Health inspection·January 25, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure the proper safety and security of medication dispensing for one of three residents reviewed (Resident CR1). Findings include: The policy entitled Storage of Medications, last reviewed on January 20, 2024, indicates that the medication supply is accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications. The policy entitled Administration Procedures for all Medications, last reviewed on January 20, 2024, does not include written guidance ensuring that the licensed nurse who pours the medication should also be the same person who administers the medication. Review of Resident CR1's closed clinical record revealed that the facility admitted her on January 8, 2024, for end-of-life care. A physician's order dated January 11. 2024, indicated that nursing staff were to administer Morphine (a narcotic pain reliever) 20 mg (milligrams) per ml (milliliters) .25 ml (milliliters) every one hour as needed for terminal distress. Interview on January 25, 2024, at 10:15 AM with Employee 1, licensed practical nurse, revealed that on the weekend of January 13, 2024, or January 14, 2024, she prepared a dose of Resident CR1's morphine and handed the syringe to Employee 2, licensed practical nurse, to administer. Employee 2 was visiting a dying family member but on medical leave from the facility and not working when Employee 1 let her administer the morphine to Resident CR1. Employee 1 did not safely ensure the correct dispensing of Resident CR1's morphine. Interview with the Administrator and Director of Nursing on January 25, 2024, at 2:30 PM confirmed the above findings. 28 Pa. Code 211.9 (a)(1)(c)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395390 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 01/25/2024 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)