Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dubois Nursing Home during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment displayed repeated verbal and physical aggression toward her roommate, including blocking access, arguing, scratching, kicking, and threatening her, while requiring anti-anxiety meds and eventual psychiatric hospitalization. The roommate, who was cognitively intact, reported fear and distress, but the record showed no documented behavior pattern assessment, monitoring, or revision of the behavior care plan, and the two residents remained in the same room until the next day.
A resident with anxiety and intact cognition received repeated PRN lorazepam doses, but the MAR lacked documentation that non-pharmacological interventions such as diversional activities, rest, or snacks were attempted first, despite the care plan requiring them. The DON confirmed that no such interventions were attempted before the doses given.
Failure to Follow Medication Orders and Report Critical Lab Results: The facility did not follow insulin sliding-scale orders for two residents when blood glucose readings reached the highest ordered range and the physician was not documented as notified. A resident receiving a Fentanyl patch was later found with two patches on, and another resident on Coumadin had abnormal PT/INR results that were not documented as reported to the physician. The DON confirmed the missed notifications and the patch issue.
Failure to flush a resident’s PICC line as ordered occurred when the resident received IV Daptomycin but the MAR lacked documented evidence of the required maintenance flush every shift on multiple occasions. The resident was cognitively intact, had a PICC in the RUE, and had orders for NS flushes before and after IV meds plus a shift flush; the DON confirmed the missing documentation.
Significant medication errors occurred for two residents when ordered antibiotics were not documented as given. One resident with cognitive impairment, MDR organism, and pressure ulcers missed multiple doses of Cefadroxil because the medication was not available from the pharmacy, and another resident with an infected joint prosthesis missed multiple IV doses of Ampicillin. The DON confirmed the missing documented administrations.
Food was served cold and not palatable. Residents reported that meals were terrible tasting, usually cold, and not always warm. During meal service, trays were delayed on the cart, the cart doors were left open while trays were passed, and hot items measured below the required temperature; meatloaf and tomato soup were lukewarm, and the soup tasted sour. The Dietary Mgr confirmed the food was not served at the proper temp.
Unsanitary conditions were found in the kitchen food prep/tray line area when three ceiling vents had dust and rust-colored buildup and one ceiling tile was covered with rust-colored buildup. The dietary PM schedule showed no documented evidence that the vents or ceiling tile had been cleaned or inspected, and the Dietary Manager confirmed the vents needed cleaning and that maintenance was responsible.
A resident with a PICC line and IV antibiotics was observed without EBP in place or PPE available in the room. Review of the clinical record found no documentation that EBP were ordered, and the DON confirmed they should have been ordered at admission.
A resident with arthritis, muscle weakness, abnormal gait, a history of falls, and orders to transfer with one assist and a front-wheeled walker was care planned as a fall risk with instructions for staff to keep the call bell within reach and encourage its use. The resident was later found on the floor after attempting to self-transfer from a wheelchair to a recliner because she could no longer tolerate sitting in the wheelchair. Observation and interviews showed the resident had been left in a wheelchair at the foot of the bed with the call bell placed on the middle of the bed, out of reach; the resident reported being unable to reach the call bell to request help, and staff, including the DON, confirmed the call bell should have been accessible.
Incomplete Diabetes Care Plan: A resident had physician orders for Humalog insulin on a sliding scale three times daily, but the clinical record did not show a care plan with specific, individualized interventions for diabetes. The DON confirmed the care plan lacked diabetes-specific interventions.
Care plans were not reviewed and revised for two residents when their needs changed. One resident’s care plan still reflected antibiotic treatment for a UTI even after the medication had ended, and the DON confirmed it was not updated. Another resident had severe cognitive impairment and dementia, with family preferences documented for meals, socks, dentures, and diet, but the care plan was not updated to reflect those preferences; the resident was also noted to be agitated and verbally abusive during morning care and medication attempts.
Failure to change an indwelling urinary catheter as ordered for a resident with neurogenic bladder and a UTI. The resident was cognitively intact and dependent on staff for daily care needs, and the care plan and MD order directed monthly catheter changes. The TAR showed the catheter was not changed as ordered, and the DON confirmed there was no documented evidence of the change.
The facility failed to notify the physician of PT/INR lab results for a resident receiving Coumadin for a prosthetic heart valve. The resident was cognitively impaired, had heart failure, and was identified as being at risk for bleeding due to anticoagulant therapy; however, the record showed no documentation that the physician was informed of the lab results, and the DON confirmed the omission.
A resident with moderate cognitive impairment, heart failure, and an order for supplemental O2 at 3 L/min via nasal cannula was observed twice receiving inappropriate respiratory care. On one occasion, the resident’s nasal cannula was connected to an empty portable O2 tank, and on another, the portable tank was set to 2 L/min instead of the ordered 3 L/min. Facility staff, including an LPN and the DON, confirmed both the empty tank and the incorrect flow rate, as well as the requirement to follow the physician’s O2 order.
The facility failed to follow its own transmission-based precautions policy and current CDC/CMS guidance for a resident on contact isolation for an MDRO. The resident, who was cognitively intact, required assistance with daily care and had a diagnosis including UTI, had a physician order for contact isolation. During observation, a nurse aide assisted the resident into the bathroom without wearing a required isolation gown, despite policy requiring gown and glove use for contact precautions. The nurse aide, an LPN, and the DON all confirmed that the resident was on contact isolation and that a gown should have been worn during this care.
A resident with cognitive impairment, sepsis, and a colostomy did not receive documented colostomy care or appliance changes over extended periods, and there were no physician orders for changing or emptying the colostomy appliance. Review of the clinical record showed no entries reflecting ostomy care from admission until transfer to the hospital and again after readmission, and the DON confirmed the absence of both ostomy orders and documentation of colostomy care.
A resident with cognitive impairment, sepsis, and an ostomy had a PICC line for which facility policy required dressing changes every 5–7 days and as needed for slippage or soilage. Physician orders also directed PICC dressing changes as needed. Review of the treatment record showed the PICC dressing was changed, then not changed again for 10 days, exceeding the facility’s required interval. The DON confirmed that, under facility policy, the dressing should have been changed within the specified timeframe but was not documented as done.
A resident with a malignant rectal neoplasm, who was cognitively intact and required assistance with daily care, had physician orders for an RN to disconnect a chemotherapy pump, flush a Medi port, and de-access the port on a recurring schedule. Review of the clinical record showed no documentation that an RN completed these ordered interventions on two scheduled occasions, and the DON confirmed the absence of documentation, demonstrating a failure to maintain complete and accurate medical records.
A resident with diabetes was admitted and did not receive prescribed insulin doses because physician orders were not promptly entered into the EHR. The resident was later found with critically high blood glucose and was hospitalized for diabetic ketoacidosis and related complications. Staff interviews and record reviews confirmed the delay in order entry led to the missed medications.
A resident with diabetes and diabetic ulcers did not receive prescribed insulin or medications after admission because physician's orders were not promptly entered into the electronic health record. This delay led to severe hyperglycemia and subsequent hospitalization for diabetic ketoacidosis and related complications.
Surveyors observed that two residents' shared bathroom was not maintained in a clean condition, with visible brown/yellow substances on the toilet seat, safety rail, and inside the toilet bowl. The Director of Housekeeping Services confirmed the need for cleaning and explained that staff should report when extra cleaning is required.
A resident with severe cognitive impairment and a diagnosed skin tear did not receive wound care as ordered by the physician. Nursing staff failed to complete daily dressing changes on multiple occasions, as confirmed by the DON and documented in the treatment records.
The facility did not ensure that care-planned safety interventions were in place for a resident at risk for falls, as a required fall mat was not positioned correctly at the bedside. Additionally, another resident with severe cognitive impairment and aggressive behaviors repeatedly engaged in physical altercations and wandered into other residents' rooms, with no new interventions documented to address these behaviors. Staff interviews confirmed these lapses in supervision and intervention.
Two residents with dementia exhibited ongoing agitation, wandering, and disruptive behaviors, but the facility did not document any new non-pharmacological interventions to address these issues, relying instead on medication adjustments and, in one case, a hospital admission. The DON confirmed that no new strategies were attempted beyond medication changes.
A resident with an order for as-needed Tramadol had multiple doses of the controlled medication signed out, but there was no documentation in the MAR or clinical record to confirm administration on those occasions. The DON confirmed the lack of documentation, resulting in a deficiency for failing to maintain accountability for controlled substances.
Three residents did not have individualized care plans that addressed their specific needs, including nutritional requirements for a diabetic on a therapeutic diet, incontinence management for a frequently incontinent resident, and dietary restrictions for a resident with a hiatal hernia. These omissions were confirmed by staff interviews and clinical record reviews.
Two residents did not receive care in accordance with professional standards: one received an incorrect dose of antipsychotic medication due to failure to discontinue a previous order, and another had a urinary catheter and PICC line remain in place without timely physician review despite family concerns, as staff did not promptly address the need for continued use of these devices.
A resident with hypertension did not consistently receive metoprolol tartrate as ordered, as staff failed to hold the medication when blood pressure or heart rate was below specified thresholds and sometimes did not document obtaining vital signs prior to administration. The DON confirmed these lapses after review of clinical records and medication administration documentation.
Three residents with indwelling urinary catheters were found with catheter tubing or drainage bags in contact with the floor, contrary to facility policy and confirmed by staff interviews. Additionally, a resident with orders for urinary output monitoring had multiple missed documentation entries, as verified by the DON.
A resident with a PICC and midline catheter did not receive required flushes with normal saline every shift as ordered by the physician and per facility policy. Review of MARs showed multiple missed or undocumented flushes across several shifts, which was confirmed by the DON.
The facility did not complete required annual performance evaluations for two nurse aides, as there was no documentation to show that evaluations due for each had been conducted. The administrator confirmed the absence of these records.
A resident reported receiving cold meals, especially when their room was among the last served. Observation of meal service confirmed that food and drink items on a test tray were below required temperatures, and a group of residents also reported delays and cold food. The Dietary Director acknowledged that the items were not at appetizing temperatures.
The QAPI committee failed to correct recurring deficiencies in areas such as care planning, quality of care, accident hazard prevention, dementia care, and infection control, despite previous plans of correction and ongoing audits.
A deficiency was cited when an LPN did not remove gloves or perform hand hygiene between removing a soiled dressing and applying a new one during wound care for a resident with surgical wounds. The facility's policy required hand sanitizing before and after glove use, but this was not followed, as confirmed by both the LPN and the DON.
The facility did not follow its policy for monthly cleaning of the kitchen stovetop, resulting in a thick accumulation of black grease on and around four burners. The Dietary Manager confirmed that the scheduled cleaning was missed, leading to the equipment not being maintained in a safe and clean condition.
A resident, who was cognitively impaired and required assistance, experienced difficulty breathing and was given oxygen. The facility failed to notify the resident's responsible party about this significant change in care, as required by their policy. The family discovered the oxygen use during a visit and expressed concern over the lack of notification. The DON confirmed the oversight.
The facility failed to develop individualized care plans for three residents. A resident with PTSD lacked specific interventions for his condition, another resident on antipsychotic medication did not have a care plan addressing her delusions and medication use, and a resident using smokeless tobacco had no care plan for its use.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident's care plan lacked a physician-ordered intervention for pain management, while another's did not reflect current needs for adaptive utensils. Additionally, care plans for residents with resolved infections and new pressure ulcers were not updated, as confirmed by staff.
The facility failed to maintain a hazard-free environment and ensure resident safety. A resident at high risk for falls fell after an EKG technician disabled alarms and did not reactivate them. Two residents were transported in wheelchairs without leg rests, contrary to protocol. Additionally, an air mattress was used for a hospice resident without assessing potential safety hazards.
A resident with a cervical collar, following a surgical repair, was observed with a soiled neck brace on multiple occasions. The resident required feeding assistance, and the collar had discoloration and a removable substance. Staff interviews confirmed the collar was not clean, compromising the resident's dignity.
A resident with dementia and significant weight loss was improperly positioned in a Broda chair during meals, preventing her from accessing her food easily. Staff confirmed the chair could not be adjusted to a more upright position, and the table was raised to fit both her chair and another resident's wheelchair. The dietitian suggested a re-evaluation of her positioning.
The facility did not follow physician's orders for a maintenance nursing program for a resident and failed to complete wound treatments as ordered for another resident. The nursing program, involving range of motion exercises, was not documented as completed on multiple occasions. Additionally, wound care for a surgical incision was not documented as completed on specified dates. The DON confirmed these deficiencies.
A resident with Stage 4 pressure ulcers did not receive physician-ordered treatments on multiple occasions, as confirmed by clinical records and the DON. The treatments included wound cleaning, application of dressings, and protective films, which were not documented as administered on specific dates.
A facility failed to provide trauma-informed care for a resident with PTSD by not completing a trauma history questionnaire. The resident, a former Navy Seal with PTSD and dementia, experienced an aggressive episode after waking from a nap. The facility's policy required trauma assessments upon admission but did not address current residents. The Nursing Home Administrator confirmed the oversight, acknowledging that the questionnaire was only conducted for new admissions.
A resident with dementia and Parkinson's disease experienced increased anxiety and confusion due to interactions with another resident. Despite concerns from the resident's niece and the resident's reluctance to move rooms, the facility primarily adjusted medications without implementing new interventions to address the resident's needs.
The QAPI committee at the facility failed to address recurring deficiencies, including accommodating a resident's needs, developing and updating comprehensive care plans, and ensuring a hazard-free environment. Despite previous plans of correction involving audits and committee reviews, the current survey revealed ongoing non-compliance with nursing home regulations.
A facility failed to follow CDC and CMS infection control guidelines for a resident with a catheter and MDRO history. Despite orders for Enhanced Barrier Precautions, a nurse aide did not wear a gown while emptying the resident's catheter bag, contrary to guidelines. The Director of Nursing confirmed the requirement for gown use during this task.
A resident, who required assistance from two staff members for transfers, fell and sustained a fracture after a nurse aide, misinformed by an LPN, attempted to transfer the resident alone. The resident, with cognitive impairment and diagnoses including dementia, was not transferred according to the care plan, resulting in a fall during a bathroom transfer.
A resident, who required assistance from two staff members for transfers, fell and sustained a fracture when a nurse aide, misinformed by an LPN, attempted to assist the resident alone. The aide was unfamiliar with the resident and lacked access to the care plan, leading to the incident.
Failure to address ongoing aggressive behaviors between roommates
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with behavioral and psychosocial needs by not implementing effective interventions to prevent or address ongoing physical and verbal behaviors. Resident 8 had severe cognitive impairment, dementia, and a behavior care plan that included identifying triggers, anticipating needs, monitoring danger to self and others, offering a stuffed animal when agitated, and using activities to assist with behaviors. Despite these interventions, records showed repeated incidents in which Resident 8 blocked access to the bathroom, argued with her roommate, became upset when the roommate was in the room, and later scratched the roommate’s face, left red marks, struck her with a baby doll, kicked her, and made threatening statements. Resident 8 required anti-anxiety medication on multiple occasions and was eventually sent to the hospital and involuntarily committed to a psychiatric unit for aggression and violent behaviors. Resident 68, who was cognitively intact and initially had no behaviors, was repeatedly affected by Resident 8’s actions and expressed fear of her roommate. A psychiatric provider note documented that Resident 68 reported Resident 8 hit her and got into her things, and after Resident 8 returned from the hospital, Resident 68 was shaking and stated she was scared to death with Resident 8 in the room. The record contained no documented evidence that Resident 8’s behaviors were assessed for patterns or precipitating factors, that staff monitored the behaviors, or that the behavior care plan was revised or new interventions were developed. The residents remained in the same room on the day Resident 8 returned, and they were not separated until the following day.
Failure to Attempt Non-Pharmacological Interventions Before PRN Lorazepam
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering a psychotropic medication for one resident. Resident 75 was cognitively intact, had a diagnosis of anxiety, and was receiving an anti-anxiety medication. The resident’s care plan directed staff to attempt non-pharmacological interventions such as diversional activities, rest, and snacks before giving PRN psychotropics. Physician orders for lorazepam 1 mg PRN for anxiety were in place, and the MAR showed the resident received lorazepam repeatedly in February and March 2026. There was no documented evidence that non-pharmacological interventions were attempted before these administrations. The DON confirmed in interview that no non-pharmacological interventions had been attempted before the listed doses and that they should have been.
Failure to Follow Medication Orders and Report Critical Lab Results
Penalty
Summary
The facility failed to follow physician orders for insulin administration and failed to notify the physician when ordered sliding-scale blood sugar results were at the highest range for two residents. Resident 6 was cognitively impaired, dependent on staff for daily care, received insulin, and had diabetes. The resident had an order for Novolog twice daily with instructions to notify the physician for blood sugar results of 401-999 mg/dL, but the MAR showed multiple 4:30 p.m. blood sugar readings in that range in January, February, and April 2026 with no documented evidence that the physician was notified. Resident 11 had an order for Humalog three times daily with instructions to notify the physician for blood sugar results of 400-600 mg/dL. The MAR showed several readings in that range at 12:00 p.m. and 6:00 p.m. in March and April 2026, but there was no documented evidence that the physician was notified on those dates and times. The DON confirmed that the physician should have been notified when the resident's sliding scale results were 400 mg/dL or greater. The facility also failed to ensure proper handling of a Fentanyl patch for Resident 8 and failed to report abnormal PT/INR results for Resident 123. Resident 8 had an order for a 12 mcg/hour Fentanyl patch to be changed every 72 hours, but after a new patch was applied, the resident was later found to have two patches on and one was removed and destroyed. Resident 123 was cognitively impaired, received anticoagulant therapy, and had a prosthetic heart valve; the resident was ordered Coumadin and PT/INR monitoring, but a PT/INR result of 16.8/1.45 on March 19, 2026 had no documented evidence of physician notification. The DON confirmed the physician was not notified of those PT/INR results.
Failure to Flush PICC Line as Ordered
Penalty
Summary
Failure to provide for the safe, appropriate administration of IV fluids occurred for one resident with a PICC line. Resident 134 was cognitively intact, had a PICC line in the right upper extremity, and received IV antibiotics. Physician orders required the PICC line to be flushed with 10 mL of normal saline before and after medication administration, with a maintenance flush every shift, and to receive 650 mg of Daptomycin IV every 24 hours for infection. The resident’s MAR showed Daptomycin was administered from March 13 through March 28, 2026; however, there was no documented evidence that the PICC line was flushed every shift as ordered on multiple dates in March and April 2026. The DON confirmed on April 30, 2026, that there was no documented evidence the PICC line was flushed every shift as ordered.
Significant medication errors with missed antibiotic doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents. Resident 19 had an admission MDS dated April 20, 2026 showing moderate cognitive impairment, extensive assistance needs, a multi-drug resistant organism, and pressure ulcers. Physician orders dated April 21, 2026 included Cefadroxil 500 mg every 12 hours for an infection until May 1, 2026, but the MAR showed no documented evidence that doses were administered on April 22 at 8:00 a.m., April 23 at 8:00 p.m., April 24 at 8:00 a.m. and 8:00 p.m., and April 28 at 8:00 p.m. Nursing notes documented that Cefadroxil was not available from the pharmacy on April 22 and April 24. Resident 145 had physician orders dated April 24, 2026 for Ampicillin 2 grams IV every four hours for an infected joint prosthesis for six weeks. The MAR showed no documented evidence that doses were administered on April 24 at 9:00 p.m., April 26 at 5:00 a.m., April 27 at 9:00 p.m., April 28 at 5:00 a.m., 5:00 p.m., and 9:00 p.m., and April 29 at 1:00 a.m. and 5:00 a.m. The DON confirmed there was no documented evidence that Resident 145 received the ordered doses on those dates and times.
Food Served Cold and Not Palatable
Penalty
Summary
The facility failed to serve food that was palatable and at proper temperatures. The facility policy for meal service, dated February 27, 2026, stated that food temperatures at the point of service would be monitored according to palatability and maintained according to Food Safety Guidelines, which required hot foods to be served at 135 degrees Fahrenheit or higher. During interviews, Resident 2 said the food was terrible tasting, cold, and not liked at all. Resident 70 said the food was usually cold and that he did not ask staff to reheat it because they did not have time. Resident 84 said the food was not always warm. On April 29, 2026, the lunch menu included meatloaf with ketchup glaze, Au gratin potatoes, creamed peas, and chocolate eclairs, with tomato soup available and served to taste. Observation of meal service showed a test tray placed on the lunch cart for the second floor and left parked against the wall until the second cart was loaded. The cart arrived on the unit at 12:02 p.m., staff passed trays while leaving the cart doors open the entire time, and the last resident was served and eating at 12:26 p.m. At 12:27 p.m., the meatloaf measured 126 degrees Fahrenheit and the tomato soup measured 123 degrees Fahrenheit; both were described as lukewarm and not hot to taste, and the tomato soup tasted sour. The Dietary Manager confirmed the food was to be palatable and was not served at the proper temperature of at least 135 degrees Fahrenheit.
Unsanitary Conditions in Kitchen Food Prep Area
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions in the kitchen's food prep/tray line area. During observation, three ceiling vents were found with an accumulation of dust and rust-colored buildup, and one ceiling tile was covered with rust-colored buildup. A review of the dietary preventative maintenance schedule for 2026 showed no documented evidence that the vents or ceiling tile had been cleaned or inspected until the date of the observation. The Dietary Manager confirmed that the vents needed cleaned and stated that maintenance was responsible for cleaning them.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC to reduce the spread of infections and prevent cross-contamination for one resident. CDC guidance on isolation precautions and the use of Enhanced Barrier Precautions (EBP) in nursing homes states that EBP includes targeted gown and glove use during high-contact resident care activities, and CMS guidance effective April 1, 2024, includes EBP for residents with chronic wounds or indwelling medical devices regardless of MDRO status. The facility policy dated February 27, 2026, stated that EBP were indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization or infection status. Physician orders for the resident included a PICC line and IV ampicillin every four hours. When the resident was observed in bed with a PICC line to the right upper arm, there was no evidence that EBP were in place or that PPE was present in the room. Review of the clinical record, including physician orders, nurse's notes, and the current care plan, found no documented evidence that EBP were ordered. The DON confirmed that EBP were not ordered at the time of admission and should have been.
Failure to Keep Call Bell Within Reach for High-Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in accident prevention and supervision for a resident with a history of falls and mobility impairments. The resident’s admission MDS showed she was cognitively intact, used a front-wheeled walker, required extensive staff assistance, and had diagnoses including arthritis, muscle weakness, and abnormal gait and mobility. Physician orders directed that she transfer with one staff assist and a front-wheeled walker. Her care plan documented that she was at risk for falls and that staff were to keep her call bell within reach and encourage her to use it to request assistance as needed. A fall investigation documented that the resident was found on the floor in her room after attempting to self-transfer from her wheelchair to her recliner because she could no longer sit in the wheelchair. Later observation showed the resident seated in her wheelchair at the bottom of her bed with leg rests on, while her call bell was lying in the middle of the bed, out of her reach. During interview, the resident stated she had been waiting for someone to put her in her recliner and could not reach her call bell to ring for help. A nurse aide confirmed that the call bell was out of the resident’s reach, and the DON confirmed that the call bell should have been within reach, demonstrating that staff failed to implement the care plan intervention to keep the call bell accessible.
Incomplete Diabetes Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with specific and individualized interventions for Resident 11’s diabetes. Physician orders for the resident included Humalog insulin subcutaneously on a sliding scale three times daily at 6:00 a.m., 12:00 p.m., and 6:00 p.m., with doses based on blood glucose levels ranging from 70 mg/dL to 600 mg/dL and instructions to notify the physician for further orders when blood sugar was 400-600 mg/dL. Review of the clinical record found no documented evidence that the resident’s care plan included specific and individualized interventions to address diabetes care needs. The DON confirmed in interview that Resident 11’s care plan did not include any specific and individualized interventions for diabetes.
Care plans not updated for changing treatment and resident preferences
Penalty
Summary
The facility failed to review and revise care plans for two residents when their care needs and preferences changed. For one resident, a significant change MDS assessment showed cognitive impairment and need for assistance with care needs, and physician orders included Macrobid for a UTI with the last dose on March 31, 2026. Although the care plan dated March 30, 2026 indicated the resident was taking an antibiotic for UTI, there was no documented evidence by April 30, 2026 that the care plan was revised to show the antibiotic had been discontinued. The DON confirmed the care plan was not updated to reflect that the resident was no longer taking an antibiotic. For another resident, an admission MDS assessment showed severe cognitive impairment, behaviors during the look-back period, dependence on staff for daily care needs, and a diagnosis of dementia. A nursing note documented family wishes that the resident be seated at a table for meals, not use a tray table, not wear yellow socks, not wear dentures until seen by a dentist, and remain on a soft diet until further notice. Another nursing note later documented the resident was difficult to wake, agitated, verbally abusive, and threatening toward staff during attempts at morning care and medication administration. There was no documented evidence that the care plan was updated to reflect the family’s preferences, and the DON confirmed the care plan should have been updated.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
The facility failed to change an indwelling urinary catheter as ordered by the physician for one resident. The resident’s admission MDS showed she was cognitively intact, dependent on staff for daily care needs, had an indwelling urinary catheter, and had diagnoses including neurogenic bladder and a UTI. Physician orders dated February 12, 2026 directed that the catheter be changed every month, and the care plan also stated that the catheter was to be changed as ordered. However, the TAR for March 2026 showed the catheter was not changed on March 12, 2026 as ordered. The DON confirmed on April 30, 2026 that there was no documented evidence the resident’s urinary catheter was changed during March 2026.
Failure to Notify Physician of PT/INR Results
Penalty
Summary
The facility failed to notify the physician of laboratory test results for one resident who was cognitively impaired, had heart failure, and was receiving anticoagulant therapy. The resident’s care plan identified a risk for bleeding due to anticoagulant use and directed that ordered labs be scheduled, reviewed, and reported to the physician. Physician orders included Coumadin 7.0 mg at bedtime for a prosthetic heart valve and a PT/INR blood draw to monitor therapeutic levels. A laboratory report dated March 19, 2026, showed PT/INR results for the resident, but the clinical record contained no documented evidence that the physician was notified of those results. Nursing notes and the lab report were reviewed, and the DON confirmed in interview that the physician was not notified of the PT/INR results obtained on March 19, 2026.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and facility policy for one resident. Facility policy dated February 27, 2026, required that residents needing oxygen have a physician’s order specifying the oxygen flow rate. An annual MDS assessment for Resident 5 dated January 22, 2026, documented moderate cognitive impairment, a need for staff assistance with daily care, diagnoses including heart failure, and receipt of supplemental oxygen. Physician’s orders dated February 13, 2024, directed that the resident receive oxygen at 3 L/min via nasal cannula. On March 3, 2026, at 11:25 a.m., the resident was observed sitting in a wheelchair in her room with a nasal cannula connected to a portable oxygen tank that was empty; an LPN confirmed the tank was empty and replaced it with a full one. Later that day at 12:04 p.m., the resident was observed in the dining room with a nasal cannula attached to a portable oxygen tank set at 2 L/min, despite the physician’s order for 3 L/min. Another LPN confirmed the flow rate discrepancy between the tank setting and the physician’s order. The DON confirmed that oxygen should have been administered according to the physician’s orders.
Failure to Follow Contact Isolation and PPE Requirements for MDRO-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow established infection prevention and control guidelines, specifically contact isolation requirements, for a resident with a multidrug-resistant organism (MDRO). CDC guidance dated July 12, 2022, and CMS infection prevention and control guidance effective April 1, 2024, call for the use of Enhanced Barrier Precautions and appropriate PPE, including gowns and gloves, during high-contact care activities for residents with MDROs or certain risk factors. The facility’s own transmission-based precautions policy dated February 27, 2026, requires staff to wear gloves and a disposable gown upon entering the room of a resident on contact precautions and to remove them before leaving the room. Resident 7’s admission MDS dated February 24, 2026, showed the resident was cognitively intact, required assistance with daily care needs, and had a medical diagnosis including a urinary tract infection. A physician order dated February 21, 2026, directed that the resident be on contact isolation for an MDRO diagnosis. On observation, a nurse aide was seen assisting this resident into the bathroom without wearing an isolation gown, contrary to the facility’s contact isolation policy. The nurse aide acknowledged she should have been wearing a gown, and an LPN confirmed the resident had orders for contact isolation for MDRO. The DON also confirmed that the nurse aide should have had a gown on when providing care to this resident.
Failure to Provide and Document Colostomy Care and Orders
Penalty
Summary
The facility failed to provide ordered and documented colostomy care for a resident who was cognitively impaired, required staff assistance for daily care, had a diagnosis of sepsis, and was admitted with a colostomy. The facility’s colostomy care policy required care per physician orders to provide good skin care and monitor the stoma and surrounding skin, but review of the clinical record showed that from the date of admission with a colostomy until the resident was sent to the hospital, there was no documentation that the ostomy appliance had been changed or that colostomy care was provided. After the resident was readmitted, there was again no documentation of ostomy appliance changes or colostomy care for an extended period. In addition, there were no physician orders in the record for changing or emptying the colostomy appliance, and the DON confirmed that there were no ostomy orders and no documented evidence that colostomy care was being provided. This lack of physician orders and absence of documented colostomy care for the resident’s ostomy appliance constituted the deficiency identified by surveyors under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Follow PICC Line Dressing Change Policy
Penalty
Summary
Surveyors found that the facility failed to follow its policy for the care and maintenance of a peripherally inserted central catheter (PICC) for one resident. The facility’s policy dated January 31, 2025, required that PICC and midline dressings remain clean, dry, and intact, and be changed every 5–7 days and as needed when wet, soiled, or not intact. The resident involved had an admission MDS showing cognitive impairment, a need for staff assistance with daily care, and diagnoses including sepsis and an ostomy. Physician orders dated November 25, 2025, directed that the resident’s PICC line dressing be changed as needed for slippage or soilage. Review of the resident’s December 2025 treatment record showed that the PICC dressing was changed on December 14, 2025, with no further documented dressing change until December 24, 2025, resulting in a 10‑day interval between changes. Based on the facility’s policy, the PICC dressing should have been changed by December 21, 2025, but there was no documentation that this occurred. In an interview on February 5, 2026, the Director of Nursing confirmed that the dressing should have been changed on December 21, 2025, in accordance with the policy.
Failure to Document Chemotherapy Pump and Medi Port Care per Physician Orders
Penalty
Summary
Surveyors identified that the facility failed to maintain complete and accurate clinical records for one resident. A quarterly MDS assessment dated November 27, 2025 documented that Resident 1 was cognitively intact, required assistance with daily care needs, and had a diagnosis of malignant neoplasm of the rectum. Physician orders dated December 11, 2025 directed that an RN disconnect the resident’s chemotherapy pump, flush the Medi port, and de-access the port every other Friday. Review of the resident’s clinical record showed no documentation that an RN performed these ordered tasks on December 12, 2025 or January 16, 2026. In an interview on February 5, 2026, the Director of Nursing confirmed there was no documented evidence that the RN completed the chemotherapy pump discontinuation, Medi port flush, and de-access as ordered, constituting a failure to ensure complete and accurate clinical records in accordance with professional standards.
Failure to Timely Enter Physician Orders Results in Missed Insulin and Hospitalization
Penalty
Summary
A deficiency occurred when a new resident with a history of diabetes and diabetic ulcers was admitted to the facility. Although the resident's physician's orders for multiple insulin regimens were reviewed with the provider on the evening of admission, these orders were not entered into the electronic health record in a timely manner. As a result, the resident did not have any medication orders available in the system for the day of admission, and missed both supper and bedtime insulin doses. The delay in entering the orders was confirmed by the Director of Nursing, who stated that the responsible RN did not input the orders until around midnight, causing the orders to be set to start the following day. The resident was found the next morning still on hospital linens, with a soiled brief and an elevated respiratory rate. Blood glucose readings were critically high, with initial values of 503 and subsequent readings remaining above 480 despite insulin administration. The resident reported feeling unwell and was subsequently sent to the hospital, where she was admitted to the ICU with diabetic ketoacidosis, altered mental status, acute kidney injury, encephalopathy, and dehydration. Review of clinical records and staff interviews confirmed that the failure to timely enter and implement physician's orders directly resulted in the resident missing essential insulin doses and requiring hospitalization.
Failure to Administer Insulin Due to Delayed Order Entry
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician's orders and professional standards of practice for a resident with diabetes and diabetic ulcers. Upon admission, the resident had specific physician's orders for multiple types and doses of insulin to be administered at various times throughout the day. However, due to a delay in entering these orders into the electronic health record system, the resident did not receive her prescribed insulin or other medications on the evening of admission. The orders were not entered until around midnight, causing the start date for medication administration to be set for the following day. As a result of not receiving her insulin, the resident was found the next morning with a significantly elevated blood sugar level of 503, which continued to rise despite subsequent insulin administration. The resident exhibited rapid breathing and reported feeling unwell, leading to her transfer to the hospital. She was admitted with diabetic ketoacidosis, altered mental status, acute kidney injury, encephalopathy, and dehydration. Staff interviews confirmed that the delay in order entry and medication administration directly contributed to the resident not receiving her required care.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment in the rooms of two residents, as required by its own policy. During multiple observations of a shared bathroom used by these residents, surveyors noted the presence of a brown/yellow removable substance on the toilet seat and metal safety rail, as well as a brown removable substance around the inside of the toilet bowl. The Director of Housekeeping Services confirmed that the bathroom required cleaning and stated that rooms are cleaned daily, with COVID-positive rooms cleaned last. She also indicated that staff are expected to notify her if additional cleaning is needed.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care for one resident. According to facility policy, licensed nurses are required to complete physician orders as written, including timing and frequency. A resident with severe cognitive impairment and a diagnosis of dementia was found to have a large skin tear on the right forearm, which was assessed by a registered nurse. The physician ordered daily wound care, including cleansing, application of xeroform, and covering with a foam dressing. Review of the Treatment Administration Record showed that the dressing changes were not completed as ordered on multiple dates. The Director of Nursing confirmed that the dressing changes were missed on the specified dates.
Failure to Implement and Maintain Safety Interventions for Residents at Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, as evidenced by the lack of implementation of care-planned interventions and insufficient supervision. One resident, who was cognitively impaired and at high risk for falls due to Alzheimer's dementia and dependence on staff for mobility and transfers, had physician orders and a care plan specifying that fall mats should be placed on both sides of the bed. During an observation, it was found that the fall mat was not positioned on the right side of the bed as required, and staff confirmed this omission, attributing it to the difficulty of moving the bedside table. Another resident, also severely cognitively impaired and diagnosed with dementia, exhibited frequent wandering and aggressive behaviors, including physical altercations with other residents, entering other residents' rooms, and rummaging through their belongings. Nursing notes documented multiple incidents where this resident physically interacted with others, such as grabbing, pushing, and hitting, as well as attempts to take mobility devices and urinate in inappropriate places. Despite these ongoing behaviors and repeated altercations, there was no documented evidence that new interventions were implemented to address the resident's wandering or aggressive actions, aside from medication adjustments and a hospital admission for behavioral issues. Interviews with facility staff, including the DON, confirmed that required safety interventions were not consistently in place for the resident at risk for falls, and that no new strategies were documented or attempted to manage the aggressive resident's behaviors and prevent further resident-to-resident altercations. The facility's policies on fall prevention and dementia care outlined the need for individualized interventions and regular updates to care plans, but these were not fully executed for the residents involved.
Failure to Implement Non-Pharmacological Interventions for Residents with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, as required by their own policy and regulatory standards. Both residents exhibited ongoing behavioral symptoms such as agitation, wandering, entering other residents' rooms, and interfering with others' belongings. Despite these persistent behaviors, there was no documented evidence that new or alternative non-pharmacological interventions were attempted to address these issues, aside from adjustments to their medications. One resident, with diagnoses including Alzheimer's disease and adjustment disorder, was noted to be severely cognitively impaired and displayed behaviors such as verbal outbursts, wandering, rummaging, and inappropriate use of other residents' belongings. Nursing notes over several months documented repeated incidents of agitation, anxiety, and disruptive behaviors, including entering other residents' rooms and taking their clothing. The care plan referenced some general activity offerings and support, but there was no documentation of new or individualized interventions being implemented in response to the ongoing behaviors. Another resident, also severely cognitively impaired with a diagnosis of dementia, demonstrated daily wandering, physical and verbal behavioral symptoms, and inappropriate interactions with other residents and their property. Despite care plans that suggested offering diversional tasks and activities tailored to the resident's interests, nursing documentation showed that these interventions were either ineffective or not consistently attempted. The only documented responses to the resident's escalating behaviors were medication adjustments and a hospital admission, with no evidence of new non-pharmacological strategies being tried. Interviews with the Director of Nursing confirmed the lack of documented new interventions for both residents.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. A review of the clinical records and controlled drug record for a cognitively intact resident receiving opioid medication revealed that several doses of Tramadol were signed out on specific dates and times. However, there was no documented evidence in the resident's clinical record, including the Medication Administration Record (MAR), to confirm that these doses were actually administered. This lack of documentation was confirmed by the Director of Nursing during an interview, indicating a failure to ensure accurate recordkeeping for controlled substances as required by regulations. The resident involved required assistance for care needs and had a physician's order for Tramadol to be given as needed for moderate to severe pain. Despite the medication being signed out, the absence of corresponding administration records led to the identified deficiency.
Failure to Develop Individualized Care Plans Addressing Resident Needs
Penalty
Summary
The facility failed to develop individualized care plans that addressed all identified needs for three residents. For one resident with diabetes on a mechanically altered, therapeutic diet, the care plan did not include any information or interventions related to nutritional needs, despite the resident expressing dissatisfaction with food choices and not being offered a night snack. The dietician confirmed that the care plan lacked necessary details regarding the resident's nutritional status. Another resident, who was alert and oriented and frequently incontinent of urine and bowel, did not have any interventions or information related to incontinence included in the care plan, as confirmed by the nursing home administrator. Additionally, a third resident with a hiatal hernia had specific dietary restrictions and requests documented in nursing notes, but the care plan did not reflect these needs. The director of nursing confirmed the omission of information regarding the hiatal hernia in the care plan.
Failure to Follow Professional Standards in Medication Administration and Device Management
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For one resident with dementia who was cognitively intact and required assistance, there was a medication error involving Abilify, an antipsychotic. After a physician ordered a dose reduction from 5 mg to 2.5 mg at bedtime, the resident received both the old and new doses on the same night, totaling 7.5 mg. This occurred because the previous order was not discontinued when the new order was implemented, resulting in an extra dose being administered. The Director of Nursing confirmed the error during an interview. For another resident admitted with a hip fracture, indwelling urinary catheter, and a PICC line, the facility did not promptly address concerns regarding the continued need for these devices. The resident's family repeatedly expressed concerns to staff about the risk of infection and questioned the necessity of keeping the catheter and PICC line in place, especially since the PICC line was not being used. Staff did not contact the physician in a timely manner to clarify the ongoing need for these devices, despite the family's ongoing distress and requests for action. The Director of Nursing confirmed that staff should have acted more promptly to address these concerns.
Failure to Administer Medication According to Physician Orders
Penalty
Summary
A deficiency was identified when a resident with hypertension did not receive medication administration in accordance with physician orders. The resident was prescribed metoprolol tartrate with specific instructions to hold the medication if the systolic blood pressure was 110 mmHg or less, or if the heart rate was below 60 beats per minute. On several occasions, documentation showed that the resident's systolic blood pressure was below the specified threshold, yet the medication was not held as ordered. Additionally, there were instances where there was no documented evidence that the resident's blood pressure or heart rate was obtained prior to administering the medication. The clinical record review and staff interviews confirmed these lapses in following physician orders. The Director of Nursing acknowledged that the medication was not held as required and that vital signs were not always obtained before administration. These findings were based on a review of the resident's Medication Administration Record and clinical documentation over a three-month period.
Failure to Maintain Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, as evidenced by multiple instances where catheter drainage bags and tubing were observed in direct contact with the floor. For three residents with indwelling catheters, observations revealed that either the catheter tubing or drainage bag was lying on the floor while the resident was in a wheelchair or bed. Staff interviews confirmed that catheter equipment should not be in contact with the floor, and the facility's policy required drainage bags to be positioned below the bladder and off the floor. In one case, a nurse aide acknowledged that the drainage bag often slid off the wheelchair, resulting in contact with the floor. Additionally, the facility failed to consistently document urinary output for a resident with a physician's order and care plan directive to measure and record output every shift. Review of clinical records showed multiple dates and shifts where no documentation of urinary output was present, contrary to facility policy and physician orders. The DON confirmed the lack of documentation for the specified dates and shifts.
Failure to Flush IV Catheters as Ordered
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids by not flushing a resident's peripherally-inserted central catheter (PICC) and midline catheter as ordered by the physician and as required by facility policy. The policy, dated January 31, 2025, specified that central venous and midline catheters should be flushed at regular intervals to maintain patency. For a resident with a diagnosis of anemia who was cognitively intact and required assistance with care, physician orders directed staff to flush the midline and PICC with 10 ml of normal saline every shift for maintenance purposes. Review of the resident's Medication Administration Records (MARs) for February, March, April, and May 2025 revealed multiple instances where there was no documented evidence that the required flushes were performed during specific shifts. These omissions were confirmed by the Director of Nursing, who acknowledged the lack of documentation for the required catheter flushes on the identified dates and shifts. The failure to follow physician orders and facility policy resulted in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two of three nurse aides reviewed. Documentation showed that annual evaluations were due for one nurse aide in November 2024 and for another in January 2025, but there was no evidence that these evaluations were conducted as required. During an interview, the Nursing Home Administrator confirmed that she could not provide documentation to show that the annual performance evaluations had been completed for these nurse aides.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing and safe temperatures, as required by its own policy and state regulations. The policy specified that hot foods must be held and served at a minimum of 135 degrees Fahrenheit, and cold foods at 41 degrees Fahrenheit or below, with temperatures to be recorded prior to each meal service. During lunch meal service observation, a test tray delivered to a resident's room at the end of the hallway was found to have food and drink items below the required temperatures: the soda was 51.5°F, the chicken was 131.5°F, the carrots were 125.4°F, and the potatoes were 133.8°F. These items were confirmed by the Dietary Director to be not at appetizing temperatures. A resident interviewed reported that meals were often cold upon arrival, particularly as their room was one of the last to receive trays. Additionally, a resident council meeting with approximately ten residents revealed similar complaints, with residents stating that food took too long to arrive and was often cold. These findings were corroborated by direct observation and staff interviews, demonstrating a pattern of delayed meal delivery resulting in food not being served at appropriate temperatures.
QAPI Committee Failed to Correct Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effectively implemented. Despite developing plans of correction following a previous survey, the facility continued to have repeated deficiencies in several key areas, including the development and implementation of comprehensive care plans, provision of quality care, maintenance of a safe environment free of accident hazards, appropriate treatment and services for residents with dementia, and compliance with infection control regulations. The QAPI committee was responsible for reviewing audit results and ensuring ongoing compliance, but failed to do so, resulting in the recurrence of these deficiencies. The deficiencies were identified during the current survey and were also present in the previous survey, indicating a lack of effective follow-through by the QAPI committee. The report specifically cites failures under F656 (comprehensive care plans), F684 (quality of care), F689 (safe environment), F744 (dementia care), and F880 (infection control), demonstrating that the facility did not maintain compliance with state and federal regulations in these areas.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow the facility's infection prevention and control policy during wound care for a resident with impaired skin integrity and multiple surgical wounds. The facility's policy required hand hygiene to be performed before and after glove use. During an observed wound care procedure, the LPN donned a gown and gloves, removed the resident's soiled right heel dressing with scissors, and proceeded to cleanse the wound and apply new dressings without removing her gloves or performing hand hygiene between the removal of the old dressing and the application of the new one. The resident involved had a care plan for impaired skin integrity and physician's orders for daily wound care, including cleansing and dressing changes. The LPN confirmed during an interview that she did not change gloves or sanitize her hands after removing the soiled dressing and before performing clean wound care. The Director of Nursing also confirmed that the correct procedure would have been to remove gloves, sanitize hands, and don new gloves before continuing with the wound care.
Failure to Maintain Safe and Clean Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, as required by its own policies and state regulations. Review of the facility's policy indicated that routine stovetop cleaning was to be performed on a monthly basis to ensure optimal functioning and cleanliness. However, observations on multiple occasions revealed a thick accumulation of black grease on and around four out of six stovetop burners, specifically those located next to the grill area. Documentation showed that the last cleaning occurred on April 1, 2025, and the next scheduled cleaning for May 1, 2025, was not completed. The Dietary Manager confirmed the presence of heavy grease buildup and acknowledged that the required cleaning had been missed.
Failure to Notify Responsible Party of Oxygen Use
Penalty
Summary
The facility failed to notify the responsible party of a resident who required oxygen, which was a significant change in the resident's care. The facility's policy, dated January 25, 2024, mandates timely notification of the resident's responsible party in such cases. The resident, who was cognitively impaired and required assistance for daily care needs, experienced difficulty breathing and was coughing harshly on August 11, 2024. Oxygen was applied for the resident's comfort. However, there was no documented evidence that the responsible party was informed about this change. The family discovered the use of oxygen during a visit on August 12, 2024, and expressed concern over not being notified. The Director of Nursing confirmed that the responsible party was not informed about the incident.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for three residents. Resident 50, who has dementia and PTSD, did not have a care plan addressing his PTSD despite experiencing episodes of aggression and anxiety. The care plan lacked interventions tailored to his history as a Navy Seal, which included dismantling alarms that triggered his PTSD. Resident 62, diagnosed with dementia and receiving antipsychotic medication for delusions and tearfulness, also lacked a care plan with specific interventions for these issues. The care plan did not address the use of antipsychotic medication in conjunction with her dementia diagnosis, leaving her care needs unmet. Resident 101, who is cognitively intact and uses smokeless tobacco, did not have a care plan addressing the use of smokeless tobacco. Despite the facility's policy on providing a safe environment related to smokeless tobacco, there was no documentation of individualized interventions for this resident's tobacco use.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to review and revise care plans for five residents, leading to deficiencies in their care. Resident 2's care plan was not updated to include a physician-ordered intervention for a heat pack to address right hip pain, despite the resident having significant pain and pressure ulcers. This oversight was confirmed by the Nursing Home Administrator. Resident 10's care plan was outdated and did not reflect the resident's current needs for adaptive eating utensils, as observed during meal times. The resident was missing a scoop plate and built-up fork and spoon, which were part of the care plan but not used, and this discrepancy was confirmed by both an LPN and the Dietitian. Resident 22's care plan was not revised to reflect the discontinuation of transmission-based precautions for COVID-19, nor did it accurately reflect the resident's medication orders, as the resident was not on an anticoagulant. Similarly, Resident 48's care plan was not updated to indicate the resolution of an MRSA infection and the change in antibiotic use for infection prevention. Lastly, Resident 105's care plan did not reflect the treatment for newly acquired pressure ulcers, as confirmed by the Director of Nursing.
Failure to Ensure Resident Safety and Hazard-Free Environment
Penalty
Summary
The facility failed to provide an environment free of accident hazards for residents at risk for falls. Resident 50, who had dementia and Parkinson's disease, was identified as high risk for falls. The care plan required a large change in position alerting device and an alarming fall mat to be used. However, during an EKG procedure, the technician disabled the alarms and did not reactivate them, leading to the resident falling and sustaining abrasions and bruising. Additionally, the facility did not ensure resident safety during transportation in wheelchairs. Two residents, Resident 60 and Resident 80, were transported without leg rests, which is against the facility's protocol. Both the nurse aide and registered nurse involved were aware of the requirement to use leg rests but failed to comply. Furthermore, the facility did not assess the safety of an air mattress provided to Resident 61, who was on hospice care and had developed a new Stage II pressure ulcer. The air mattress was placed on the resident's bed without documented evidence of an assessment for potential safety hazards, which was confirmed by the Director of Nursing.
Failure to Maintain Clean Medical Equipment
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing clean durable medical equipment. Resident 105, who had undergone a cervical 4/cervical 5 surgical repair with discectomy, was dependent on staff for care needs, including feeding assistance. The resident was required to wear a hard cervical collar at all times as per physician's orders. Observations on multiple occasions revealed that the resident's cervical collar was discolored and had a brown, red, removable substance on the padded areas around the chin, neck, and mouth. Interviews with a nurse aide and the Director of Nursing confirmed that the neck brace was soiled and not clean, which compromised the resident's dignity.
Failure to Properly Position Resident for Meals
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 10, who had nutritional and self-care concerns. The resident's quarterly Minimum Data Set (MDS) assessment indicated that she was usually understood, could usually understand others, had dementia, and experienced significant weight loss without being on a prescribed weight-loss regimen. The care plan and physician's orders specified that the resident should be positioned in a Broda chair for meals, which was not properly executed during observations. During lunch meals, the resident was observed in a slightly reclined Broda chair with leg rests, preventing her from being positioned close to the table. This positioning required her to fully extend her arm to reach her food and use a fork to pull her flow cup closer, indicating difficulty in accessing her meal. Interviews with staff confirmed the improper positioning of the resident during meals. An LPN confirmed that the Broda chair could not be adjusted to a more upright position, and the table was raised to accommodate both the resident's chair and another resident's specialized wheelchair. The dietitian acknowledged the need for the table to be higher to fit the chairs but suggested that therapy could re-evaluate the resident's positioning during meals. These findings highlight the facility's failure to ensure proper positioning for Resident 10, impacting her ability to eat independently and potentially contributing to her nutritional concerns.
Failure to Follow Physician's Orders for Nursing Program and Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for a maintenance nursing program for a resident, identified as Resident 22, and did not complete wound treatments as ordered for another resident, identified as Resident 48. For Resident 22, the quarterly Minimum Data Set (MDS) assessment indicated the need for a maintenance nursing program involving active range of motion for the right lower extremity and passive range of motion for the left lower extremity twice daily. However, documentation revealed that these exercises were not completed on several occasions in May and June 2024, with some entries marked as not applicable (NA). The Director of Nursing confirmed the non-compliance with the prescribed program. For Resident 48, the quarterly MDS assessment showed the resident was cognitively intact and required assistance for care needs, including wound care for a surgical wound. Physician's orders specified daily wound treatment for the resident's right great toe amputation incision. However, there was no documented evidence that the treatments were completed as ordered on specific dates in April and May 2024. The Director of Nursing confirmed the lack of documentation for the required treatments.
Failure to Administer Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered by the physician for a resident with two Stage 4 pressure ulcers. The resident's clinical records and Treatment Administration Records (TAR) revealed multiple instances where prescribed treatments were not administered on specific dates. These treatments included cleaning wounds with Vashe wound cleanser, applying various dressings such as silver calcium alginate and foam dressings, and using no-sting barrier film and skin prep to protect and promote healing of the wounds. The deficiencies were confirmed through a review of the resident's TAR and an interview with the Director of Nursing, who acknowledged the lack of documented evidence that the treatments were provided as ordered. The failure to administer these treatments occurred on several occasions across different months, indicating a pattern of non-compliance with physician orders for wound care management.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that residents were assessed and received trauma-informed care to mitigate triggers for residents with PTSD. Specifically, the facility did not complete a trauma history questionnaire for Resident 50, who had a diagnosis of PTSD and dementia. The facility's policy on Trauma Informed Care required an assessment upon admission to identify trauma and triggers, but it did not address current residents with PTSD. Resident 50, a former Navy Seal with a history of dismantling bombs, experienced an episode of PTSD, which included aggressive behavior, after waking from a nap. The staff attempted to redirect and calm the resident, eventually administering medication to deescalate the situation. The facility's failure to complete a trauma history questionnaire for Resident 50 was confirmed during an interview with the Nursing Home Administrator. The administrator acknowledged that the questionnaire was only conducted for new admissions and not for current residents. This oversight resulted in a lack of documented evidence of specific triggers for Resident 50, which could have been used to prevent re-traumatization. The deficiency was identified under 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services.
Inadequate Dementia Care and Intervention
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia and Parkinson's disease, leading to increased anxiety, confusion, and behavioral issues. The resident, who was sometimes understood and could sometimes understand others, exhibited paranoid behaviors and confusion, believing that other residents and staff were involved in scenarios related to his deceased daughter. Despite these behaviors, the facility's primary response was to adjust the resident's medication, increasing the dose of Sertraline and administering Trazodone as needed for restlessness. The resident's niece, who is also his power of attorney, expressed concerns about the resident's deteriorating condition and requested a room change due to the noise and interactions with another resident across the hall. However, the resident was reluctant to move, citing concerns about the new environment. The facility attempted to address the situation by discussing the possibility of a room change with the resident, but no new interventions were documented to address the resident's increased anxiety and confusion when he refused to move. Interviews with the Director of Nursing confirmed that the resident's behaviors had increased due to interactions with another resident, and the only interventions attempted were medication adjustments. There was no evidence of other strategies being implemented to manage the resident's anxiety and confusion, such as environmental modifications or alternative therapeutic approaches. This lack of comprehensive intervention contributed to the deficiency in providing appropriate care for the resident's dementia-related needs.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included a failure to accommodate a resident's needs, develop comprehensive care plans, update residents' care plans, and ensure that the residents' environment remained free from accident hazards. The facility had previously developed plans of correction for these issues, which included conducting audits and presenting the results to the QAPI committee for further monitoring. However, the current survey revealed that these plans were ineffective in addressing the recurring deficiencies. Specifically, the facility's plan of correction for accommodating a resident's needs, cited in a previous survey, was not successfully implemented, as indicated by the current survey findings under F558. Similarly, the plans of correction for developing and updating comprehensive care plans, cited under F656 and F657, respectively, were not effectively executed, leading to ongoing non-compliance. Additionally, the facility's efforts to ensure a hazard-free environment for residents, as cited under F689, were inadequate, resulting in repeated deficiencies. These findings highlight the QAPI committee's ineffectiveness in correcting deficient practices and ensuring compliance with nursing home regulations.
Failure to Follow Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the CDC and CMS, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a catheter and a history of multidrug-resistant organisms (MDRO). The resident, who was clearly understood and required assistance with care needs, had a care plan and physician's orders indicating the need for EBP due to the presence of a Foley catheter and MDRO history. Despite these orders, an observation revealed that a nurse aide did not wear a gown while performing a high-contact care activity, specifically emptying the resident's catheter bag, which is contrary to the guidelines for EBP. During an interview, the nurse aide indicated a misunderstanding of the requirement, believing that a gown was only necessary during direct care, not while emptying the catheter bag. This misunderstanding was confirmed by the Director of Nursing, who acknowledged that the staff should have been wearing a gown during the task. The deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and nursing services.
Failure to Implement Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to implement a care plan for a resident who required assistance from two staff members for transfers, resulting in a fall and fracture. The resident, who was cognitively impaired and had diagnoses including dementia and high blood pressure, was assessed to need assistance from two staff and a front-wheeled walker for transfers. However, during an incident, a nurse aide, who was not familiar with the resident, was incorrectly informed by an LPN that the resident required only one staff member for assistance. Consequently, the nurse aide attempted to transfer the resident alone, leading to the resident losing balance and falling. The incident occurred when the resident was being transferred from the toilet to a wheelchair. The nurse aide, unable to steady the resident, witnessed the resident fall, resulting in a fracture of the left tibia and fibula, and a lump on the forehead. The nurse aide later stated that she did not have access to the resident's care plan on the iPad and was unaware of how to find the transfer status in the charting system. The LPN denied telling the nurse aide that the resident was a one-assist for transfers. The Nursing Home Administrator confirmed that the resident was supposed to be assisted by two staff members, and the care plan was not followed, leading to the incident.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for a resident, resulting in a fall with a fracture. The resident, who was cognitively impaired and required assistance for daily care needs, was supposed to be transferred by two staff members and a front-wheeled walker. However, during an incident, a nurse aide, who was not familiar with the resident, was informed by an LPN that the resident was an assist of one. The nurse aide proceeded to assist the resident to the bathroom alone, which led to the resident losing balance and falling during the transfer from the toilet to the wheelchair. The nurse aide did not have access to the resident's care plan on the iPad and was unaware of how to find the transfer status in the charting system. The LPN denied telling the nurse aide that the resident was a one-assist for transfers. The Nursing Home Administrator confirmed that the resident was to be assisted by two staff members, and the transfer status was not followed according to the care plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 129 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dubois
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christ The King Manor | 2.3 mi | ★★★★★ | 4 | 0 |
| Highland View Rehabilitation & Healthcare Center | 9.9 mi | ★★★★★ | 7 | 0 |
| Ridgeview Healthcare And Rehabilitation Center | 14.2 mi | ★★★★★ | 21 | 0 |
| Mulberry Healthcare And Rehabilitation Cent | 16.8 mi | ★★★★★ | 34 | 0 |
| Mountain Laurel Healthcare And Rehabilitation Ctr | 18.5 mi | ★★★★★ | 33 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Dubois Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.