Health inspection·February 11, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies, and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of three residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of the current facility policy entitled Pain Assessment/Management, revealed at the time of a pain interview, if it is determined that the resident is having pain on a scale of 7 to10, or severe pain (regardless of frequency), or is having frequent or constant pain (that the resident does not feel is tolerable), the resident will be placed on a pain management program, unless otherwise documented on the pain assessment. The pain management program consists of assessing/observing for pain at least every shift and updating the physician if pain is not being managed effectively. Pain management will be documented on the Medication Administration Record (MAR, a form utilized to document the administration of medications) by licensed staff. The charge nurse will update the physician if the resident's pain is not being managed effectively. Clinical record review revealed the facility admitted Resident 1 on June 26, 2024, with diagnosis including displaced bimalleolar fracture of right lower leg (a severe injury to the ankle joint and bones of the lower leg) and displaced osteochondral fracture of her right patella (a break in the cartilage and bone of the kneecap). Nursing documentation dated January 19, 2025, at 6:15 AM revealed the registered nurse found Resident 1 on the floor and upon assessment she was found with complaints of pain rating five out of 10 in her right knee. Documentation noted Resident 1's right outer canthus (the outer or inner part of the eye where the upper and lower lids meet) with a 2.5 centimeter (cm) by 3 cm ecchymotic contusion (bruising. Documentation revealed Resident 1 was assisted from the floor with a maxi lift and three staff. Resident 1 was noted to be yelling out in pain during the entire process. The registered nurse noted Resident 1's verbalization of pain did not match her cathartic reaction. The registered nurse noted as needed Tylenol and an ice pack were provided for pain relief. Nursing documentation dated January 19, 2025, at 6:15 AM revealed the licensed practical nurse found Resident 1 lying on the floor in her bathroom doorway complaining of severe pain. Review of Resident 1's neurological checklist dated January 19, 2025, noted staff assessed Resident 1's pain as a seven out of 10, noting she grimaced and showed nonverbal signs of pain. Review of Resident 1's MAR dated January 2025, noted an order dated June 28, 2024, for nursing staff to administer Resident 1 Tylenol 325 milligrams (mg), two tablets every four hours as needed for (continued on next page) 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 02/11/2025 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)