Northern Dauphin Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Northern Dauphin Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 5, 2023

  Based on facility policy review, clinical record review, and interviews with residents and staff, it was determined that the facility failed to implement a process to ensure effective safety measures to prevent elopement, prior to and following incident of resident elopement, for two of 26 residents reviewed who are permitted to go outside independently (Residents 1 and 2). This failure placed Residents 1 and 2 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. […]

• Actual harm, isolatedF600Oct 22, 2025

  Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from abuse, which resulted in actual harm as evidenced by multiple skin tears and penetrating wounds to the back of the head and neck after a resident to resident altercation for one of three residents reviewed (Resident 2). Findings Include:Review of facility policy, titled Abuse Policy, undated, revealed, in part, the resident has the right to be free from abuse. […]

• Actual harm, isolatedF689Dec 2, 2022

  Based on clinical record review, review of select facility documentation, and staff and resident interviews, it was determined that the facility failed to implement interventions to ensure resident safety during transport, which resulted in actual harm, evidenced by an acute tibia (shin bone) fracture for one of three residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting left side (inability to move, severe weakness, or rigid movement on either side of the body that occurs when blood flow to a part of the brain is suddenly stopped and oxygen cannot get to that part, causing damage to the brain cells) and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF836Jul 11, 2024

  Based on a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, S211.12 Nursing Services, dated February 23, 2023; with an effective date of July 1, 2023, indicated the following subsections. (f.1) In addition to the director of nursing services, a facility shall provide all of the following: (2) Effective July 1, 2023, a minimum of 1 nurse aide (NA) per 12 residents during the day, 1 NA per 12 residents during the evening, and 1 NA per 20 residents overnight. […]

• No harm, potential for more than minimal, widespreadF880Jun 17, 2021

  Based on review of the facility's infection control policy, observations and staff interviews, it was determined that the facility failed to consistently implement and maintain infection control practices, including PPE use, to prevent spread of the COVID-19 infection on two of two nursing units observed (First and Second floor nursing units). Findings include: Review of the facility's current policy titled, Coronavirus (Covid-19) Policy Interim Infection Prevention and Control Guidance and Policy is to provide an overview of key actions required to prevent the potential of infection to patients and staff. […]