Dubois Nursing Home

In the surveyor’s words

From the most serious findings on record at Dubois Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF742Apr 30, 2026

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to prevent physical and verbal behaviors, and/or failed to develop and implement new interventions to address ongoing physical and verbal behaviors for two of 44 residents reviewed (Residents 8, 68) resulting in psychosocial harm for one resident (Resident 68). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 31, 2026, indicated that the resident was severely cognitively impaired, had verbal behaviors directed at others 1-3 days, and had diagnoses that included dementia. […]

• Actual harm, isolatedF658Jan 2, 2026

  Based on review of Pennsylvania's Nursing Practice Act, clinical records and staff interviews, it was determined that the facility failed to enter a new resident's physician's orders into the electronic health record which caused the resident to miss two doses of insulin resulting in hospitalization for elevated blood sugars, for one of five residents reviewed (Resident 3). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of… […]

• Actual harm, isolatedF684Jan 2, 2026

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 3). Findings include:admission paperwork for Resident 3, dated December 19, 2025, indicated that she was a diabetic with diabetic ulcers and that her blood sugar prior to leaving the hospital that day was 182. A nursing note for Resident 3, dated December 19, 2025, indicated that she was admitted from the hospital at 5:30 p.m. […]

• Actual harm, isolatedF656Apr 10, 2024

  Based on a review of clinical records and investigation documents as well as staff interviews, it was determined that the facility failed to implement a care plan for one of five residents reviewed (Resident 2) who was an assist of two for transfers, resulting in a fall with fracture. This deficiency is being cited as past noncompliance. Findings include: An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. […]

• Actual harm, isolatedF689Apr 10, 2024

  Based on review of investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of five residents reviewed (Resident 2), resulting in a fall with fracture. This deficiency was cited as past non-compliance. Findings include: An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. […]