Northern Dauphin Nursing and Rehabilitation Center

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for four of 36 residents reviewed (Residents 1, 12, 43, and 103).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice for two of five residents reviewed with PTSD (Post Traumatic Stress Disorder) (Residents 8 and 90).

Inspectors wroteBased on facility policy review, observations, review of resident council minutes, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on one of two nursing units observed (1st floor).

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure an annual performance review is completed for each nurse aide for five of five nurse aide performance evaluations reviewed (Employees 10, 11, 12, 13, and 14). Findings Include: Review of the facility's list of nurse aide staff revealed Employee 10 had a hire date of February 24, 2025; Employee 11 had a hire date of March 4, 2024; Employee 12 had a hire date of May 8, 2023; Employee 13 had a hire date of January 18, 2021; and Employee 14 had a hire date of March 18, 2009. Requests for the most recent yearly performance reviews revealed Employees 10, 11, 12, 13, and 14 did not have an annual performance review completed within the previous 12 months. [...]

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to notify the resident's representative of a medication change for one of six residents reviewed for unnecessary medications (Resident 179). Findings Include: Review of Resident 179's clinical record revealed diagnoses that included Alzheimer's Disease and hypertensive heart disease (complications of the heart caused by long-term, unmanaged high blood pressure). Review of Resident 179's pharmacy recommendation, dated February 27, 2026, revealed a recommendation for a gradual dose reduction (GDR) of the Resident's Memantine (also known as Namenda; a medication used to treat moderate to severe dementia associated with Alzheimer's Disease). Further review of the recommendation revealed that on March 6, 2026, the provider agreed with the GDR of Memantine, and wrote orders for the GDR. [...]

Inspectors wroteBased on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to follow physician orders for wound care for one of four residents reviewed (Resident 15); and failed to follow physician orders for obtaining weights and medication administration for one of 36 residents reviewed (Resident 100).

Inspectors wroteBased on facility policy review, product packaging review, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the medication error rate was not five percent or greater, based on three medication errors out of 29 opportunities.

Inspectors wroteBased on facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, observations, and resident and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment to prevent the development and spread of communicable diseases and infections by not covering a wound known to be infected by a multi-drug resistant organism for one of four residents reviewed (Resident 15).

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for six of eight residents reviewed (Residents 1, 2, 3, 4, 5, and 6). Findings Include: Review of facility policy, titled Administering Medications, dated April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. [...]

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from abuse, which resulted in actual harm as evidenced by multiple skin tears and penetrating wounds to the back of the head and neck after a resident to resident altercation for one of three residents reviewed (Resident 2). Findings Include:Review of facility policy, titled Abuse Policy, undated, revealed, in part, the resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interview, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living for four of 32 residents reviewed (Residents 7, 26, 93, and 118). Findings Include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting with a last revised and reviewed date of April 2025, revealed, in part, 3. 'Unavoidable decline' may occur if the resident: c. refuses care and treatment to restore or maintain functional abilities and: (3) the refusal and details of the interventions refused are documented in the resident's clinical record. [...]

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide resident-directed care and services in accordance with professional standards of practice, and consistent with the resident's physician orders, to ensure the resident's highest level of well-being for three of 32 residents reviewed (Residents 93, 136, and 264).

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, including monitor resident weights per physician order and inform the physician of significant weight loss, for four of 32 residents reviewed (Resident 5, 123, 136, and 152).

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined the facility failed to assist residents in obtaining routine and emergency dental care for two of 32 residents reviewed (Residents 5 and 93).

Inspectors wroteBased on facility policy review, CDC guidance review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 5, 18, 26, and 37). Findings Include: Review of facility policy, titled Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures, reviewed April 11, 2025, revealed This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention [CDC] to prevent the transmission of COVID-19 within the facility. The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed at least once a month by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber in a timely manner for two of five residents reviewed (Residents 23 and 72).

Inspectors wroteBased on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in two of two nourishment pantries.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing and prevent infection of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident 2).

Inspectors wroteBased on clinical record review, select document review and staff interview, it was determined that the facility failed to prevent accident hazards for one of five residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide personal care and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for seven of fifteen residents reviewed (Resident 5, 6, 7, 8, 9, 10, and 11).

Inspectors wroteBased on clinical record reviews and staff interview, it was determined that the facility failed to obtain laboratory services for one of 15 residents reviewed (Resident 3).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure resident privacy was protected for one of five residents reviewed, after a video baby monitor was placed in a resident's room (Resident 3).

Inspectors wroteBased on a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident or their representative received written notice of the facility bed-hold policy at the time of transfer for one of nine residents reviewed (Resident 9), and failed to ensure that the written notice of the facility bed-hold policy at the time of transfer included the reserve payment required for four of nine residents (Residents 3, 4, 9, and 136). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). [...]

Inspectors wroteBased on facility policy review, record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident's right to participate in the care planning process, and failed to review and revise the resident plan of care for two of 31 resident's reviewed (Residents 10 and 125).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 31 residents reviewed (Residents 10 and 136).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for two of three residents reviewed for pressure ulcers (Residents 1 and 135).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for one out of six residents reviewed for accident hazards (Resident 48).

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen, two of two nourishment areas, and one of two medication storage areas.

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 3).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 96).

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of 10 residents reviewed for limited range of motion (Residents 10 and 84).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of seven residents reviewed (Resident 47), and failed to notify the physician of a significant weight loss for one of seven residents reviewed for nutritional status (Resident 81).

Inspectors wroteBased on observations, clinical record review, policy review, and resident and staff interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory care (Residents 57 and 397).

Inspectors wroteBased on clinical record review, policy review, observations, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of nine residents reviewed for infection control (Resident 17).

Inspectors wroteBased on clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for five of 10 residents reviewed (Resident 5, 7, 8, 9, and 10).

Inspectors wroteBased on facility policy review, clinical record review, and interviews with residents and staff, it was determined that the facility failed to implement a process to ensure effective safety measures to prevent elopement, prior to and following incident of resident elopement, for two of 26 residents reviewed who are permitted to go outside independently (Residents 1 and 2). This failure placed Residents 1 and 2 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. [...]

Inspectors wroteBased on facility policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to report a resident elopement to the Department of Health as required for Residents 1 and 2. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff. Review of Employee 4's (Receptionist) statement, dated October 1, 2023, revealed, [Resident 1] + [Resident 2] were already sitting in the family room when I came in at 7:45. [...]

Inspectors wroteBased on observations, review of the facility assessment tool, as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of two nursing units (first and second floor nursing units).

Inspectors wroteBased on observations, review of the facility assessment tool as well as staff interviews, it was determined that the facility failed to ensure resident equipment was maintained in a safe operating condition on one of two nursing units (first floor nursing unit).