Dubois Nursing Home
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Actual harm
with the Director of Nursing on December 29, 2025 at 3:24 p.m. revealed that the Registered Nurse that entered the orders into the computer 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 further confirmed that Resident 3 did not receive her supper or bedtime insulin.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Residents Affected - Few Note: The nursing home is disputing this citation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
01/02/2026
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-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 3).
Findings include:admission paperwork for Resident 3, dated December 19, 2025, indicated that she was a diabetic with diabetic ulcers and that her blood sugar prior to leaving the hospital that day was 182. A nursing note for Resident 3, dated December 19, 2025, indicated that she was admitted from the hospital at 5:30 p.m. and that her physician's orders for medications were reviewed with the provider at 6:06 p.m.Physician's orders, dated December 19, 2025, for Resident 3 included orders for the resident to receive insulin Lispro with sliding scale coverage three times per day with meals; insulin Lispro with sliding scale coverage nightly at bedtime; insulin lispro 7 units daily before breakfast; insulin lispro 3 units two times a day before lunch and supper; insulin Glargine 20 units daily before breakfast; and insulin Glargine 30 units daily before supper.A nursing note for Resident 3, dated December 20, 2025, indicated that the resident was checked at 9:20 a.m. and was still laying on the hospital linens with a soiled disposable pad and brief, and was breathing at 33 breaths per minute (normal is 12 - 20 breaths per minute). The note indicated that
the resident did not receive her insulin or medications the night before. Her blood sugar at that time was
- 503. A repeat blood sugar one hour after medication administration was 530. Her respiratory rate remained
fast. At noon her blood sugar was 484 and she was again medicated with insulin. At 1:00 p.m. her blood sugar was 497. The nurse was instructed to send the resident to the hospital because the patient stated
she did not feel well.A nursing note dated December 21, 2025 at 1:15 a.m. revealed that the resident was admitted to the hospital with Diabetic Ketoacidosis (DKA - a condition in which the body is lacking insulin and breaks fat down for fuel which produces acidic ketones that build up in the blood causing illness requiring hospitalization), altered mental status, and acute kidney injury, encephalopathy (any illness that changes brain function or structure) and dehydration. A review of Resident 3's December 2025 Medication Administration Record (MAR) revealed that she did not have any orders entered into the electronic health
record system for December 19, 2025. A medication entry audit revealed that the orders for Resident 3's medications were entered on December 19, 2025 between 11 p.m. and 12 a.m. and that they were entered to start on December 20, 2025.Interview with the Director of Nursing on December 29, 2025 at 3:24 p.m. revealed that the Registered Nurse that entered the orders into the computer 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 further confirmed that Resident 3 did not receive her supper or bedtime insulin.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Dubois Nursing Home in DUBOIS, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUBOIS, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Dubois Nursing Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.