Inspection·December 10, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based 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). Residents Affected - Few Findings include: Review of Resident 2's clinical record revealed diagnoses that included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter blood properly). Review of a fall incident report that occurred on November 1, 2024, at 11:30 PM, revealed that a nurse aid (NA) found Resident 2 while answering the roommate's call bell, lying prone position in the bathroom. The fall resulted in a hematoma to Resident 2's face, and Resident 2 was transported to the hospital. Further review of the fall incident report, revealed a witness statement by the nurse aid (NA 1) that found Resident 2, with the following description of occurrence, Just seen her at 11:00 PM in her rest room having loose bowel movements. Resident was found face down in bathroom. Review of Resident 2's care plan revealed a focus area for falls, initiated on February 9, 2023, with an intervention for 15-minute checks, initiated on May 1, 2024, and provide staff education that the Resident must transfer and ambulate with assist of one to prevent falls, initiated on May 17, 2024. Review of Resident 2's care plan revealed a focus area for activities of daily living (ADLs), with an initiation date of February 8, 2023, and an intervention that Resident 2 requires staff participation to use toilet, initiated on February 8, 2023, and transfer with rolling walker and assist of 2, initiated on February 16, 2023. Review of Resident 2's clinical record ADL toilet use: support provided task for the past 30 days (November 10, 2024 - December 9, 2024) revealed that Resident 2 either required 1-person physical assist or 2-persons physical assist to use the toilet. Review of Resident 2's clinical record ADL toilet use: self-performance task for the past 30 days (November 10, 2024 - December 9, 2024), revealed that Resident 2 either required limited staff assistance, extensive staff assistance, or total staff dependence to use to toilet. (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 5 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 12/10/2024 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)