Health inspection·June 13, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on clinical record review, review of the facility grievance log, and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for seven of seven residents reviewed for room moves (Residents 4, 6, 11, 12, 13, 14, and 15). Findings include: Review of the facility grievance log (a log of received concerns/complaints) revealed a concern form submitted by Resident 4's family related to a room move. The grievance form was dated June 4, 2024. The concern was presented in an attached letter. The letter was from Resident 4's daughter and indicated that her brother was in to visit her father on June 4, 2024, and was told by her father that he was moving to another room. The letter indicated that they were upset because of the lack of communication as they were not notified ahead of time of the room move. Interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 12:15 PM revealed that Resident 4's room was moved from B unit to C unit, along with several other residents on June 4, 2024, in order to consolidate and temporarily close down a unit due to low census and staffing. He indicated that the residents/responsible parties were provided with a 24-hour notice of the room moves by telephone. He said that Resident 4's responsible party was supposed to be called but the person responsible missed calling them. The grievance form indicated the same. He also acknowledged that the notification was not provided in writing to the resident or to the responsible parties. The surveyor obtained a list of room moves that occurred in the facility on June 4, 2024, from the NHA and six other residents were reviewed related to the room moves. Review of Resident 6's clinical record revealed that she moved from B-unit to C-unit on June 4, 2024. There was a progress note dated June 4, 2024, at 10:05 AM, a little less than five hours prior to the room move, that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 11's clinical record revealed that he moved from C-unit to A-unit June 4, 2024. There was a progress note dated June 5, 2024, at 6:05 PM that indicated the resident and the responsible party were notified of the room move via telephone Review of Resident 12's clinical record revealed that she moved from B-umit to C-unit on June 4, 2024. There was a progress note dated June 4, 2024, at 10:00 AM, just 5 hours prior to the move, that indicated the resident and the responsible party were notified of the room move via telephone. (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: 395172 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 395172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Penn Village, The 51 Route 204 Selinsgrove, PA 17870 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)