Health inspection·December 6, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an investigation of an unknown injury for one of one resident reviewed (Resident 28). Residents Affected - Few Findings include: The policy entitled Abuse Prohibition last reviewed on July 18, 2024, indicates that the facility uses an incident reporting system to report, investigate, and track all unusual incidents. Incidents of unknown origin are investigated according to the facility's stand-up meeting/investigation of unusual incidents. Suspicious injuries, occurrences, trends, or patterns that may constitute abuse are identified and investigated. Review of Resident 28's clinical record revealed nursing documentation dated September 26, 2024, at 2:30 PM that indicated Resident 28 was complaining of right leg pain. Nursing staff administered Tylenol (for pain relief) that was ineffective and notified Resident 28's physician. Nursing documentation dated September 27, 2024, at 2:30 PM indicated that Resident 28 continued to complain of pain in her right lower extremity from her hip to ankle. Nursing staff obtained a physician order for an x-ray of her right knee. Review of Resident 28's x-ray report dated September 27, 2024, indicated that her right knee demonstrated irregularity suggesting a tibial plateau fracture (a break at the top of the tibia bone in the knee joint, typically due to impact trauma). Nursing documentation dated September 28, 2024, at 2:04 AM revealed that the facility obtained a physician's order to send Resident 28 to the emergency room for treatment of her injury. Review of the emergency room documentation dated September 28, 2024, at 3:07 AM confirmed Resident 28's right knee tibial plateau fracture and indicated that her diagnosis also included ligamentous knee injury (a tear or sprain in one of the knee's four major knee ligaments). Nursing documentation dated September 28, 2024, at 11:00 AM revealed that Resident 28 returned from the emergency room with a right leg immobilizer (a splint used to keep stabilize or restrict movement of the leg). There was no documented evidence or incidents noted in Resident 28's clinical record to indicate how this injury occurred. Interview with the Director of Nursing on December 5, 2024, at 9:08 AM confirmed that the facility did not complete an investigation into Resident 28's fractured tibial plateau fracture to rule out the potential for abuse and neglect. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 2 of 21 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 12/06/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 23 residents reviewed (Residents 108 and 112). Residents Affected - Few Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting her right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. Further review of Resident 108's clinical record revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 25, 2024, in which facility staff assessed Resident 108 as having no impairment of her upper extremities. Interview with the Director of Nursing on December 5, 2024, at 10:22 AM confirmed Resident 108's functional limitation in her range of motion was coded in error on the MDS dated [DATE]. Review of Resident 112's clinical record revealed an MDS dated [DATE], that indicated the facility assessed him as being discharged to a hospital setting. Nursing documentation dated September 21, 2024, at 10:35 AM revealed that the facility discharged Resident 112 to his home. Interview with the Director of Nursing on December 5, 2024, at 10:23 AM confirmed that Resident 112's September 21, 2024 MDS was coded in error regarding his discharge status. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 3 of 21 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 12/06/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure quality of care related to a cardiac pacemaker use for one of 23 residents reviewed (Resident 68). Residents Affected - Few Findings include: Interview with Resident 68 on December 4, 2024, at 11:14 AM revealed that she had a history of heart disease, and that she had a cardiac pacemaker (medical device implanted in the chest with wires to the heart to deliver electrical signals to control a heart rate) placed. Resident 68 pointed to an electronic device on her bedside stand and stated that a representative from the pacemaker monitoring company calls the nurses' station when she begins to show signs that fluid is accumulating in her body. Resident 68 stated that her Lasix (diuretic medication, used to remove excess fluid from the body) is sometimes adjusted because of this symptom change. Clinical record review for Resident 68 revealed no physician orders or plan of care that indicated that Resident 68 had a cardiac pacemaker. Diagnoses listed in Resident 68's clinical record included the following: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (ongoing failure of the heart to pump effectively that results in fluid buildup in the body that can worsen suddenly requiring treatment) Paroxysmal atrial fibrillation (irregular heartbeat in the upper part of the heart that can be intermittent) An admission physician's progress note (history and physical) dated July 18, 2024, indicated that the facility admitted Resident 68 following a hospitalization for heart failure. The documentation noted a surgical history that included heart ablation (sections of the heart are surgically treated to stop abnormal electrical signals, Ablate Heart Dysrhythm Focus). The documentation indicated that Resident 68 had an, AICD (automatic implantable cardioverter defibrillator, battery-operated device that can provide electrical impulses to maintain a normal rhythm and provide electrical shocks to the heart to correct life-threatening fast rhythms) per her records. The surveyor reviewed the above concerns that Resident 68 had an internal cardiac pacemaker; however, her physician orders and plan for her care did not address the use of this device, during an interview with the Director of Nursing and the Nursing Home Administrator on December 5, 2024, at 2:00 PM. A physician's order (following the surveyor's questioning) dated December 5, 2024, at 4:37 PM noted that Resident 68 had an, ACID and HF Integration, completed for alerts and every 91 days as scheduled by a consulting cardiology provider. The cardiology provider monitors and would notify the facility of any issues. Interview with the Director of Nursing on December 6, 2024, at 10:07 AM confirmed that Resident 68's cardiac pacemaker device could identify a potential fluid accumulation around her heart for which the monitoring company would call the facility. The facility was unaware how this device (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 4 of 21 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 12/06/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm communicates with the monitoring company (e.g., via satellite, internet, cell phone); or what emergency procedures (e.g., power supply) would be necessary to continue its functioning when the facility would experience an interruption in utilities. The interview also confirmed that the device was not addressed in Resident 68's plan of care. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 5 of 21 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 12/06/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for one of three residents reviewed (Residents 108). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following a cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. She stated that she no longer receives physical therapy. Review of Resident 108's admission Minimum Data Set (MDS, an assessment completed at specific intervals to determine care needs) dated September 25, 2024, noted Resident 108 had impairment on one side of her lower extremity. Review of physical therapy documentation dated November 8, 2024, noted the discharge recommendations for Resident 108 was for staff to complete passive range of motion (PROM) and active range of motion (AROM) exercises to both Resident 108's lower extremities to maintain ability for clothing management and daily hygiene tasks. Therapy discharge documentation noted therapy established PROM/AROM exercises and trained staff. Further review of Resident 108's clinical record revealed no evidence that staff implemented PROM or AROM programs. Interview with Employee 5 (physical therapist) on December 6, 2024, at 10:30 AM confirmed that a range was motion program was never established for Resident 108, and nursing staff were not educated. The above findings for Resident 108 were reviewed with the Director of Nursing on December 6, 2024, at 1:12 PM. 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 6 of 21 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 12/06/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement care to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis services (Resident 62). Residents Affected - Few Findings include: Interview with Resident 62 on December 3, 2024, at 12:58 PM revealed that he required dialysis treatments (treatment for kidney failure; a machine filters extra fluid and waste products from the blood) three times a week, and that the treatment was administered through a fistula (surgical connection between an artery and a vein making a larger blood vessel for dialysis treatment) located in the area over his right bicep (upper arm) muscle. Resident 62 stated that staff obtain blood pressure assessments from his leg. Resident 62 stated, Once in a while a nurse will come in and think that she's going to take it in my arm, but I tell her to do it in my leg. Observation of Resident 62 and his room during the interview revealed no indicators that Resident 62 had right arm use restrictions. Clinical record review for Resident 62 revealed no physician's order or plan of care intervention that restricted staff use of his right arm for blood pressure assessments or blood draws. The surveyor reviewed the above concern that staff could utilize Resident 62's right arm inappropriately causing potential damage to his dialysis fistula during an interview with the Nursing Home Administrator and the Director of Nursing on December 4, 2024, at 2:00 PM. Interview with the Director of Nursing on December 5, 2024, at 10:40 AM confirmed that the right arm limb restriction was not included in Resident 62's plan of care until following the surveyor's questioning. Observation of Resident 62's room on December 6, 2024, at 9:15 AM revealed that Resident 62 was out of the facility for his dialysis treatment. A sign above the right side of his bed noted, No BP (blood pressure) right arm. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 7 of 21 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 12/06/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two of two residents reviewed for accident hazards (Residents 19 and 108). Findings include: Observation of Resident 19 on December 4, 2024, at 11:52 AM revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Resident 19's bed was also equipped with a headboard and a footboard. The surveyor requested evidence of an assessment for need, an assessment for entrapment risks, and consent for the use of the bed assistive devices for Resident 19 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 8 (registered nurse/infection control prevention coordinator) on December 4, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on December 5, 2024, at 10:10 AM indicated that the facility utilized a bed system measurement device to assess four zones of potential entrapment risks presented with the use of a bed rail. The interview indicated that the facility could not provide documentation of the assessment completed to determine Resident 19's need for the assistive device, the assessment of potential entrapment risks from the use of the device on Resident 19's bed, or a consent obtained prior to installation of the device for Resident 19. A new physician's order obtained on December 5, 2024, at 11:04 AM (following the surveyor's questioning), indicated that Resident 19 was to use a bed enabler rail to assist with bed mobility. A Side Rail Assessment Form dated December 5, 2024, indicated that occupational therapy staff recommended side rails as an enabler for Resident 19. A Side Rail Consent Form signed by Resident 19 on December 5, 2024, indicated a desire for the assistive device. A Bed System Measurement Device Test Results Worksheet dated December 5, 2024, indicated that maintenance staff assessed Resident 19's bed assistive device for entrapment risks. Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM, revealed that she has limited range of motion to her right side following her stroke. Observation of Resident 108 on December 3, 2024, at 11:26 AM and 1:14 PM, revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Observation of Resident 108 on December 4, 2024, at 11:17 AM revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Observation of Resident 108 on December 5, 2024, at 11:01 AM revealed she was in bed, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 8 of 21 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 12/06/2024 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 0700 assist bars were removed bilaterally from the head of her bed. Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator on December 5, 2024, at 11:57 AM confirmed that Resident 108 was unable to use the bilateral assist bars mounted on her bed. He stated the facility had no documentation of the assessment completed to show the need for Resident 108's assist bars, the assessment of potential risks from the use of the device on Resident 108's bed, or consent obtained prior to the installation of the device for Resident 108. Residents Affected - Some 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 9 of 21 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 12/06/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs related to call bell response time for two of 23 residents reviewed (Resident 19 and 52). Findings include: Interview with Resident 19 on December 4, 2024, at 11:34 AM revealed that when she rings her call bell, staff will come in and then say they will be back but never come back. Review of Resident 52's Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 11, 2024, indicated the facility assessed her as being cognitively intact and needing the extensive assistance of two staff members for toileting. Observation on December 3, 2024, at 9:54 AM revealed that Resident 52 rang her call bell. The call bell continued to ring until 10:26 AM, 32 minutes after Resident 52 initiated the call bell. At 10:26 AM, Employee 1, nurse aide, entered Resident 52's room, the call light went out, and Employee 1 immediately walked back out of Resident 52's room. Interview with Resident 52 on December 3, 2024, at 10:29 AM revealed that she needed to move her bowels and needed the bed pan but Employee 1 flew out of here. This surveyor instructed Resident 52 to ring the call bell again. After Employee 1 exited Resident 52's room, this surveyor observed her collecting breakfast trays. Employee 1 was not providing any other care to residents. Observation on December 3, 2024, at 10:29 AM revealed that Resident 52's call bell was answered a second time, 35 minutes after Resident 52's initial call for assistance. Review of Resident 52's clinical record revealed that she has a diagnosis of irritable bowel syndrome (a condition that affects the digestive system). Nursing documentation dated December 2, 2024, at 4:40 PM indicated that Resident 52 had not had a bowel movement for three days. Nursing staff administered Milk of Magnesia (a medication used to treat occasional constipation) on December 2, 2024, at 6:31 PM. Interview with the Administrator and Director of Nursing on December 5, 2024, at 2:00 PM acknowledged the above findings for Resident 52. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 10 of 21 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 12/06/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to ensure adequate labeling and storage of medications and biologicals on one of three nursing units (Station III) and for one of 23 residents reviewed (Resident 29). Findings include: Observation of the Station III nursing unit on [DATE], at 10:41 AM revealed an unlocked medication cart. The medication cart was sitting in a heavily occupied area of the nursing station. The unlocked medication cart was accessible to non-licensed staff, visitors, and other residents. The unlocked medication cart remained unattended until 10:46 AM. Interview with Employee 3, licensed practical nurse, on [DATE], at 10:46 AM confirmed the above observations. During a medication administration observation on [DATE], at 9:00 AM revealed Employee 2, licensed practical nurse, administering medications to Resident 29. Employee 2 indicated that Resident 29 administers her own eye drops. Employee 2 prompted Resident 29 to find her eye drops and administer them during the medication administration observation. Resident 29 reached into a zippered pouch that contained other items such as writing implements and pulled out a bottle of eyedrops. The bottle of eyedrops had some small brown colored stains on it, and the label was rubbing off. The eyedrops were not labeled with the resident's name or administration details. This surveyor was unable to identify that actual name of the eyedrops, other than it was a saline eye drop. Resident 29 could not remove the lid to the eyedrops, as the lid appeared stuck. Employee 2 had to assist Resident 29 to remove the stuck lid. The bottle of eye drops had an expiration date of [DATE]. Resident 29 administered the eyedrops using the bottle of eyedrops she found in her zippered pouch. Employee 2 then told Resident 29 that those eyedrops were expired after the surveyor informed her of the expiration date. Interview with the Administrator and Director of Nursing on [DATE], at 2:03 PM acknowledged the above findings. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 11 of 21 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 12/06/2024 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine prophylactic dental services for one of three residents reviewed for dental concerns (Resident 62). Residents Affected - Some Findings include: Interview with Resident 62 on December 3, 2024, at 12:49 PM revealed that he had natural teeth, but the, hygienist has never been here. Resident 62 indicated that no dental professional had cleaned his teeth, and he brushes his teeth. Interview with the Director of Nursing on December 5, 2024, at 10:40 AM confirmed that there was no evidence that a hygienist or dental professional provided prophylactic (preventative) cleaning of Resident 62's teeth in the past year. Following the interview with the Director of Nursing, the facility provided one progress note from the facility's consulting dental provider dated September 17, 2024, that was noted as an annual exam by the dentist. The progress note indicated that there was heavy soft plaque/food debris buildup, light hard calculus (hard deposit when soft plaque becomes calcified) deposits, moderate gingival (gum) inflammation/swollen bleeding gums, and moderate risk for caries (cavities/decay). The recommended treatment plan was for prophy (preventative cleanings) every six months. The facility provided no clinical record evidence that Resident 62 received routine prophylactic dental cleanings in the past year. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 12 of 21 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 12/06/2024 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 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 items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Residents Affected - Some Findings included: Initial tour of the facility's main kitchen on December 3, 2024, between 7:55 AM and 9:00 AM revealed the following: The dry storage goods area revealed the following: A bag of elbow macaroni had a blank date sticker on it and contained no open or use by date. There was a hole in the bottom of the bag. A temperature control unit on the wall had a significant accumulation of a black substance on the vents. An open container of whole rosemary had an expired use date of May 2024. An open container of blue food coloring had an unreadable use by sticker. The bottle was hand dated 1-30-19. The walk-in freezer contained several cardboard boxes that held food items (snickerdoodle dough, whipped topping, and cherry turnovers) that were located under the internal circulation fans. The boxes had a large accumulation of ice on them. A walk-in cooler contained eight cardboard boxes that held orange juice containers. The boxes noted, store at 0 degrees Fahrenheit. Three boxes observed were stamped by the facility with a date of November 8, 2024, and one box had a date of October 30, 2024. A concurrent interview with Employee 6, Dietary Manager, revealed the dates indicated when the items were pulled from the freezer to thaw for use. A review of the manufacturer's instructions for the items revealed the items come frozen, thaw before serving, mark each case with the date the product was thawed, once thawed the items are to be kept refrigerated, and once thawed they are to be used within 10 days of thawing. The orange juice was not used within 10 days of thawing. Further observation of the walk-in cooler revealed a low-fat cottage cheese with an expired use by date of 12/2, and two open bags of cubed cheese that had an expired facility use by date of 12-2-24. Observation of a second walk-in cooler revealed the following: Several clear containers of pudding with expired facility use by dates of December 1, 2024, and December 2, 2024. A thawed box of hot dogs with a facility use by date of 11/30/24. A container of hot dog chili sauce with a manufacturer's use by/freeze by date of November 29, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 13 of 21 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 12/06/2024 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 2024. Level of Harm - Minimal harm or potential for actual harm Two containers of baked lima beans with an expired use by date of November 24, 2024. A large bag of shredded lettuce with an expired use by date of November 30, 2024. Residents Affected - Some Two coated wire storage racks of items located near the center of the kitchen, that Employee 6 identified as clean, had items stored on the bottom shelves (one rack had various baking pans; the other rack had large black colored storage tubs and plate lids). There was no protective covering to protect these clean items on the bottom shelf from mop splash during floor cleaning. A green colored plastic tray in the sink next to the dishwasher had an extensive build-up of a black colored substance on it. A temperature control unit located on the wall in the food prep area had visible dust on it and a black colored build-up on the vents. The tops of the commercial coffee machine and juice machine had an accumulation of dust. Observation revealed an employee at a food prep area with a beard and no facial hair restrainer (beard guard). The employee was identified by administrative staff as Employee 7, dietary staff, and revealed the employee should have a beard cover. The above findings were reviewed with Employee 6 at the time of the findings. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 4, 2024, at 2:50 PM. 483.60(i) Food Procure, Store/Prepare/Serve -Sanitary Previously cited 1/5/24 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 14 of 21 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 12/06/2024 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for three of three residents reviewed with a signed arbitration agreement (Residents 19, 62, and 68). Residents Affected - Some Findings include: Review of an Agreement to Resolve Disputes by Voluntary Mediation and/or Mandatory Binding Arbitration, (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving the right to a trial) signed by Resident 19 on February 22, 2023, revealed that the document stipulated that, Subject to Section 6 of this Agreement, the Arbitration shall be administered by (name of arbitrator services company designated by the facility). In the event (name of arbitrator services company designated by the facility) is unable or unwilling to serve, then the request for Arbitration must be submitted to the Facility within thirty (30) days of receipt of notice of (name of arbitrator services company designated by the facility) unwillingness or inability to serve as a neutral arbitrator. The parties shall mutually select an alternative neutral arbitration service within thirty (30) days thereafter. The agreement afforded the facility the selection of the arbitrator (third-party decision-maker contracted to resolve a dispute) initially unless the facility-selected arbitrator could not provide the services. Resident 62 signed an arbitration agreement with the same verbiage on April 20, 2023. Resident 68 signed an arbitration agreement with the same verbiage on July 15, 2024. The surveyor reviewed the above concerns regarding the arbitration agreements signed by Residents 19, 62, and 68 during an interview with the Nursing Home Administrator and the Director of Nursing on December 4, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on December 5, 2024, at 10:10 AM confirmed that the facility's current arbitration agreement did not stipulate that both parties would agree upon a neutral arbitrator unless the arbitrator that was selected by the facility was unable or unwilling to provide the services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a)(j) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 15 of 21 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 12/06/2024 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 a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement transmission-based precautions for one of 23 residents reviewed (Resident 103). Residents Affected - Few Findings include: Review of the facility policy, Contact Precautions, last reviewed without changes on July 18, 2024, revealed that in addition to standard precautions, use contact precautions for specified residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin-to-skin contact that occurs when performing resident care activities that require touching the resident's dry skin) or by indirect contact (touching) with environmental surfaces or resident care items in the patient's environment. In addition to wearing a gown as outlined under standard precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent. A sign will be posted at the resident's doorway to indicate to visitors that they should check with the nurse before entering to ensure proper precautions are followed. A physician's order will be obtained and written when placing a resident on precautions and when precautions can be discontinued. Review of the facility policy, Enhanced Barrier Precautions, last reviewed without changes on July 18, 2024, revealed that enhanced barrier precautions will be initiated for any resident with an infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply. A sign will be posted at the resident's doorway to alert staff. A physician's order will be obtained and written when placing a resident on enhanced barrier precautions. Providers and staff must also wear gloves and gowns for high contact activities that include changing briefs or assisting with toileting. Clinical record review for Resident 103 revealed nursing documentation dated September 9, 2024, at 2:10 PM that the facility readmitted Resident 103 from the hospital. A physician's order dated September 9, 2024, instructed staff to administer Cephalexin (Keflex, a first-generation cephalosporin antibiotic, refers to the first group of cephalosporins discovered), every six hours for Resident 103's urinary tract infection, for five days. A laboratory report for a urine specimen collected September 9, 2024, revealed that Resident 103's urine indicated an infection with ESBL E-Coli (extended-spectrum beta-lactamases Escherichia coli, bacteria typically found in the gut that produces a chemical that makes some antibiotics ineffective in treating the bacterial infection), This patient may require isolation. This gram-negative bacilli displays in vitro (experiments outside a living organism) resistance to multiple antibiotics. This patient may require isolation. The report indicated that the E-Coli found was resistant to Cefazolin (a first-generation cephalosporin). Nursing documentation dated September 13, 2024, at 7:44 PM indicated that the physician ordered the antibiotic, Cipro, to treat Resident 103's urinary tract infection (UTI). Resident 103 received the antibiotic, Keflex, previously. Review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 16 of 21 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 12/06/2024 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 determine resident care needs) dated November 6, 2024, assessed Resident 103 as always incontinent of bowel and bladder. There was no evidence in Resident 103's clinical record to indicate that the facility implemented any isolation precautions for Resident 103 upon her readmission to the facility or after the final laboratory report that indicated an infection with a multiple drug resistant organism (MDRO). Review of plans of care developed by the facility to address Resident 103's care needs revealed a plan of care that included Resident 103's urinary tract infection diagnosis that did not include the implementation of contact or enhanced barrier precautions. Observation of Resident 103 on December 5, 2024, at 12:41 PM revealed she was in bed, with covers pulled down to her thighs, dressed in a shirt and an incontinence brief (no pants). Interview with the Director of Nursing on December 5, 2024, at 12:50 PM confirmed that the facility did not have evidence of the implementation of enhanced barrier or contact precautions upon the knowledge of a MDRO UTI for Resident 103. The facility also did not have any additional laboratory testing that indicated the absence of the MDRO in Resident 103's urine. Interview with Employee 9 (nurse aide) on December 5, 2024, at 12:55 PM confirmed that Resident 103 was incontinent of bowel and bladder, and dependent upon staff for care, which included the use of incontinence briefs. Employee 9 stated that she was going to provide Resident 103 incontinence care for the first time since earlier that morning. Employee 9 did not use an isolation gown to indicate the use of enhanced barrier or contact precautions. There was no indication by Resident 103's doorway or in her room that indicated the use of enhanced barrier or contact precautions. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control Previously cited deficiency 1/5/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 17 of 21 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 12/06/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer and administer an influenza immunization unless refused for one of five residents reviewed for immunizations (Resident 3). Residents Affected - Few Findings include: The facility policy entitled, Influenza Vaccine, last reviewed without changes on July 18, 2024, revealed that residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and October 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized. Prior to vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record. For those who receive the vaccine, the date of vaccination will be documented in the resident's medical record. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Current CDC (Centers for Disease Control) guidance at https://www.cdc.gov/flu/vaccines stipulates that, For most people who need only one dose of influenza vaccine for the season, September and October are generally good times to be vaccinated against influenza. Ideally, everyone should be vaccinated by the end of October. Clinical record review for Resident 3 revealed that the facility admitted her on May 13, 2022. Review of Resident 3's immunization history revealed that she received an influenza immunization on January 14, 2022 (before entering the facility), and October 25, 2023 (while a resident of the facility). Resident 3's clinical record contained no evidence that she received an influenza vaccine for the 2024-2025 influenza season. The surveyor requested any additional immunization documentation for Resident 3 during an interview with Employee 8 (registered nurse/infection control prevention coordinator) on December 4, 2024, at 9:26 AM. Interview with Employee 8 on December 4, 2024, at 10:37 AM confirmed that Resident 3 was a resident in the facility for over two years, and that the facility could not produce an informed consent for the influenza vaccine since the one completed in 2023. The interview confirmed that the facility did not have evidence that Resident 3 or her responsible party declined the 2024-2025 influenza vaccine. The surveyor reviewed the above concerns regarding Resident 3's influenza vaccination status during an interview with the Director of Nursing and the Nursing Home Administrator on December 5, 2024, at 2:00 PM. Interview with Employee 8 on December 5, 2024, at 2:49 PM confirmed that there was no documentation in Resident 3's medical record regarding declination or administration of the 2024-2025 seasonal influenza vaccine. Employee 8 stated that she would attempt to find any progress note documentation regarding any contact with Resident 3's responsible party regarding obtaining consent or refusal of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 18 of 21 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 12/06/2024 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 0883 the vaccine. Level of Harm - Minimal harm or potential for actual harm Nursing documentation created by Employee 8 on December 5, 2024, at 3:12 PM indicated that she attempted to contact Resident 3's responsible party regarding vaccine consents. Residents Affected - Few 28 Pa. Code 211.5(f) Medical records 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 19 of 21 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 12/06/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for one of five residents reviewed for immunizations (Resident 3). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed without changes on July 18, 2024, revealed that each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The resident (or resident representative) could accept or refuse a COVID-19 vaccine, and to change his/her decision. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident/resident representative is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Residents/resident representatives must sign a consent to vaccinate form prior to receiving the vaccine. Booster vaccine doses are provided in accordance with current CDC guidance. Efforts to help the resident obtain vaccination are documented. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record. Clinical record review for Resident 3 revealed that the facility admitted her on May 13, 2022. Review of Resident 3's immunization history revealed that she did not receive a COVID (a contagious respiratory illness caused by a virus) immunization booster in the fall of October 2023, because Resident 3's responsible party refused the immunization consent. Nursing documentation dated August 17, 2024, at 3:11 PM revealed that testing indicated Resident 3 had COVID and the facility implemented isolation precautions. On October 25, 2024, Employee 8, registered nurse/infection control, documented that Resident 3 was not eligible for a COVID booster for 2024-2025 because the facility did not have consent to administer the vaccine. Resident 3's clinical record contained no additional information that the facility offered or administered Resident 3's COVID immunization after October 2023. Interview with Employee 8 on December 4, 2024, at 9:26 AM indicated that the facility did not administer a COVID booster to Resident 3 because Resident 3's responsible party refused the consent to the vaccine. Employee 8 stated that she would provide the consent form that documented Resident 3's responsible party's declination of informed consent. Interview with Employee 8 on December 4, 2024, at 10:37 AM confirmed that Resident 3 did not receive any COVID vaccines since her admission to the facility in 2022. The interview also confirmed that the facility could not produce an informed consent for the COVID vaccine that evidenced that Resident 3's responsible party declined the booster vaccine. The surveyor reviewed the above concerns regarding Resident 3's COVID immunization status during an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395390 If continuation sheet Page 20 of 21 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 12/06/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview with the Director of Nursing and the Nursing Home Administrator on December 5, 2024, at 2:00 PM. Interview with Employee 8 on December 5, 2024, at 2:49 PM confirmed that there was no documentation in Resident 3's medical record regarding declination or administration of a COVID booster immunization since 2023. Employee 8 stated that she would attempt to find any progress note documentation regarding any contact with Resident 3's responsible party regarding obtaining consent or refusal of the vaccine. Nursing documentation created by Employee 8 on December 5, 2024, at 3:12 PM indicated that she attempted to contact Resident 3's responsible party regarding vaccine consents. 28 Pa. Code 211.5(f) Medical records 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 21 of 21