Millersburg, PA

Northern Dauphin Nursing And Rehabilitation Center

2-star overall rating with 2-star inspections with abuse icon flag with $11,921 in total fines with 10 recent health deficiencies

990 Medical Road, Millersburg, PA

(717) 692-4751

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

194

Certified beds

Average residents

162

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ephram Lahasky

Operator or chain grouping

Approved since

1979-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

28 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.50

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.74

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.86

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.10

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.24

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

2.75

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,002

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

9.09

Composite VBP score used to determine payment impact.

Payment multiplier

0.9808

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.69% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 6.29% · Performance 7.98% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.93

Baseline 54.84% · Performance 55.80% · Measure score 1.93 · Achievement 1.93 · Improvement 0

Adjusted total nurse staffing

1.71

Baseline 3.16 hours · Performance 3.56 hours · Measure score 1.71 · Achievement 1.71 · Improvement 1.05

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.87%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 53 · Observed rate 13.21% · Lower 95% interval 7.09%
Discharge to community	36.29%	50.57% 14.3 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 20% · Lower 95% interval 22.21%
Medicare spending per beneficiary	0.64	1.02 0.4 pts better
Drug regimen review with follow-up	28.13%	95.27% 67.1 pts worse	Numerator 9 · Denominator 32
Falls with major injury	3.13%	0.77% 2.4 pts worse	Numerator 1 · Denominator 32
Discharge self-care score	15%	53.69% 38.7 pts worse	Numerator 3 · Denominator 20
Discharge mobility score	20%	50.94% 30.9 pts worse	Numerator 4 · Denominator 20
Pressure ulcers or injuries, new or worsened	6.25%	2.29% 4 pts worse	Numerator 2 · Denominator 32 · Adjusted rate 4.56%
Healthcare-associated infections requiring hospitalization	7.98%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 12.5% · Lower 95% interval 4.3%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 124
Staff flu vaccination coverage	28.82%	42% 13.2 pts worse	Numerator 49 · Denominator 170
Discharge function score	25%	56.45% 31.5 pts worse	Numerator 5 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.2 0.4 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	74.9%	86.9% 12 pts worse	93.4% 18.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 68.5% · Q2 76.9% · Q3 78.2% · Q4 75.5% · 4Q avg 74.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.4%	93.5% 2.1 pts worse	95.5% 4.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.2% 0.9 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.9% · Q3 1.9% · Q4 2.6% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.8%	6.5% 2.7 pts better	11.4% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.8% · Q3 6.1% · Q4 3.5% · 4Q avg 3.8%
Percentage of long-stay residents who lose too much weight	8.7%	6.5% 2.2 pts worse	5.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.1% · Q3 8.8% · Q4 6.2% · 4Q avg 8.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.9%	19.9% About the same	19.6% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 20.0% · Q3 20.8% · Q4 18.5% · 4Q avg 19.9%
Percentage of long-stay residents who received an antipsychotic medication	23.3%	18.7% 4.6 pts worse	16.7% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 27.3% · Q3 24.0% · Q4 20.5% · 4Q avg 23.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	19.9%	19.6% 0.3 pts worse	16.3% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.0% · Q3 27.3% · Q4 23.4% · 4Q avg 19.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.8%	18.3% 4.5 pts better	14.9% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 10.3% · Q3 16.4% · Q4 16.2% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	0.9% 0.7 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.6% · Q3 1.8% · Q4 0.5% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.2%	1.7% 2.5 pts worse	1.7% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.8% · Q3 5.8% · Q4 3.3% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.6%	26.4% 0.2 pts worse	19.8% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 27.4% · Q3 25.3% · Q4 26.6% · 4Q avg 26.6%
Percentage of long-stay residents with pressure ulcers	4.4%	5.3% 0.9 pts better	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.9% · Q3 4.2% · Q4 7.9% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	33.3%	68.9% 35.6 pts worse	81.7% 48.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 26.3% · Q3 17.0% · Q4 45.0% · 4Q avg 33.3%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	9.8% 9.8 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	30.4%	68.7% 38.3 pts worse	79.7% 49.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 30.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.4%	23.1% 1.3 pts worse	23.9% 0.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 22.7% · Expected 22.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-12 · Fire 2025-06-12

10 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-07-11 · Fire 2024-07-11

18 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-09-14 · Fire 2023-09-14

16 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-23

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2026-01-20

G · Actual harm 2025-10-22

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-10-20

E · Potential for more than minimal harm 2025-06-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-07-23

E · Potential for more than minimal harm 2025-06-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-23

E · Potential for more than minimal harm 2025-06-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-23

E · Potential for more than minimal harm 2025-06-12

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-07-23

E · Potential for more than minimal harm 2025-06-12

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-07-23

D · Potential for more than minimal harm 2025-06-12

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-07-23

D · Potential for more than minimal harm 2025-06-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-23

D · Potential for more than minimal harm 2025-05-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-05-27

D · Potential for more than minimal harm 2024-12-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-01-14

D · Potential for more than minimal harm 2024-12-10

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-01-14

D · Potential for more than minimal harm 2024-12-10

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2025-01-14

D · Potential for more than minimal harm 2024-10-30

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-11-18

F · Potential for more than minimal harm 2024-07-11

F836 · Administration Deficiencies

Health

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-13

E · Potential for more than minimal harm 2024-07-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-07-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-13

D · Potential for more than minimal harm 2024-04-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-08

J · Immediate jeopardy 2023-10-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-10-05

F836 · Administration Deficiencies

Health

Corrected 2023-10-17

E · Potential for more than minimal harm 2023-09-14

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-14

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-14

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-14

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-11-08