Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based 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).
Residents Affected - Few
Findings include:
Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure)
and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing,
blockage, or spasm).
Review of Resident 5's current physician orders reveal an order for the following: No blood pressure in left
arm every shift for previous graft from left arm, with a start date of March 24, 2024.
Review of Resident 5's clinical record Blood Pressure Summary documentation for the past 30 days (March
23, 2024, through April 18, 2024) revealed Resident 5 had their blood pressure taken in their left arm on the
following dates and times: March 27, 2024 at 3:25 PM; April 2, 2024, at 9;17 PM, April 5, 2024, at 10:02
AM, April 9, 2024, at 10:23 PM, April 11, 2024, at 1:12 PM, and April 15, 2024, at 1:28 AM.
During an interview with Resident 5 on April 18, 2024, at approximately 11:15 AM, revealed that a nurse
had woken the Resident up in the middle of the night (date unknown) trying to put a cuff on their left arm to
check blood pressure, and Resident 5 woke up and told them to stop, and the nurse finally stopped.
Resident 5 said they had a graft put in their left arm and could not have anything on that arm as it could be
life threatening.
Review of the facility's grievance log for the past three months revealed a grievance filed on behalf of
Resident 5 on March 29, 2024, with the following concern: Nurse woke patient for blood pressure and tried
to use left arm. He has a no stick/no blood pressure alert bracelet and a sign on wall explaining no stick no blood pressure.
Further review of the grievance revealed a summary of findings, which included: Have identified agency
staff involved, reached out to agency staff to request re-education be performed.
Review of electronic correspondence received from the Nursing Home Administrator (NHA) on April 18,
2024, at 5:12 PM, revealed that she acknowledged there was an issue with Resident 5's blood pressure,
and had added additional measures to ensure their blood pressure is taken in the correct arm as ordered
by the physician.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395428
Printed: 05/15/2026
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
395428
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northern Dauphin Nursing and Rehabilitation Center
990 Medical Road
Millersburg, PA 17061
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident 7's clinical record revealed diagnoses that included hyperlipidemia (a condition in which
there are high levels of fat particles [lipids] in the blood) and osteoarthritis (type of arthritis that occurs when
flexible tissue at the ends of bones wears down).
Review of Resident 7's current comprehensive person-centered care plan revealed the following focus
area: The Resident has an activities of daily living (ADL) self-care performance deficit related to
rhabdomyolysis, muscle weakness, and cognitive impairment, with the intervention to include: Transfer: The
Resident requires two-person assist with full mechanical lift, with an initiation date of January 2, 2024, and
a revision date of March 10, 2024.
Review of Resident 7's clinical record revealed an ADL transfer task relating to transfer support provided,
specifically how the Resident moves between surfaces to or from: bed, wheelchair, and standing position
for the past 30 days (March 20, 2024, through April 17, 2024), revealed Resident 7 was documented as
being transferred with a one-person physical assist on the following dates and times: March 26, 2024, at
4:14 PM; April 6, 2024, at 2:23 PM; and April 7, 2024, at 9:40 PM.
Review of Resident 8's clinical record revealed diagnoses that included osteoarthritis (type of arthritis that
occurs when flexible tissue at the ends of bones wears down) and hypertension.
Review of Resident 8's current comprehensive person-centered care plan revealed the following focus
area: The Resident has an ADL self-care performance deficit related to lack of coordination, muscle
weakness, cognitive impairment, and abnormal gait and mobility, with the intervention to include: Transfer
with total mechanical lift and assist of two-person, with an initiation date of October 17, 2022, and a revision
date of January 20, 2024.
Review of Resident 8's clinical record revealed an ADL transfer task relating to transfer support provided,
specifically how the Resident moves between surfaces to or from: bed, wheelchair, and standing position
for the past 30 days (March 20, 2024, through April 17, 2024), revealed Resident 8 was documented as
being transferred with a one-person physical assist on the following dates and times: March 22, 2024 at
2:42 PM; March 26, 2024, at 8:59 PM; March 31, 2024, at 2:59 PM; and April 6, 2024, at 12:20 PM.
Review of Resident 9's clinical record revealed diagnoses that included heart failure (a condition that
develops when your heart doesn't pump enough blood for your body's need) and hypertension.
Review of Resident 9's current comprehensive person-centered care plan revealed the following focus
area: The Resident has an ADL self-care performance deficit related to dyspnea on exertion and
abnormality of gait and mobility, with the intervention to include: Transfers with total mechanical lift and
assist of two-person, with an initiation date of November 21, 2022, and a revision date of March 26, 2024.
Review of Resident 9's clinical record revealed an ADL transfer task relating to transfer support provided,
specifically how the Resident moves between surfaces to or from: bed, wheelchair, and standing position
for the past 30 days (March 20, 2024, through April 17, 2024), revealed Resident 9 was documented as
being transferred with a one-person physical assist on the following dates and times: April 1, 2024, at 11:43
AM; April 6, 2024, at 1:59 PM; April 11, 2024, at 7:43 PM; and April 13, 2024, at 3:36 AM and 8:14 PM.
Review of Resident 10's clinical record revealed diagnoses that included type 2 diabetes (a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395428
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
395428
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northern Dauphin Nursing and Rehabilitation Center
990 Medical Road
Millersburg, PA 17061
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
long-term condition in which the body has trouble controlling blood sugar and using it for energy) and
hypertension.
Review of Resident Review of Resident 10's current comprehensive person-centered care plan revealed
the following focus area: The Resident has an ADL self-care performance deficit related to gout, chronic
obstructive pulmonary disease, and weakness, with the intervention to include: Transfer: The Resident
requires full mechanical lift and two-person assist, with an initiation date of March 25, 2024, and a revision
date of April 8, 2024.
Review of Resident 10's clinical record revealed an ADL transfer task relating to transfer support provided,
specifically how the Resident moves between surfaces to or from: bed, wheelchair, and standing position
for the past 30 days (March 20, 2024, through April 17, 2024), revealed Resident 10 was documented as
being transferred with a one-person physical assist on the following dates and times: March 25, 2024, at
9:04 PM; March 26, 2024, at 1:49 PM, 4:02 PM, and 11:34 PM; March 27, 2024, at 10:44 AM and 3:40 PM;
March 28, 2024, at 2:45 PM and 11:46 PM; March 29, 2024, at 2:37 PM; March 30, 2024, at 11:23 PM;
March 31, 2024, at 10:40 AM; and April 5, 2024, at 9:46 AM and 7:39 PM.
During an interview with the Nursing Home Administrator on April 18, 2024, at 2:00 PM, revealed they
believe the staff were miss-clicking the documentation and marking the Residents above being a
one-person physical assist in error.
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395428
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the April 19, 2024 survey of NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER?
This was a inspection survey of NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER on April 19, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER on April 19, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.