Dubois Nursing Home: Repeated Safety Failures - PA
Dubois Nursing Home's quality assurance and performance improvement committee, the internal body responsible for catching and correcting problems before regulators do, failed to implement its own plans to keep residents' care plans current and their living environment free from accident hazards, according to a federal inspection completed June 27, 2024.
The findings trace a failure that spans nearly a year. Inspectors first cited the facility for accident hazard violations following a survey that ended July 27, 2023. The facility's response was a plan of correction that promised audits would be completed. Less than nine months later, in April 2024, inspectors returned and cited the same category of violation again. Again, the facility produced a plan of correction. Again, it promised audits.
By June 2024, inspectors were back a third time. What they found was a quality committee that had not successfully carried out its own commitments.
That committee, known in federal nursing home oversight as the QAPI committee, exists specifically to prevent this kind of cycle. Its purpose is not to respond to inspectors after violations are found, but to identify problems internally and fix them before anyone gets hurt. At Dubois Nursing Home, the committee's plan to ensure ongoing compliance with care plan requirements had not been implemented. The accident hazard corrections it had pledged twice over had not held.
The care plan violation, cited under federal tag F657, concerns something fundamental to how nursing homes operate. A resident's care plan is the document that tells staff who that person is medically, what their risks are, and what needs to be done to protect them. When care plans go out of date, the staff working with a resident may be working from incomplete or wrong information.
The accident hazard findings tell a parallel story. A nursing home environment is full of potential dangers for people who may use wheelchairs, have dementia, struggle with balance, or rely on others for basic movement. Identifying and removing those hazards is not a one-time task. It requires the kind of ongoing monitoring that a functioning quality committee is supposed to provide. At Dubois Nursing Home, that monitoring failed to produce lasting results across three separate inspection cycles.
What makes the June 2024 findings particularly pointed is that the failure documented is not simply a failure to fix a problem. It is a failure to execute the fix that the facility itself designed, wrote down, and submitted to regulators. The audits that were promised did not translate into sustained compliance. The committee charged with making sure corrections stuck did not succeed in doing so.
Federal oversight of nursing homes depends heavily on the assumption that facilities will follow through on their own plans of correction. Inspectors cannot be present every day. The system is built around the idea that when a facility identifies a problem and commits to addressing it, that commitment means something. When the same deficiency reappears after two correction cycles, that assumption breaks down.
The residents living at Dubois Nursing Home during this period had care plans that may not have reflected their current conditions and needs. They lived in an environment that the facility had twice promised to make safer and twice failed to maintain. Whether any resident was harmed as a direct result of outdated care plans or unaddressed hazards is not detailed in the inspection findings.
What the record does show is a committee that met, produced paperwork, and did not get the job done. And a third inspection that found the same residents in the same building, still waiting for a fix that had been promised to them twice before.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2024-06-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
Dubois Nursing Home in DUBOIS, PA was cited for violations during a health inspection on June 27, 2024.
The findings trace a failure that spans nearly a year.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.