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Complaint Investigation

Northern Dauphin Nursing And Rehabilitation Center

December 23, 2025 · Millersburg, PA · 990 Medical Road
Citations 1
CMS Rating 2/5
Beds 194
Provider ID 395428
Healthcare Facility
Northern Dauphin Nursing And Rehabilitation Center
Millersburg, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER in MILLERSBURG, PA — inspection on December 23, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

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

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLERSBURG, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.