Health inspection·January 5, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm with serious injuries, including diagnoses of traumatic subarachnoid hemorrhage (bleeding in the brain), right hip contusion, and scalp laceration for one of one resident reviewed for abuse (Resident 41). Findings include: The facility policy entitled Abuse Prohibition, last reviewed without changes on July 20, 2023, revealed it is the policy of the facility that every resident will be free from mistreatment, neglect, and misappropriation of property. The facility will do all that is within its control to prevent occurrences of abuse. This will be managed through a system of employee screening, staff training, resident and family awareness programs, procedures to identify abuse and contributing factors, procedures to report and investigate occurrences, and corrective actions to prevent occurrences of abuse. The supervision of staff to identify inappropriate behaviors, when such staff behaviors or unsafe techniques are identified, the staff member's supervisor must intervene and correct the inappropriate behavior or unsafe technique. The monitoring of the provision of care and services and supervising the delivery of care to ensure that neglect of care does not occur. Clinical record review for Resident 41 revealed nursing documentation dated December 24, 2023, at 11:20 AM noting the registered nurse entered Station One and heard yelling on the front hall. The registered nurse observed Resident 41 lying on the floor on the right side of the bed with a lift sling and lift at his feet. Blood was noted on the back of Resident 41's head. Nursing documentation dated December 24, 2023, at 6:39 PM noted Resident 41 was sent to the hospital at 12:05 PM, was admitted , and transferred to the trauma intensive care unit with diagnoses of subarachnoid hemorrhage, right hip contusion (bruise), and occipital scalp laceration. A review of the facility investigation dated December 24, 2023, at 11:20 AM revealed while Employee 8 (nurse aide) was transferring Resident 41 in the maxi lift, Resident 41 slid out from the sling and fell onto the floor. Resident 41 was noted with a hematoma forming on the back of his head, with a laceration on top of the hematoma. A statement from Employee 8 revealed she attached the lift, and at that time her hall partner returned from break and stopped in to say she would be down in a minute. Employee 8's statement revealed she began to lift Resident 41, while Resident 41's daughter was moving his wheelchair into the hall. Employee 8 noted she began to move Resident 41 into bed and without warning Resident 41 slid down through the sling, and his head hit the floor. Further review of Resident 41's clinical record revealed a physician's order dated September 12, 2023, that indicated Resident 41 transfers with two staff assist, using the maxi lift. A review of Resident 41's task history (where nurse aides document the care provided to residents) in point click care (electronic medical record) also noted Resident 41's transfer status was maxi lift with the assistance of two staff. A review of the PB22 (Provider Bulletin 22, form required from the facility to document an investigation of abuse and/or neglect) submitted to the Department of Health on December 28, 2023, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 2 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 Level of Harm - Actual harm Residents Affected - Few Employee 8 transferred Resident 41 from his wheelchair to his bed via the full mechanical lift. During the process, Resident 41 slid off the lift sling onto the floor causing a laceration to the back of his head. It was reported that another nurse aide stopped by the room and stated she would be back in a minute to help, but Employee 8 chose not to wait and proceeded on her own to lift and transfer Resident 41. The facility investigation concluded that Resident 41 was not safely secured for transfer, and a two-person assist was not present during the transfer, which was listed on Resident 41's task [NAME] for transfers. A review of Employee 8's personnel file revealed that she received a verbal warning on January 8, 2019, due to transferring a resident with one assist when the resident was care planned two assist. There was no documentation of education. Employee 8 received a verbal warning again on March 18, 2019, for transferring a resident incorrectly who was ordered a maxi lift. The verbal warning noted this is the second resident Employee 8's supervisor had witnessed her transfer not according to the resident's plan of care. There was no documentation of education. Employee 8 received a written warning on January 2, 2020, for again not following a resident's plan of care regarding two assists with a maxi lift. The written warning noted Employee 8 admitted she did not follow the resident's plan of care. A review of the Personnel Policy handbook provided by Employee 3 (human resources) revealed any employee may be discharged without warning for one of the following, including abusive and inconsiderate treatment of residents, and negligence in the performance of duties directly related to care of a resident. An interview with Employee 3 on January 4, 2024, at 12:32 PM confirmed Employee 8 had three previous violations for not transferring residents appropriately. She stated the facility does not have a specific protocol for progressive discipline, indicating it would be on a case-by-case basis. The facility failed to ensure that a resident remained free from neglect, which resulted in actual harm. These findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on January 4, 2023, at 1:22 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 3 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for one of four residents reviewed (Resident 8). Findings include: A review of Resident 8's clinical record revealed that the facility transferred her to the hospital on November 5, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 8's transfer to the hospital. Interview with Employee 2, social worker, on January 4, 2024, at 10:14 AM confirmed the above findings and indicated that she had not sent any transfer notices to the Office of the State Long-Term Care Ombudsman for resident transfers. Employee 3 indicated that she was pulling the wrong report and transfers were not listed on the report that she sent. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 4 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 2). Residents Affected - Few Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 2 revealed a current physician's order for staff to administer Oxygen 2 LPM (liters per minute) via nasal cannula (NC, tubing to deliver Oxygen via the nose) at HS (hour of sleep, bedtime). Observation of Resident 2's Oxygen concentrator on January 2, 2024, at 11:18 AM revealed that their Oxygen was set at 3 LPM. Concurrent interview with Resident 2 revealed that the Oxygen concentrator was to be set at 2 LPM, that she was unable to turn the concentrator off herself, and she forgot to ask staff to turn it off when they were in her room. Further observation of Resident 2 on January 3, 2024, at 8:58 AM revealed she was sleeping in bed and her oxygen concentrator was set at 3 LPM. On January 4, 2024, at 9:32 AM Resident 2 was not wearing their Oxygen NC. The NC was unbagged and lying across the top of the Oxygen concentrator. The concentrator was turned off and there was a bag attached to the concentrator and available for the NC to be placed therein. The surveyor reviewed the above information for Resident 2 during with the Director of Nursing on January 4, 2024, at 10:00 AM and 2:45 PM. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 5 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food and maintain equipment in a sanitary manner and ensure temperature monitoring was in place to prevent the potential spread of food borne illness in the facility's main kitchen. Findings included: An observation of the facility's main kitchen with Employee 1 (food service director) on January 2, 2024, from 9:39 to 9:56 AM revealed the following: In the dry storage room, there was a bag of frosted flakes cereal opened, not secured, and not dated. There was a bag of powdered sugar opened with a use-by date of December 21, 2023, available for use. In the freezer, there was an open bag of frozen chicken breasts, with three chicken breasts, not secured, or dated. In the refrigerator, there was a pan of prime rib, covered with no date. An interview with Employee 1 revealed that the meat was cooked prior. Observation of the cool-down logs with Employee 1 on January 2, 2024, at 9:46 AM revealed the prime rib was listed on the log but there were no temperatures recorded. An interview with Employee 1 confirmed there was no evidence that the prime rib was cooled appropriately to prevent potential food-borne illness. A review of the kitchen's dishwasher temperature logs for December 2023 revealed the following: December 2, 3, 8, 18, and 21, 2023, the wash and rinse cycle for the dinner meal was not recorded. December 4, 2023, there were no temperatures documented for breakfast, lunch, and dinner meals. Observation of the ice machine in the facility's main kitchen revealed that the ice machine did not have the appropriate air gap as defined in the 2018 International Plumbing Code. A review of the 2021 International Plumbing Code revealed the following: 801.2 Protection. Devices, appurtenances, appliances, and apparatus intended to serve some special function, such as storage of ice or foods, that discharge to the drainage system, shall be provided with protection against backflow, flooding, fouling, contamination, and stoppage of the drain. 802.1.1 Food handling. Equipment and fixtures utilized for the storage, preparation and handling of food shall discharge through an indirect waste pipe by means of an air gap. 802.3.1 Air gap. The air gap between the indirect waste pipe and the flood level rim of the waste receptor shall be not less than twice the effective opening of the indirect waste pipe. The vents on the front of the ice machine were extremely dusty. The above concerns were reviewed with the Nursing Home Administrator and Director of Nursing during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 6 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0812 a meeting on January 3, 2024, at 2:40 PM. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14 (a) responsibility of licensee Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 7 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on one of three nursing units (Nursing Unit 1; Resident 44). Residents Affected - Few Findings include: Review of the policy titled, Droplet Precautions, last reviewed without changes on July 20, 2023, revealed that in addition to standard precautions, droplet precautions will be used for residents with known or suspected to have serious illnesses transmitted by droplets (large particle droplets) that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures. An illness list included COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus). The policy further noted to wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities when there is an expectation of possible exposure to infectious material. Review of the Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated July 2023, noted the type of precautions utilized for COVID-19 infections included: Airborne, Droplet, Contact, and Standard. Further precautions and comments noted Airborne precautions preferred, N95 or higher respiratory protection, surgical mask if N95 is unavailable, and eye protection (goggles, face shield). Observation of Resident 44's room on January 2, 2024, at 12:00 PM revealed an isolation tote hanging on the door that included various personal protective equipment (PPE) such as gowns, gloves, and N95 respirators. A sign attached to the door frame indicated droplet precautions in the room. The sign noted that everyone must clean their hands before entering and when leaving the room, and to make sure their eyes/nose/mouth are fully covered before entry. Clinical record review for Resident 44 revealed the resident tested positive for COVID-19 on December 27, 2023, at 8:30 PM. A current care plan for Resident 44 revealed that the resident had a potential for complications related to a positive test for COVID-19. One of the interventions noted to implement and maintain transmission-based precautions. Observation of Resident 44's room on January 2, 2024, at 12:04 PM revealed Employee 6, housekeeping and Employee 7, housekeeping, were in the resident's room. Employee 6 was observed cleaning the stripped bed with a cleaning rag while talking to Employee 7. The resident was in a chair next to the bed. Employee 6 was observed only wearing a surgical mask and gloves. Employee 6 and Employee 7 then exited the room. Employee 6 continued to wear her mask and the gloves she was just cleaning with. An interview with Employee 6 on January 2, 2024, at 12:06 PM revealed that Resident 44 was on isolation precautions for Covid. When asked what PPE the employee was supposed to wear in the room, the employee noted she was supposed to wear a mask. Upon further questioning by the surveyor, the employee was unsure if she was to wear an N95 or gown or eye protection and would have to check. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 8 of 9 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 395390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nottingham Village 58 Neitz Road Northumberland, PA 17857 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few employee was observed twice reaching up and grabbing her surgical mask with her gloved hand and pulling it away from her face during the conversation. Employee 6 also held the cleaning rag she was using in the room to clean the bed. When further asked if Employee 6 was to wear eye protection as the sign on the door indicated the employee was unsure. Employee 6 failed to utilize the appropriate transmission-based precautions and ensure an environment free from the potential spread of infection. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on January 3, 2023, at 2:00 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 9 of 9