Dubois Nursing Home: Call Bell Left Out of Reach - PA
A state inspection of Dubois Nursing Home, completed April 30, 2026, found that a resident with a documented history of falls had been left without access to her call bell, the device she depended on to summon staff when she needed to move. The resident, identified in inspection records as Resident 75, was cognitively intact and fully aware of her situation. She had been waiting. Nobody came.
Resident 75 had arthritis, muscle weakness, and an abnormal gait. Her doctor had ordered that she transfer only with one staff member assisting and a front-wheeled walker. Her care plan, updated April 1, directed staff to keep her call bell within reach at all times and to encourage her to use it whenever she needed help.
On April 28, at 9:25 in the morning, she was found on the floor of her room. She had tried to move herself from her wheelchair to her recliner because, she told staff, she couldn't sit in the wheelchair any longer. No one had come to help her. She transferred alone, fell, and was found on the floor.
Forty-eight hours later, inspectors arrived.
At 10:26 a.m. on April 30, they observed Resident 75 sitting in her wheelchair, leg rests on, positioned at the foot of her bed. Her call bell was lying in the middle of the bed, well beyond her reach. She told inspectors she had been waiting for someone to move her to her recliner. She couldn't reach the call bell to ask.
The nurse aide standing nearby, interviewed at 10:27 a.m., confirmed that the call bell was out of reach. The Director of Nursing, interviewed that afternoon, confirmed the same thing: the call bell should have been within the resident's reach.
There was no dispute about what happened. Everyone agreed the call bell was in the wrong place. The question the inspection record leaves unanswered is how long she had been sitting there, waiting, before inspectors walked in.
The facility's own care plan had named the call bell as the primary safeguard against exactly this kind of situation. Resident 75 was not someone who could safely get up and move on her own. Her diagnosis, her doctor's orders, and her care plan all said so. The fall two days earlier had demonstrated what happened when she tried.
CMS rated the violation at the minimal harm level, meaning inspectors determined that no additional harm resulted from the April 30 incident. That rating reflects the outcome inspectors could document, not the hour or more that Resident 75 may have spent waiting in her chair, unable to call anyone, two days after a fall that happened for the same reason.
Inspectors cited the facility under Pennsylvania nursing home regulations governing resident care policies and nursing services.
Dubois Nursing Home serves a small community in Clearfield County. The inspection covered 44 residents. Only one violation was cited. It involved one resident, one call bell, and a care plan that said exactly what staff were supposed to do.
Resident 75 knew what she needed. She knew she couldn't transfer safely alone. She knew she was supposed to call for help. She reached for the call bell and it wasn't there. So she sat and waited, the same way she had waited two days before, until she decided she couldn't wait anymore and tried to get up by herself, and fell.
Whether she reached for the bell again on April 30 before inspectors arrived, or whether she had already given up on it, the record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2026-04-30 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 6, 2026 · Our methodology
Dubois Nursing Home in DUBOIS, PA was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records as Resident 75, was cognitively intact and fully aware of her situation.
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.