Health inspection·December 23, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wouldn't wake up to take the medication. Resident 1 stated that he is a light sleeper and a light tap would have woken him up. Resident 1 further stated that he used to be a pharmacy technician, so he knew the 4:00 AM dose of oxycodone he was provided was not oxycodone and knew it was loratadine. He stated that he saved the pills as evidence that he was not provided his oxycodone. Review of facility's controlled substance record form (a form used to maintain accurate records of all controlled substances that are being administered), revealed a signature for the nurse dispensing the medication, the date, time and amount dispensed, and the amount of medication remaining. Review of Resident 1's controlled substance record for the oxycodone, 5 mg, one tablet five times a day, revealed Employee 1 signed that the medication was dispensed on December 7, 2025, at 4:00 PM; December 7, 2025, at 8:00 PM; and December 7, 2025, at 12:00 AM.Review of Employee 1's time card report revealed she was not working on December 7, 2025, at 12:00 AM. Review of Resident 1's controlled substance record for the oxycodone, 10 mg at 4:00 AM, revealed Employee 1 signed that the medication was dispensed on December 7, 2025, at 4:00 AM.Review of Employee 1's time card report revealed she was not working on December 7, 2025, at 4:00 AM.Review of a typed statement by Employee 1, undated, in reference to the shift worked on December 7, 2025, 3:00 PM-7:00 AM, revealed At approximately 3:30 AM, I administered [Resident 1] his ordered medication and directly observed him taking it. The statement mentioned nothing about the 12:00 AM dose, in which Resident 1 stated he did not receive. During an interview with the Director of Nursing (DON) on December 22, 2025, at 11:40 AM, she stated that Employee 1 was an agency nurse and the DON notified the agency of the allegation and notified the agency that the nurse was not to return to the facility to work. She further stated that the police were notified but she has not yet received an update regarding their investigation. The DON stated that she called Employee 1 in for a face-to-face interview and for a drug test, but Employee 1 was a no-show. Review of Resident 2's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung, leading to inflammation and other problems that block airflow and make it hard to breathe) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 2's MAR revealed an order for oxycodone 5 mg, give one tablet every 12 hours as needed for pain. Review of Resident 2's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 7, 2025, at either 2:30 PM or 4:30 PM. The time was illegible. Review of Employee 1's timecard revealed she did not clock in on December 7, 2025, until 2:47 PM. Review of the MAR revealed the oxycodone was not signed off as being administered at 2:30 PM nor 4:30 PM. -December 7, 2025, at 4:47 PM-signed off on the MAR at 4:47 PM. -December 8, 2025, at 4:40 AM-not signed off on the MAR as being given. Review of a statement from Resident 2, dated December 8, 2025, revealed that Resident 2 stated the last time he asked for his oxycodone was on December 6, 2025.Review of Resident 2's MAR revealed he received his oxycodone on December 6, 2025, at 2:13 AM. During an interview with Resident 2 on December 22, 2025, at 1:38 PM, he stated his chart says that he received pain medication when he didn't. He stated the incident happened a couple of weeks ago. Review of Resident 3's clinical record revealed diagnoses that included COPD and anxiety disorder (persistent, excessive worry about everyday things). Review of Resident 3's December 2025 MAR revealed an order for oxycodone 5 mg, give one tablet every 3 hours as needed for pain. Review of Resident 3's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 2, 2025, at 4:15 PM- signed off on the MAR as being administered at 4:03 PM, prior to the medication being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395428 If continuation sheet Page 2 of 4 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 12/23/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dispensed-December 2, 2025, at 8:15 PM- signed off on the MAR at 7:15 PM, one hour prior to the medication being dispensed-December 2, 2025, at 11:20 PM- signed off on the MAR at 11:25 PM-December 3, 2025, at 2:50 AM and December 3, 2025, at 6:15 AM. There was no corresponding time on the MAR for the 2:50 AM dose nor the 6:15 AM dose. There was an entry on the MAR for the oxycodone being given at 4:41 AM, but there was no corresponding time on the controlled substance record that an oxycodone was dispensed at or around 4:41 AM. Review of facility interview with the Resident, dated December 8, 2025, revealed Resident 3 stated she only takes her oxycodone at bedtime to help her sleep. During an interview with Resident 3, on December 22, 2025, at 1:51 PM, she stated that she doesn't take her oxycodone every night and if she does take it, she does not take it more than once a night. Resident 3 was asked if she can recall a night that she took it more than once, and she denied a time that she took her oxycodone more than one time in a night. Review of Resident 3's MARs for November 2025 and December 2025, revealed that with the exception of December 2 and 3, 2025, Resident 3 did not receive her oxycodone more than one time a day/night. Review of Resident 4's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus and COPD. Review of Resident 4's December 2025 MAR revealed an order for oxycodone 5 mg, give 3 tablets every four hours as needed for severe pain. Review of Resident 4's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 7, 2025, at what appears to be 4:30 PM, although the time was illegible- signed off on MAR at 5:38 PM, one hour and eight minutes after the medication was dispensed -December 7, 2025, at 8:00 PM, which the initial time was scribbled out and 8:00 PM was written at the side-signed off on MAR at 9:48 PM, one hour and 48 minutes after the medication was dispensed -December 8, 2025, at 12:00 AM, which the initial time was scribbled out and 12:00 AM was written at the side-nothing signed off on the MAR as being given-December 8 at 3:00 AM- signed off on the MAR at 3:05 AM. Review of Resident 4's statement, dated December 8, 2025, revealed that on December 7, 2025, he stated he received pain medications around 5:30 PM and 9:30 PM. During an interview with Resident 4, on December 22, 2025, at 1:42 PM, he stated that on December 7, 2025, his last dose of pain medication was between 9 and 9:30 PM. He stated that the next day, on December 8, 2025, the unit manager had him fill out a statement of when he had his pain medication last. He stated that he really has to be in pain to ask for pain medications in the middle of the night and he rarely does that. He again confirmed that the last time he received pain medication on December 7, 2025, was between 9 and 9:30 PM. Review of Employee 1's typed statement, undated, revealed that during the 3:00 PM-11:00 PM portion of her shift, Resident 4 requested his pain medication at 4:00 PM and again at 8:00 PM. The ordered medication was retrieved and provided as requested. The statement further stated that during the 11:00 PM-7:00 AM portion of the shift, she was notified by a nurse aide that Resident 4 reported pain and requested his pain medication at 12:00 AM and 3:00 AM. Employee 1 stated I retrieved the ordered medication both times and placed it on his bedside table per his prior request. After approximately 10-15 minutes, I returned to check whether he had taken the medication, and the medication cup was no longer present on the table during both checks.Review of Resident 5's clinical record revealed diagnoses that included anxiety disorder and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 5's December 2025 MAR revealed an order for oxycodone, 5 mg, give one tablet every 12 hours as needed for pain. Review of Resident 5's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 1, 2025, although the date was barely legible, at 4:30 PM-nothing signed off on the MAR on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395428 If continuation sheet Page 3 of 4 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 12/23/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete December 1. Review of Employee 1's timecard revealed she did not work on December 1, 2025. -December 2, 2025, at 9:00 PM- signed off on MAR at 9:09 PM. Resident 5 was unable to be interviewed.Review of Resident 5's December MAR, as of December 22, 2025, revealed that the only time the oxycodone was documented as being given in December 2025 was on December 2 at 9:09 PM. Review of Resident 6's clinical record revealed diagnoses that included high blood pressure and Type 2 Diabetes Mellitus. Review of Resident 6's December 2025 MAR revealed an order for oxycodone, 5 mg, give 10 mg every four hours as needed for severe pain. Review of Resident 6's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 6, 2025, at 2:30 PM- signed off on the MAR at 3:35 PM. Employee 1 did not clock in until 2:42 PM on December 6-December 6, 2025, at 6:30 PMsigned off on the MAR at 7:26 PM, almost one hour after the medication was dispensed-December 6, 2025, at 10:30 PM- signed off on the MAR at 10:30 PM. Resident 6 was discharged from the facility on December 18, 2025, and therefore was unable to be interviewed. Review of Employee 1's typed statement, undated, revealed that during her December 7, 2025 shift, from 3:00 PM-7:00 AM, revealed All medications given during the shift were documented and signed off in both the electronic medication administration record and the paper medication book immediately after administration. During an interview with the Nursing Home Administrator, DON, and ADON, on December 22, 2025, at 2:23 PM, the DON and ADON stated that nurses should give and document controlled substances within a couple minutes of dispensing the medication, not an hour or more later. They further stated that medications should be documented every time they are given. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395428 If continuation sheet Page 4 of 4