor on March 20, 2025, at 1:06 p.m., confirmed the sprinkler head deficiency.

Plan of Correction - To be completed: 07/07/2025

The sprinkler heads in the kitchen dishwasher area will be replaced by the vendor.
Random Audits will be completed monthly for X3 for buildup on sprinkler heads. Results of those audits will be reported at the monthly 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 May 20, 2025, it was determined that Dubois Nursing Home was in compliance with the 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:

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