F-F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 395430 Department of Health & Human Services Printed: 08/27/2025 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 05/15/2025
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 41233 potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was Residents Affected - Few determined that the facility failed to maintain their infection prevention and control program for hand hygiene
during wound care for one of 49 residents reviewed (Resident 59).
Findings include:
The facility's policy regarding hand hygiene, dated January 31, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated March 31, 2025, indicated that the resident was understood and able to understand others. Physician's orders for Resident 59, dated May 7, 2025, included an order to cleanse the right heel surgical wound thoroughly with Vashe (a wound cleanser) and gauze. Apply silver calcium alginate (a type of silver infused wound dressing) on the wound bed, then cover with an ABD and wrap with kerlix and tape; perform daily and as needed. A care plan for the resident, dated April 26, 2025, revealed that the resident had impaired skin integrity related to multiple surgical wounds.
Observations on May 15, 2025, at 8:36 a.m. revealed that Licensed Practical Nurse 8 donned a gown and gloves and with scissors she removed Resident 59's right heel dressing; then without removing her gloves and performing hand hygiene, she cleansed the area with Vashe and gauze. She then applied silver calcium alginate to the wound bed, covered the area with an ABD and wrapped kerlix (gauze) around the resident's heel, and taped the dressing closed. She then gathered her garbage, removed her gloves, and washed her hands.
Interview with Licensed Practical Nurse 8 on May 15, 2025, at 8:36 a.m. confirmed that while performing wound care on Resident 59, she removed the soiled dressing and without changing her gloves and hand sanitizing, she went on to perform clean wound care.
Interview with the Director of Nursing on May 15, 2025, at 10:25 a.m. confirmed that Licensed Practical Nurse 8 should have removed her gloves, sanitized her hands, and donned new gloves after removing the old dressing and before placing the new one.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 395430 Department of Health & Human Services Printed: 08/27/2025 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 05/15/2025
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 0908 Keep all essential equipment working safely.
Level of Harm - Minimal harm or 41233 potential for actual harm Based on review of policies and cleaning schedules/documents, as well as observations and staff interviews, Residents Affected - Few it was determined that the facility failed to ensure that essential kitchen equipment was maintained in a safe operating condition.
Findings include:
The facility's policy regarding routine stovetop cleaning, dated January 31, 2025, indicated that in order to keep all equipment at optimal levels of functioning and cleanliness, a routine cleaning schedule would be followed.
Observations of the kitchen stove top on May 12, 2025, at 9:46 a.m. and May 13, 2025, at 8:38 a.m. and 1:37 p.m., revealed that there was a thick accumulation of black grease on and around four out of six stove top burners. These burners were located next to the grill area on the stovetop.
Review of the kitchen cleaning schedule for April and May 2025 indicated that the stovetop was to be cleaned monthly.
Interview with the Dietary Manager on May 14, 2025, at 11:08 a.m. confirmed that there was a large accumulation of heavy grease on and around four of the stovetop burners. She indicated that on April 1, 2025, the stovetop was cleaned and that it should have been cleaned again on May 1, 2025 and it was not.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code 211.6(c) Dietary Services.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 395430