Dubois Nursing Home: Wound Care Skipped 10 Days - PA
The resident, identified in inspection records as Resident 2, sustained a seven centimeter by nine centimeter skin tear with bruising on their right forearm in mid-August. Staff discovered the wound on August 19 during routine care.
A registered nurse assessed the injury and documented its significant size. The wound measured roughly three inches by three and a half inches.
The facility's physician ordered specific daily wound care the following day. The treatment protocol required staff to cleanse the skin tear with wound cleanser, pat it dry, apply xeroform gauze dressing with petroleum, and cover it with foam dressing. The orders specified this care should occur daily and as needed.
But nursing staff failed to follow the physician's instructions repeatedly over the next 19 days.
Treatment records show the ordered dressing changes were skipped on August 20, 23, 24, 27, 28, and 29. Staff again failed to provide the care on September 2, 3, 6, and 7.
The resident's August assessment revealed severe cognitive impairment and dementia. They could sometimes understand others and were sometimes understood by staff, but required assistance for all daily care needs.
Dubois Nursing Home's own policy, updated January 1, 2025, states that licensed nurses must complete physician orders exactly as written regarding timing and frequency.
When state inspectors interviewed the Director of Nursing on September 9 at 2:09 p.m., the administrator confirmed that Resident 2's dressing changes were not completed as ordered on all the documented dates.
The inspection occurred following a complaint to state health authorities. Inspectors reviewed three residents' care during their investigation and found the wound care failures affected one of the three.
Skin tears are common injuries among elderly nursing home residents, particularly those with cognitive impairments who may not understand or remember to avoid activities that could damage fragile skin. Proper wound care prevents infection and promotes healing.
The facility's treatment administration records provided clear documentation of the missed care dates spanning nearly three weeks. Each missed treatment represented a failure to follow the physician's specific medical orders for a vulnerable resident.
Pennsylvania nursing home regulations require facilities to provide nursing services according to physician orders and resident care needs. The state cited Dubois Nursing Home under this regulation for failing to ensure proper wound care delivery.
The inspection classified the violation as causing minimal harm or potential for actual harm to residents. State health officials noted that few residents were affected by the identified deficiency.
Federal regulations require nursing homes to provide treatment and care according to physician orders, resident preferences, and care goals. Facilities must maintain systems to ensure medical orders are carried out as prescribed.
The missed dressing changes occurred despite clear documentation in the resident's medical record and specific physician instructions for daily wound care. The facility's own policies supported the requirement for nurses to follow physician orders as written.
Resident 2's case illustrates how documentation gaps can affect vulnerable residents who depend entirely on staff for medical care. With severe cognitive impairment and dementia, the resident could not advocate for themselves or request the missing wound care.
The skin tear discovery on August 19 should have triggered consistent daily care according to the physician's August 20 orders. Instead, treatment records show a pattern of missed care that continued into September.
State inspectors found the facility failed to ensure physician orders were followed despite having written policies requiring compliance with medical directives. The Director of Nursing's confirmation of the missed treatments validated the inspectors' findings from medical record reviews.
The complaint investigation revealed systemic issues with following physician orders for wound care at the facility. Treatment administration records provided clear evidence of the repeated failures to provide ordered medical care to a cognitively impaired resident who could not advocate for proper treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Dubois Nursing Home in DUBOIS, PA was cited for violations during a health inspection on September 9, 2025.
Staff discovered the wound on August 19 during routine care.
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.