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Dubois Nursing Home: Care Plan Failures Repeat - PA
The problem wasn't that no one had tried....
Latest reports, citations, and penalties from CMS data
The problem wasn't that no one had tried....
Federal inspectors arrived at the northeastern Montana nursing facility on March 13, 2025, responding to a complaint....
The violation was the same one cited in November 2018, November 2019, and again in January 2024....
Out of six residents whose records were sampled during the inspection, Resident 40 was the one whose advocate was left in the dark....
The records still weren't right....
On January 29, 2025, at 11:31 a.m., inspectors at Willow Terrace watched a licensed nurse enter the room of Resident R271 wearing only gloves....
The care plan deficiencies were still there....
The citation, tagged F689, stems from an incident on April 9, 2025....
The inspection was triggered by a complaint, not a routine survey....
The previous citations came in November 2019 and again in May 2024....
Inspectors who visited Weirton Geriatric Center on April 24, 2025 found the facility was not following it....
A resident who doesn't receive a bed hold notice doesn't know whether their room will still be there when they're discharged....
The facility's own corrective plan acknowledges each of those failures, without disputing them....
Nobody on the facility's quality committee knew it was happening....
Inspectors visited the facility on May 28, 2025, and documented what they observed during wound care....
The problem surfaced in May 2024, ran for a week, and then returned in June....
Inspectors also cited the facility under two Pennsylvania state nursing regulations....
A care plan is the document that drives decisions about a resident's medications, therapies, diet, and personal needs....
What they found at Windber Woods Senior Living & Rehabilitation Center during a March 2025 inspection was that none of it had worked....
What that complaint described, and what inspectors found when they arrived, is not detailed in the publicly available narrative....