Dubois Nursing Home: Insulin Failure Sent Resident to ICU - PA
She was hospitalized the next day with diabetic ketoacidosis, acute kidney injury, encephalopathy, altered mental status, and dehydration. Federal inspectors, who completed a complaint inspection on January 2, 2026, cited the facility for actual harm.
The orders were not complicated to understand. The physician had written them the evening of her admission: insulin Lispro with sliding scale coverage three times per day with meals, more at bedtime, fixed doses before breakfast, lunch, and supper, and two separate doses of insulin Glargine. The nursing notes show the orders were reviewed with the provider at 6:06 p.m. that same evening.
Nobody entered them into the computer.
A medication entry audit showed the orders weren't put into the electronic health record until somewhere between 11 p.m. and midnight on December 19. Because of when they were entered, the system set the start date as December 20. The resident's supper insulin was never given. Her bedtime insulin was never given.
The December 2025 Medication Administration Record confirmed it: no orders existed in the system for December 19 at all.
When inspectors interviewed the Director of Nursing on December 29, she confirmed what the records showed. The registered nurse responsible for entering the orders, she said, "did not get around to entering them until around midnight on December 19, which pushed the start date of the orders until December 20." She confirmed the resident did not receive her supper or bedtime insulin.
By 9:20 the next morning, the resident's blood sugar had climbed to 503. Staff gave her insulin. An hour later it was 530, still rising. At noon it had dropped only to 484. At 1 p.m. it was 497. The resident told staff she did not feel well. A nurse was instructed to send her to the hospital.
Diabetic ketoacidosis develops when the body, starved of insulin, begins breaking down fat for fuel. That process produces acidic ketones that accumulate in the bloodstream. The condition requires hospitalization. In this case it came with complications: the resident's kidneys were acutely injured, her brain function was altered, and she was severely dehydrated.
She had been a resident for less than 36 hours.
The inspection covered five residents. Only Resident 3 was flagged for this deficiency. The violation was cited under Pennsylvania nursing services regulations and carries a finding of actual harm, the federal designation used when inspectors conclude that a deficiency caused real injury to a resident, not merely the risk of one.
What the record shows is a gap that should not have existed. A diabetic patient admitted from the hospital, with active ulcers and a same-day blood sugar already elevated, had physician's orders ready and reviewed within the first hour of her admission. A nurse's administrative delay, a few hours of not getting around to it, meant those orders effectively didn't exist on paper until the next calendar day. The electronic system did the rest.
The resident spent the night of December 19 without insulin. She spent part of December 20 still in her admission linens, still in a soiled brief, her body working through a crisis that had been building for hours before anyone checked her. She was in a hospital bed by December 21, with damage to her kidneys and her brain.
The inspection report does not say whether she recovered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 19, 2026 · Our methodology
Dubois Nursing Home in DUBOIS, PA was cited for violations during a health inspection on January 2, 2026.
She was hospitalized the next day with diabetic ketoacidosis, acute kidney injury, encephalopathy, altered mental status, and dehydration.
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.