Inspection·October 22, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few at 4:00 PM, after the Resident's smoke break, Employee 5 heard screaming. Employee 5 entered Resident 2's room and observed Resident 1 behind Resident 2's chair, and Employee 5 observed what appeared to be Resident 1 punching Resident 2 in the head. Employee 5 stated that as the residents were separated, Employee 5 noticed Resident 1 had a pen in her hand and had been stabbing Resident 2 in the neck. Employee 5 said she observed multiple marks on the back of Resident 2's neck as well as a mark on the back of her head. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 22, 2025, at 11:21 AM, they stated that they are unaware of any prior interactions between Resident 1 and Resident 2. They stated that the attack on Resident 2 was unprovoked and occurred right after both Residents attended smoking club. During an interview with Employee 6 (Activities Director), on October 22, 2025, at 12:20 PM, she stated that on October 15, 2025, during smoking club, there were no altercations between Residents 1 and 2. She stated that everyone seemed to be in a good mood and that Residents 1 and 2 did not even speak to each other. She further stated that where they sit during smoking club, they don't even face each other. At this time, Employee 7 (Activities) added that she was also present during smoking club on October 15, 2025. She stated that it was a normal smoking club activity and nothing was out of the ordinary involving either resident. During a surveyor interview with Resident 2 on October 22, 2025, at 12:28 PM, Resident 2 stated that Resident 1 came into Resident 2's room. Resident 2 told Resident 1 that wasn't her room and then Resident 1 pushed Resident 2 into her bed. Resident 2 stated that Resident 1 then started stabbing her. Resident 2 said at first, she thought Resident 1 was punching her but then realized she was being stabbed with a pen. Resident 2 stated that she immediately yelled for help and staff immediately came in to separate the residents. Resident 2 told the surveyor, I don't know what I did. I didn't do anything. Resident 2 stated that just prior to the incident, both her and Resident 1 were outside in smoking club together. She stated that they did not speak to each other and that she did not even look at Resident 1.Review of Resident 2's clinical record revealed that immediately after the incident, Resident 2 was offered to be sent to the hospital, but she declined. Resident 2 did agree to receive a Tetanus shot, which was administered on October 16, 2025. Review of Resident 2's physician orders revealed an order dated October 15, 2025, to cleanse the back of the head and neck with NSS, apply TAO and cover with a dry dressing. Further review revealed an order for alert charting, monitor wounds on the back of the neck for signs and symptoms of infection and monitor healing. On October 22, 2025, at 2:41 PM, the NHA and DON provided the facility's plan of correction that was put into place as a result of the facility's investigation, in which Resident 1 stabbed Resident 2 with a pen. The facility's education and audits were reviewed during the survey. As of October 20, 2025, facility staff were educated on identifying resident triggers, interventions and behaviors, and how to respond to and report any concerns. As of October 20, 2025, audits were completed for all residents to determine any behaviors, triggering events, and specific interventions utilized for those behaviors. Care plans were reviewed and updated as needed. Prior to the abbreviated survey, the facility failed to ensure residents were free from abuse, resulting in harm to Resident 2 as evidenced by multiple skin tears and penetrating wounds to the back of her head and neck after being stabbed with a pen by Resident 1. The facility reported the incident timely, investigated the incident thoroughly and initiated interventions in an effort to prevent a future incident. Review of facility documentation revealed that on October 20, 2025, the facility had completed education for staff and continued audits to ensure compliance. During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no abuse concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 (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 10/22/2025 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)

F 0600 Pa. Code 201.29 (a) Resident rights Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395428 If continuation sheet Page 3 of 3