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. Page 1 of 2 395172 395172 06/13/2024 Manor at Penn Village, The 51 Route 204 Selinsgrove, PA 17870

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 13's clinical record revealed that she moved from B-unit to C-unit on June 4, 2024, at 3:00 PM. There was a progress note dated June 4, 2024, at 10:03 AM, a little less than five hours before she moved, that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 14's clinical record revealed that she moved from B-unit to F-unit on June 4, 2024. There was a progress note dated June 5, 2024, at 5:50 PM that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 15's clinical record revealed that he moved from room B-unit to C-unit on June 4, 2024. There was a progress note dated June 5, 2024, at 6:04 PM that indicated the resident and the responsible party were notified of the room move via telephone. The facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for Residents 4, 6, 11, 12, 13, 14 and 15. The NHA and Director of Nursing were made aware of the concerns related to room moves during a meeting on June 13, 2024, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing services 395172 Page 2 of 2