Inspection·May 6, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few Findings include: Review of Resident 2's clinical record revealed diagnoses that included hypokalemia (low levels of potassium in the blood) and hyperlipidemia (having high levels of fats in the blood). Further review of Resident 2's clinical record revealed that she had an incontinence associated dermatitis (IAD) on her sacrum that was acquired on February 11, 2025. Resident 2 was seen by the wound clinic on February 18, 2025, with a treatment plan to cleanse the wound daily and as needed with soap and water, pat dry, and treat with medical grade honey, calcium alginate, and cover with bordered gauze. Review of Resident 2's February 2025 Medication Administration Record (MAR) revealed a physician's order for medical grade honey wound and burn dressing external paste, apply to sacrum topically every day shift for masd (moisture-associated skin damage), cleanse sacrum with soap and water, pat dry, apply medical grade honey, calcium alginate and cover with bordered gauze daily and as needed, with a start date of February 19, 2025, and an end date of March 13, 2025. Further review of Resident 2's February 2025 MAR revealed there was no documentation that she received the treatment ordered above on February 20, 2025, as the box was left blank, indicating the treatment was not completed. Review of Resident 2's March 2025 MAR revealed there was no documentation that she received the treatment ordered above on March 8, 2025, as the box was left blank, indicating the treatment was not completed. Review of Resident 2's clinical record revealed she was seen by the wound clinic on March 11, 2025, where it refers to the wound on the resident's sacrum as an unstagable pressure ulcer. During a staff interview with the Nursing Home Administrator on May 5, 2025, at approximately 1:30 PM, revealed she was unable to provide an explanation as to why Resident 2's MAR documentation was blank on February 20, 2025, and March 8, 2025, and would expect staff to be documenting after they have completed treatment on a resident. (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 2 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 05/06/2025 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)