Dubois Nursing Home

F-F558, revealed that the QAPI committee was ineffective in correcting deficient practices related to accommodating a resident's needs.

The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during

the survey ending April 10, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.

The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited

during the survey ending April 10, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plans of correction for deficiencies regarding ensuring that the residents' environment remained free from accident hazards, cited during surveys ending July 27, 2023, and April 10, 2024, revealed that audits would be completed. The results of the current survey, cited under

F-F689.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 395430 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395430 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dubois Nursing Home 212 S. Eighth St. Dubois, PA 15801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 28 Pa. Code 201.14(a) Responsibility of Licensee.

Level of Harm - Minimal harm or 28 Pa. Code 201.18(e)(1) Management. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 395430 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395430 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dubois Nursing Home 212 S. Eighth St. Dubois, PA 15801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 42079 potential for actual harm Based on review of established infection control guidelines and residents' clinical records, as well as Residents Affected - Few observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 40 residents reviewed (Residents 17).

Findings include:

CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common

in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024.

The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated May 13, 2024, revealed that the resident was clearly understood and could understand others, required assistance with care needs, and had a catheter (a thin, flexible tube inserted into

the bladder to drain urine from the bladder). A care plan for Resident 17 regarding enhanced barrier precautions, dated April 30, 2024, revealed that the resident had EPB in place due to MDRO history and foley placement.

Physician's orders for Resident 17, dated May 1, 2024, included an order for resident to receive enhanced barrier precautions due to foley catheter placement and history of MDRO every shift.

Physician's orders for Resident 17, dated November 17, 2023, included orders to provide irrigation with 250 milliliters (ml) of normal saline as needed for leakage and blockage of the catheter.

Observations of Resident 17 on June 24, 2024, at 12:47 p.m. revealed that the resident had signage at the entrance to her room to indicate that infection control measures for EBP were in place related to her catheter. Nurse Aide 7 was wearing gloves while draining the tea-colored catheter bag into a cylinder, then entered the bathroom. Nurse Aide 7 was not wearing a gown during the task of emptying the catheter bag.

Interview with Nurse Aide 7 at the time of observations revealed that she only needed to wear a gown when providing care; however, Resident 17 was on enhanced precautions because she had a catheter.

Interview with the Director of Nursing on June 27, 2024, at 1:18 p.m. confirmed that Resident 17 had EBP, and staff should have been wearing a gown to empty the catheter bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 395430 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395430 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dubois Nursing Home 212 S. Eighth St. Dubois, PA 15801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 28 Pa. Code 201.14(a) Responsibility of Licensee.

Level of Harm - Minimal harm or 28 Pa. Code 201.18(e)(1) Management. potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 395430