Health inspection·February 4, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for two of three residents reviewed (Residents 73 and 98) and maintain a resident's restorative nursing program for two of three residents reviewed (Residents 85 and 98). Findings include: Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Tasks list for Resident 85 revealed the following restorative nursing program (a formal, planned, and organized care program designed to restore lost abilities or maintain potentially deteriorating functions): Ambulation/locomotion; patient will ambulate 100 to 150 feet with a rolling walker and supervision. A physical therapy discharge summary for Resident 85 dated September 25, 2024, at 9:55 AM revealed the resident was discharged from therapy with a reason noted as maximum potential achieved, referred for a restorative nursing program/functional maintenance program. Review of facility documentation titled, Therapy Communication to Restorative Nursing Program, dated September 27, 2024, revealed recommendations from therapy that included the resident will ambulate 200 to 300 feet with a rolling walker and supervision. An interview with Employee 4, Director of Rehabilitation, on January 30, 2025, at 1:29 PM confirmed that the above program was recommended by physical therapy for Resident 85 upon discharge from therapy on September 25, 2024. Employee 4 further stated that the nurse aides complete the restorative programs with the resident. A review of the task documentation for Resident 85's restorative nursing program for October 2024, November 2024, and December 2024, revealed that there was only one date (November 7, 2024) that was documented as having the program completed until the resident went back on active physical therapy on January 10, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at 2:25 PM. There was no further clinical documentation provided by the facility for Resident 85 to indicate the restorative program was completed or why the restorative program was entered differently into the electronic health record than what therapy had recommended. Interview with Resident 73 on January 28, 2025, at 12:45 PM revealed that she was no longer receiving skilled therapy services, and staff were supposed to walk with her twice a day. Resident 73 stated that she could not recall the exact day when staff last walked with her, but it was during the previous week. Resident 73 stated that staff said to her, .why don't (skilled therapy staff) come up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 2 of 28 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 02/04/2025 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)

F 0688 and walk you? Level of Harm - Minimal harm or potential for actual harm Clinical record review for Resident 73 revealed an active physician's order dated January 9, 2025, that instructed staff to complete a restorative nursing program for Resident 73 to ambulate 100 feet with a roller walker with supervision, verbal cues, and a brace (due to risk for hip dislocation). Residents Affected - Some Review of a Documentation Survey Report (electronic documentation completed by nurse aide staff to record care and services provided) dated January 2025, revealed that staff did not complete the restorative ambulation program with Resident 73 twice daily on any day since the physician's order on January 9, 2025. The documentation indicated that staff did not complete the program at least once a day on the following days: January 15, 2025 (staff documented not applicable for day shift) January 16, 2025 January 18, 2025 January 21, 2025 January 23, 2025 January 25, 2025 January 26, 2025 January 28, 2025 The surveyor reviewed the above concerns regarding Resident 73's restorative ambulation program during an interview with the Director of Nursing and the Nursing Home Administrator on January 30, 2025, at 1:46 PM. In an interview and observation of Resident 98 on January 28, 2025, at 2:15 PM, the resident stated he had finished his therapy last week, and that he had come to the facility almost paralyzed (partially incapable of movement) but was now walking with the use of a walker and staff assistance. Resident 98 stated since his therapy ended last week no one has walked him on the unit. Resident 98 indicated he had walked once because he went by himself to the nursing station. Review of a physical therapy discharge summary for Resident 98 dated January 23, 2025, revealed the physical therapist discharged the resident on January 23, 2025, with a diagnosis of gait impairment and recommendations for a restorative nursing program, noting the resident's prognosis to maintain his current level of functioning was good with consistent staff follow-through. In an interview with Employee 4, on January 31, 2025, at 10:13 AM, Employee 4 indicated when therapy is finished with a resident and recommending a restorative nursing program a form is completed and provided to nursing staff to order and to implement the program that is indicated on the nursing units. A Therapy Communication to Restorative Nursing Program form for Resident 98 dated January 23, 2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 3 of 28 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 02/04/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm indicated the resident's functional status on that date was ambulating 200-250 feet with a rolling walker and contact guard (caregiver places one to two hands on the resident to help with balance) assistance, and transfers with assistance. The recommendation on the form was for the resident to be ambulated up to 250 feet using a rolling walker and staff assistance for mobility and to perform other active range of motion therapeutic exercises to the resident's bilateral lower extremities in three sets of 10. Residents Affected - Some There was no evidence provided to indicate Resident 98's restorative nursing program to include mobility and range of motion was ordered/implemented or completed at all since his discontinuation of therapy on January 23, 2025. An interview with the Nursing Home Administrator on January 31, 2025, at 10:35 AM confirmed the above findings regarding Resident 98. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited: 1/26/2024; 3/6/2024 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 4 of 28 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 02/04/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions to prevent future falls or accidents for two of six residents reviewed for falls (Residents 83 and 164). Findings include: Clinical record review for Resident 83 revealed a physician's order dated November 1, 2023, for staff to position fall mats beside Resident 83's bed bilaterally. A plan of care developed by the facility identified Resident 83's risk for falls related to gait and balance problems, incontinence, sits himself up on the side of the bed, and is impulsive (will attempt to pick things off floor independently). The plan of care listed interventions that included Resident 83 was not to sit on the side of his bed for meals. He was to be out of bed in his wheelchair for meals or sit up 90 degrees in bed with a tray table in front of him. The plan of care did not include an active intervention to use bilateral fall mats beside his bed although there was an active physician's order to implement them. Observation of Resident 83 on January 28, 2025, at 12:05 PM revealed he was in his bed with a fall mat on the left side of his bed. There was no fall mat on the right side of his bed. Staff entered the room to deliver Resident 83's lunch meal tray. Staff lowered Resident 83's bed so his feet would touch the floor and assisted him to sit on the side of his bed to eat his lunch. Staff assisted Resident 83 with opening or cutting food items and left the room while Resident 83 began eating his lunch. Observation of Resident 83 on January 30, 2025, at 9:39 AM revealed he was in bed. There was only one fall mat positioned on the floor on the left side of his bed. There was no fall mat on the right side of his bed. Interview with Employee 6 (licensed practical nurse) on January 30, 2025, at 9:41 AM confirmed that Resident 83 only had one fall mat on the left side of his bed. Employee 6 made a telephone call to obtain another fall mat for Resident 83. The surveyor reviewed the above concerns related to Resident 83's positioning for his lunch meal and his fall mats during an interview with Employee 1 (assistant director of nursing) and the Nursing Home Administrator on January 31, 2025, at 10:34 AM. The interview confirmed that Resident 83's plan of care was corrected to have bilateral fall mats after the surveyor's questioning. The interview indicated that the facility discontinued the intervention to prevent Resident 83 from sitting on the side of his bed for meals after the surveyor's questioning. The policy entitled Accident and Incident Investigation last reviewed on December 16, 2024, indicates that certain accidents and incidents, including injuries of unknown origin, will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. The investigation will included interviews with the resident, all staff involved (directly or indirectly), and any family, visitors, or volunteers, which may have had contact with the resident and may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 5 of 28 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 02/04/2025 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)

F 0689 help with the investigation. Level of Harm - Minimal harm or potential for actual harm Review of Resident 164's clinical record revealed nursing documentation dated December 8, 2024, at 4:48 PM that indicated nursing staff found a dark purple bruise measuring 29 cm (centimeters) by 18 cm on her right abdominal area and a dark purple bruise measuring 18 cm by 6 cm on her left abdominal area. Resident 164 indicated that she did not know how she got those bruises. Residents Affected - Few Review of the facility's investigation into Resident 164's bruising dated December 8, 2024, indicated that Resident 164 is unaware of her safety needs, and that she was observed bumping self on the side of her chair and bathroom rail. There was no documented evidence that the facility collected any other staff statements aside from the staff member who reported it to the nurse. There was no documented evidence to indicate that the facility attempted to implement interventions to decrease future occurrences, since determining that a cause could be the bathroom railing or her wheelchair. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Resident 164. 483.25(d)(1)(2) Accidents Previously cited deficiency 1/26/24, 5/1/24, and 9/12/24 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 6 of 28 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 02/04/2025 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)

F 0692 Provide enough food/fluids to maintain a resident's health. 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 staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition resulting in a significant weight loss for two of six residents reviewed (Residents 100 and 101). Residents Affected - Few Findings include: Clinical record review for Resident 100 revealed the resident was admitted to the facility on [DATE], from the hospital, with a history of multiple stokes (when blood flow to the brain is interrupted leading to brain cell damage). Further review revealed Resident 100 had required the insertion of a PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted into the stomach to administer food and fluids when a person is unable to eat or drink normally) on September 3, 2024, and had since transitioned to eating again by mouth. Review of Resident 100's hospital records for October 18 - November 6, 2024, prior to her admission revealed the resident was noted to be receiving a regular diet in the hospital with nutritional supplementation by mouth and enteral (by tube) feedings only if the resident's evening meal was less than 50 percent, with the ability to increase to all meals less than 50 percent if the resident regressed. Review of Resident 100's diet orders at the facility upon admission on [DATE], revealed the resident's PEG tube was still in place at the time of her admission, and a two-gram sodium diet regular texture was ordered by mouth. A water flush was ordered for the resident's PEG tube of 60 ml two times for patency (keep open), with no enteral feedings ordered. Resident 100's weight on November 6, 2024, was documented as 197.8 pounds. A nutrition evaluation dated November 8, 2024, completed by the registered dietitian noted Resident 100's meal intake was between 50-100 percent most meals, and the resident had a PEG tube present with no tube feeding orders at that time. It was noted the resident's weight on November 7, 2024, was 196 pounds, that the resident was receiving a regular diet, and the resident had a PEG tube in place but not in use. The dietitian recommended a two gram sodium restriction diet due to the resident having a history of congestive heart failure (a condition that happens when you heart can't pump blood well enough to give your body a normal supple and blood and fluids collect in your lungs and legs over time) and no enteral feed unless the residents food intake or weight declined. The resident's weekly weight would be monitored. Review of Resident 100's weight documentation revealed the resident was documented as weighing 196.1 on November 9, 2024, and decreasing to 191.4 pounds on November 18, 2024, and 191 pounds on December 2, 2024. Resident 100 lost 6.8 pounds since her admission weight on November 6, 2024, a 3.4 percent loss. A dietary note dated November 18, 2024, at 2:25 PM reflected Resident 100's weight change since admission to 191.4 pounds, and noted the resident's sodium restricted diet, that the resident was eating 50-100 percent of meals, noting some occasionally low, and the resident had enteral feeding access with no tube feeding regimen at the time. The note indicated some weight change may be due to fluid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 7 of 28 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 02/04/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shifts, although there was no supporting documentation to reflect edema or changes in edema/fluid. No dietary changes were recommended at the time. An additional dietary note for Resident 100 on December 4, 2024, at 9:08 AM referenced the resident's weight on December 2, 2024, of 191 pounds, noting no tube feedings via the PEG tube access with 50-100 completion of most meals with occasional very low intakes for three days, with no nutrition adjustments made. A review of Resident 100's meal intake records for November and December 2024, revealed the resident was consuming 50 - 100 percent of meals most often in November with some occasional lower intakes or an occasional refusal of a meal. Review of December meal intakes revealed an increase in refusal of meals, and an increase in meals with less than 50 percent consumed. Resident 100 was not documented as having a weight assessment again until December 31, 2024, which reflected a weight of 176.4 pounds, a 21.4-pound (significant 10.8 percent) weight loss since admission to the facility. There were no dietary notes, nutrition assessments, or further weekly weights for Resident 100 from December 2 to December 31, 2024, who presented a high nutritional risk upon admission and in her first month at the facility as the resident had only had the PEG tube inserted two months prior to her admission, transitioned to eating by mouth again, and presented weight loss in the first few weeks in the facility. A dietary note dated January 1, 2025, at 7:41 PM noted the weight of 176.8 pounds for Resident 100, and the resident's diet was changed to regular with no salt packed and a health shake was added by mouth with all meals, and weekly weight monitoring for four weeks was initiated. It was again noted the resident had PEG enteral feed access with no tube feeding regimen. Resident 100 was weighed on January 6, 2025, at 174.2pound, a further loss of 2.6 pounds since the December 31, 2024, weight. Resident 100 did not have a documented weight again until January 24, 2025, of 167.9 pounds, another 6.3-pound decrease, and 29.9 pounds (15 percent severe weight loss) since admission on [DATE]. A dietary note dated January 17, 2025, referenced the January 6, 2025, weight with no additional nutrition adjustments or interventions, and did not address the resident had missed a weekly weight after January 6, to the date of the note. A dietary note then dated January 24, 2025, also only referenced the weight on January 6, 2025, with an additional medication pass nutritional supplement being added, but did not address missing weekly weights. The resident was not documented as being weighed again until January 24, 2025, as noted above reflecting further loss. A physician assistant's encounter note dated January 8, 2025, indicated the resident was seen as nursing staff was asking for medication time changes as the resident was difficult to awaken in the mornings, and staff were questioning the continued need for the PEG tube as it had not been used since her admission to the facility. Physician's assistant encounter documentation dated January 15, 2025, noted staff expressed concern that the resident seemed depressed and has not been eating well, noting she lost weight since being admitted to the facility. The note indicated the tube is not being used as the resident can tolerate a regular diet. There was no evidence of any discussion if the PEG tube would need utilized for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 8 of 28 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 02/04/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm the resident, the extent of Resident 100's weight loss, or that the resident had not been weighed since January 6, 2025. Nursing documentation dated January 15, 2025, at 10:52 AM noted an appointment was made with gastroenterology regarding PEG tube removal for Resident 100 on January 23, 2025. Residents Affected - Few Resident 100 was sent to gastroenterology on January 23, 2025, for PEG tube removal despite no further weight assessment since January 6, 2025, as the resident had last reflected a weight loss, or discussion as to if the PEG tube may need to be utilized again for the resident. A review of Resident 100's consultation report from the Nutrition and Weight Management facility (gastroenterology) dated January 23, 2025, noted the resident is on nutrition support currently, tube feeds, but reportedly does not take them and has been maintaining herself on a PO (by mouth) diet alone. It was noted the removal of the tube was not warranted as the resident can have the tube stay in for nine months to a year prior to removal, and the resident is losing weight and will very likely need the PEG tube. It also noted the resident's weight needed to be monitored more closely to determine malnutrition status, and close dietitian follow up was needed to help oversee the tube care and use. Resident 100 presented to the facility as high nutritional risk and in the resident's initial weekly weights for four weeks after admission, the resident experienced decreasing weight. No further weekly weights were continued after that time when the weights ended on December 2, 2024. The resident's intakes continued to show decline in December 2024, with the next weight on December 31, 2024, reflecting a significant 21-pound weight loss since the resident's admission to the facility in the beginning of November 2024. When weekly weights were initiated again on January 1, 2025, by the dietitian, a weight was documented for January 6, 2025, with further loss, and not again until January 24, 2025, with additional weight loss. The resident's last available weight was January 27, 2025, of 166.7 a 9.7-pound loss since December 31, 2024, significant 5.4 percent for one month, and 31.1-pound loss (15.7 percent) since the November 6, 2024, admission. No feedings through the PEG tube were ordered/attempted at any time during the resident's stay as of January 31, 2025, as a supplemental intake as the resident's weight and intakes declined, or any evidence they were discussed to be implemented/attempted when the resident's intakes were poor/refused and the weight kept decreasing. The only reference regarding the PEG tube was for removal as noted above. There was no evidence adequate monitoring was implemented (weights) to monitor a high-risk resident, or that additional measures were implemented/attempted timely to prevent the significant weight loss for the resident. The above information for Resident 100 was reviewed with the Nursing Home Administrator on January 31, 2025, at 10:38 AM. Review of Resident 101's clinical record revealed that the facility weighed him on January 2, 2025, as 186.1 pounds. The facility weighed Resident 101 on January 5, 2025, as weighing 175.2 pounds, a significant 5.86 percent weight loss in just three days. A dietary note dated January 8, 2025, indicated that the registered dietician implemented weekly weights for Resident 101. Weight documented on January 9, 2025, indicated that the facility weighed Resident 101 at 164 pounds, another 6.39 percent weight loss in four days. Weight documented on January 13, 2025, indicated that the facility weighed Resident 101 at 155 pounds, another 5.49 percent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 9 of 28 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 02/04/2025 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)

F 0692 loss in four days. Level of Harm - Minimal harm or potential for actual harm There was no documented evidence in Resident 101's clinical record to indicate that Resident 101's physician was notified of continued weight loss on January 9, 2025, or on January 13, 2025, and no documented evidence that the facility implemented additional interventions to deter further weight loss until this surveyor questioning. Residents Affected - Few Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:15 AM, confirmed the above findings for Resident 101. 483.25 g(1) Maintain acceptable parameters of nutritional status Previously cited 4/9/24 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 10 of 28 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 02/04/2025 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory concerns (Residents 49 and 96). Residents Affected - Few Findings include: Clinical record review for Resident 96 revealed a diagnosis list that included the following: respiratory failure with hypoxia (low levels of oxygen in the body), chronic obstructive pulmonary disease (COPD, a lung disease that causes restricted airflow and breathing problems), and dependence on supplemental oxygen. Review of current physician orders for Resident 96 revealed an order dated January 15, 2025, that instructed staff to administer supplemental oxygen at four liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose) with humidification. Resident 96's care plan revealed the resident has COPD and an intervention noted is to administer humidified oxygen via nasal prongs as ordered. Observation of Resident 96 on January 29, 2025, at 10:38 AM and January 30, 2025, at 8:53 AM and 9:27 AM revealed that Resident 96 was in bed. The resident was being given supplemental oxygen via nasal cannula. Each observation revealed the oxygen was being administered at 1.5 LPM and not 4 LPM as ordered by the physician. Interview with Employee 7, licensed practical nurse, on January 30, 2025, at 9:27 AM revealed that Resident 96 is supposed to administered supplemental oxygen via nasal cannula at 4 LPM. Employee 7 proceeded to change the oxygen to the correct flow rate of 4 LPM as noted in the order. The above information for Resident 96 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at 2:15 PM. Clinical record review for Resident 49 revealed an active physician's order dated October 13, 2024, for staff to administer supplemental oxygen for a pulse ox (pulse oximeter, an assessment done by a small device applied to the tip of a finger to assess the amount of oxygen in the blood) below 92 percent. The order did not include at what liter flow staff were to administer the supplemental oxygen. Observation of Resident 49 on January 29, 2025, at 10:21 AM revealed no supplemental oxygen in use. Review of Resident 49's MAR and TAR (Medication Administration Record and Treatment Administration Record, electronic documentation completed by licensed staff to record care provided) dated January 2025, revealed no oxygen saturation assessments obtained by staff. Review of Resident 49's plans of care developed by the facility to address diagnoses and problems that require special focus by the facility and the implementation of individualized interventions revealed no intervention to use supplemental oxygen. A focus area initiated on September 18, 2024, indicated that Resident 49 had altered respiratory status and difficulty breathing related to secretions and pneumonia (infection of the lungs). Staff resolved (discontinued) the intervention for oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 11 of 28 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 02/04/2025 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as ordered for a pulse ox below 92 percent on December 3, 2024, however, the physician's order requiring this assessment continued as an active order after that date. Interview with Employee 2 (licensed practical nurse) on January 29, 2025, at 10:26 AM confirmed that licensed staff were not obtaining routine pulse ox assessments for Resident 49 although her physician orders required the application of supplemental oxygen for an assessment less than 92 percent. The surveyor reviewed the above concerns regarding Resident 49's physician ordered oxygenation assessments and supplemental oxygen during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (assistant director of nursing) on January 29, 2025, at 1:45 PM. The facility discontinued Resident 49's physician order for supplemental oxygen on January 29, 2025, at 2:45 PM (following the surveyor's questioning). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 12 of 28 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 02/04/2025 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)

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 observation, review of nursing staffing schedules, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet residents' schedules for activities of daily living for two of three residents reviewed for concerns regarding resident choices (Residents 66 and 25). Findings include: Observation of Resident 66 on January 29, 2025, at 9:13 AM revealed he was in his bed. Resident 66 stated that he must wait for staff to transfer him out of bed to his wheelchair. Resident 66 stated that the time he gets out of bed is dependent upon how many nurse aides are working. Resident 66 stated that he is usually out of bed at 6:30 AM, which is his choice and preference. Resident 66 stated that he considered it to be exceptionally late for him to still be in bed at 9:13 AM. Interview with Resident 25 on January 29, 2025, at 9:33 AM revealed that staff assisted her out of bed at 8:00 AM that morning. Resident 25 stated that she prefers to be out of bed early, by 6:30 AM, because she does not like to eat her breakfast in her bed due to her likelihood of dropping food items in her bed. Resident 25 stated that she had to eat her breakfast in bed this morning because staff did not assist her to transfer to her chair. Interview with Employee 11 (nurse aide) on January 30, 2025, at 10:16 AM confirmed that Residents 66 and 25 were not out of bed at their preferred time on January 29, 2025, because there were only three nurse aides assigned to the unit at the time. Employee 11 stated that there were four nurse aides on the unit on January 30, 2025, and everyone was out of bed per their preferred schedule. The surveyor reviewed the above concerns related to sufficient staffing to meet residents' needs during an interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2025, at 1:46 PM. 28 Pa. Code 201.18(b)(3)(e)(1)(6) Management 28 Pa. Code 211.12(d)(4)(5)(f.1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 13 of 28 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 02/04/2025 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)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 8 and 9). Residents Affected - Some Findings include: The facility noted the following hire dates for two employees reviewed for performance evaluations: Employee 8's hire date: May 29, 2013. Employee 9's hire date: October 27, 1998 A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with Employee 10, human resources, on January 31, 2025, at 11:15 AM confirmed that performance evaluations were not completed on the two employees. 483.35(d)(7) Nurse Aide Perform Review-12 Hr/yr In-Service Previously cited 1/26/2024 28 Pa. Code 201.19 (2) Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 14 of 28 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 02/04/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for three of five residents reviewed (Residents 77, 20, and 63). Findings include: The policy entitled Monthly Drug Regimen Review, last reviewed on December 16, 2024, indicates that during a drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Reports are to be addressed by the attending physician within one to 21 days, unless urgent. If follow up to the consultant pharmacist recommendations are not completed within the specified time frame, this should be reported to the Medical Director. Review of Resident 77's clinical record revealed a pharmacy form entitled Consultation Report dated June 21, 2024, indicating that the consultant pharmacist identified that Resident 77 was taking Ativan (for anxiety) 0.5 mg (milligrams) as needed longer than 14 days without a stop date. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation from the pharmacist. The facility did not obtain a physician's order to stop Resident 77's Ativan until November 4, 2024, five months after the recommendation. A pharmacy form entitled Consultation Report dated July 31, 2024, indicated that the consultant pharmacist identified that Resident 77 was taking an activating antidepressant (which can act as a stimulant) at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. A pharmacy form entitled Consultation Report dated November 27, 2024, indicated that the consultant pharmacist again identified that Resident 77 was taking an activating antidepressant at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. The facility obtained a physician's order on January 30, 2025, to switch Resident 77's antidepressant to a morning administration, six months after it was first recommended and after questioning by this surveyor. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Resident 77. Clinical record review for Resident 20 reveled a pharmacist monthly consultation recommendation report dated April 20, 2024, to evaluate the resident's medications of Aripiprazole (used for schizoaffective (mental health) disorder,), Clozapine (used for schizophrenia), Bupropion (an antidepressant), Lorazepam (used for anxiety), Melatonin (used to help sleep), and Sertraline (an antidepressant), for an annual dose reduction. Facility staff were not able to produce any evidence Resident 20's physician reviewed/responded to the pharmacy recommendation. Additional pharmacy consultation reports for Resident 20 dated May 2, 2024, recommending a trial dose reduction of the resident's Aripiprazole and Bupropion, and another dated October 15, 2024, recommending medications be evaluated as possible causes or contributors to a fall, were identified with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 15 of 28 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 02/04/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm no evidence provided of any physician review/response to the recommendations within 30 days or of the recommendation. The above information was confirmed with the Nursing Home Administrator on January 31, 2025, at 12:33 PM. Residents Affected - Some Clinical record review for Resident 63 revealed a pharmacy consultant note dated October 31, 2024, at 5:29 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled Consultation Report for Resident 63 revealed a pharmacy recommendation dated October 31, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis (preventatively). The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated June 21, 2024, at 9:21 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated June 21, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis. The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated April 16, 2024, at 2:12 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated April 16, 2024, that indicated the resident received three or more central nervous system active medications, which can cause and increased risk for falls and fractures. The listed medications included the following: Venlafaxine Hydrochloride (a medication used to treat depression and/or anxiety), Quetiapine Fumarate (an antipsychotic medication), and Gabapentin (a medication used to treat certain things such as seizures and nerve pain). The recommendation from the pharmacist included to reevaluate the combination and consider a trial dose reduction of one of these medications. The physician's response section of the form revealed no response from the physician. An interview with Employee 1, assistant director of nursing, on January 31, 2025, at 10:30 AM confirmed the pharmacist recommendations for Resident 63 and no documented evidence that the physician reviewed or responded to the recommendations. The Administrator was also present during the interview. 483.45(c) Drug Regimen Review Previously cited 1/26/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 16 of 28 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 02/04/2025 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)

F 0756 28 Pa. Code 211.9 (k) Pharmacy services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 17 of 28 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 02/04/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of six residents reviewed (Residents 69, 77, and 85). Findings include: Review of Resident 69's clinical record revealed a physician's order dated January 5, 2025, that indicated nursing staff may administer Ativan (for anxiety) 0.5 mg (milligrams) every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 69's physician documented a rational for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order on January 30, 2025, to discontinue the use of the Ativan after the surveyors questioning. Review of Resident 77's clinical record revealed a physician's order dated May 21, 2024, that indicated nursing staff may administer Ativan 0.5 mg every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 77's physician documented a rationale for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order to discontinue the Ativan on November 4, 2024, almost six months after it being initiated. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Residents 69 and 77. Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Medication Administration Record (MAR) for Resident 85 revealed an order for Lorazepam (Ativan, a medication used to treat anxiety) dated December 16, 2024, and discontinued January 4, 2025, that noted: Lorazepam 0.5 mg; give 0.25 mg by mouth three times a day. Facility documentation dated December 31, 2024, revealed an FYI (for your information) written to the physician that noted, Please review narc (narcotic) sheet. Med errors noted. Ordered Lorazepam 0.5 mg, give 0.25 mg three times a day and 0.5 mg as needed every eight hours. Please note and advise. The physician acknowledged that they were aware and signed and dated the document on January 4, 2025. No further orders were noted on the documentation. Nursing documentation for Resident 85 dated January 3, 2025, at 6:35 PM noted the staff member observed an FYI to the physician regarding the family's concern for lethargy and an Ativan medication error from December 28-31, 2024. Resident was receiving double doses of Ativan. The staff member also made the family aware of, .med errors. Nursing documentation for Resident 85 dated January 3, 2025, at 11:14 PM noted a late entry for 12/31/2024. The staff member reported the registered nurse (RN) who was being relieved informed of, Ativan med errors she noted during the 1600 (4:00 PM) med pass. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 18 of 28 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 02/04/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nursing documentation for Resident 85 dated January 3, 2025, at 11:47 PM noted an assessment that indicated resident excessively sleeping. Nursing documentation for Resident 85 dated January 6, 2025, at 2:03 PM revealed that on one card the regular and as needed orders were merged. The combined orders were discontinued. The medication card that was delivered from the pharmacy on December 11, 2024, were 0.5 mg tablets and the directions noted to give 0.5 (half) tablet for a total dose of 0.25 mg per dose. The tablets that were sent were not scored and could not be cut in half. New cards are to be sent with the new clarified order. Nursing documentation for Resident 85 dated January 6, 2025, at 2:32 PM noted that on the evening of January 3, 2025, it was reported to nursing that something didn't look right with the medication card / sheet for the resident. This was documented as discussed with the RN supervisor who investigated and reported it was more of a transcription issue due to the way the card came from pharmacy and was very confusing. The documentation further noted that the order, as it was initially written in the electronic health record, combined both the routine and the as needed order onto one order and so it was filled in that manner from the pharmacy, which led to confusion. A review of the facility document (the documentation that comes with the pharmacy medication packs to track administration and accountability of the controlled medication) titled, Controlled Medication Utilization Record, revealed the following medication instructions for Resident 85: Give 0.5 (half) tab (0.25 mg total) by mouth every 8 hours routine and one tab by mouth every eight hours as needed for anxiety. The following administrations for the Lorazepam were marked on the Controlled Medication Utilization Record: December 28, 2024: 1:00 PM, 5:00 PM; dose given at each timestamp indicated one December 29, 2024: 10:00 AM, 1:00 PM, 5:00 PM; dose given at each timestamp documented as one December 30, 2024: 10:00 AM, 1:00 PM, and a second 1:00 PM was documented; doses given at each timestamp documented as one December 31, 2024: 10:00 AM, 1:00 PM; dose given at each timestamp documented as one December 31, 2024: 5:00 PM; dose given documented as one with 1/2 (half) marked as wasted. There was only one instance during the time of December 28, 2024, to December 31, 2024, (which was December 31, 2024, at 5:00 PM), where half a tablet of Ativan was wasted as indicated in the directions on the Controlled Medication Utilization Record to administer a half tab for the routine dose (0.25 mg). An interview with the Director of Nursing (DON) on January 29, 2025, at 1:45 PM revealed that Resident 85 was getting a double dose of Ativan. There was no further clinical documentation provided by the facility to indicate that Resident 85 was not being administered a double dose of Lorazepam during the medication administration dates from December 28-31, 2024, or any investigative report related to a medication error as indicated by the staff in the nursing documentation and documentation to the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 19 of 28 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 02/04/2025 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)

F 0758 483.45(c) Drug Regimen Review Level of Harm - Minimal harm or potential for actual harm Previously cited 1/26/24 28 Pa. Code 211.9(k) Pharmacy services Residents Affected - Some 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 20 of 28 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 02/04/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (C Nursing Unit and F Nursing Unit; Residents 40 and 66). Residents Affected - Some Findings include: The facility's medication error rate was 10 percent based on 30 medication opportunities with three medication errors. Observation of Resident 40's medication administration pass on January 30, 2025, at 9:00 AM revealed that Employee 7, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 7 proceeded to place the resident's medications in a disposable medication pouch and crush them with a tablet crusher and then mix them in pudding. Clinical record review for Resident 40 revealed a physician/'s order dated May 20, 2024, that noted crushable medications may be crushed, mixed, and administered together unless contraindicated. Physician orders for Resident 40 dated April 25, 2022, revealed Isosorbide Mononitrate (a medication used to help widen the blood vessels and prevent chest pain) ER (extended release) 30 milligrams (mg), give one tablet by mouth one time a day. The pill package (the package from pharmacy which contained the medications) for the Isosorbide Mononitrate noted, Do not chew or crush before swallowing. A physician's order for Resident 40 dated January 14, 2025, for Pantoprazole Sodium Oral Tablet Delayed Release (DR) (a medication used to treat certain stomach problems), give 20 mg by mouth one time a day. Employee 7 administered 40 mg of the medication instead of 20 mg as noted in the order. The pill package for the Pantoprazole noted, Do not chew or crush. The medication was also crushed by Employee 7 prior to administration. An interview with Employee 7 on January 30, 2025, at 12:29 PM confirmed the medications were crushed for Resident 40 and Employee 7 administered 40 mg of Pantoprazole. The pill package for the 20 mg of Pantoprazole was found in the bottom drawer of the medication cart. The above information was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 30, 2025, at 2:00 PM. Facility documentation titled, Common Oral Dosage Forms That Should Not Be Crushed, provided by the facility on January 31, 2025, revealed that both the Isosorbide ER and Pantoprazole DR were on the list. Clinical record review for Resident 66 revealed an active physician's order for staff to administer 10 units from a Humalog Kwikpen (a disposable single-patient-use prefilled pen containing 300 units of Humalog, an injectable hormone used to lower blood sugar. You can give more than one dose from the pen) before meals. Instructions regarding the use of a Humalog Kwikpen (https://pi.lilly.com/us/humalog-kwikpen-um.pdf) stipulate that the user is to prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 21 of 28 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 02/04/2025 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step six of the instructions note to turn the insulin pen dose knob to two units. Step seven instructs to hold the pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at the top. Step eight is to continue holding the pen with the needle pointing up, push the dose knob in until it stops, and a zero is seen in the dose window; there should be insulin visible at the tip of the needle. Then the user can select the desired dose. Observation of a medication administration pass on January 28, 2025, at 11:37 AM revealed Employee 2 (LPN)prepared medications for administration. Employee 2 obtained a Humalog Kwikpen and a disposable needle from the medication cart. Employee 2 applied the needle to the tip of the Humalog Kwikpen and dialed 10 units for administration to Resident 66. Employee 2 entered Resident 66's room and administered the insulin medication into Resident 66's right upper arm. Employee 2 did not prime the needle before administration of Resident 66's insulin medication. Interview with Employee 2 on January 28, 2025, at 11:53 AM confirmed that she did not prime the needle before administering Resident 66's insulin. The surveyor reviewed the above concerns regarding Resident 66's insulin administration during an interview with the NHA, DON, and Employee 1 (assistant director of nursing) on January 30, 2025, at 2:16 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 22 of 28 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 02/04/2025 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)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide necessary dental services for one of one resident reviewed for dental concerns (Resident 20). Residents Affected - Some Findings include: In an interview and observation of Resident 20 on January 28, 2025, at 12:46 PM the resident was observed to have visible black/decayed appearance of her lower teeth with multiple teeth missing. Resident 20 stated she did not recall seeing a dentist since she had been at the facility. Clinical record review for Resident 20 revealed the resident was admitted to the facility on [DATE]. Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 20, 2024, revealed the resident was assessed as having natural teeth with no likely cavities or broken natural teeth. A review of Resident 20's active plan of care revealed the resident has a care plan initiated on February 5, 2019, indicated the resident has oral/dental health problems related to poor nutrition and poor dentition. The plan of care indicated interventions of the same date to coordinate arrangements for dental care, transportation as needed/ordered. A review of a facility Request for Service form dated March 3, 2023, for Resident 20 revealed the resident selected yes as wishing to be seen for dental care. Facility staff did not provide any evidence to indicate Resident 20 had seen a dentist, or evidence the resident refused a dentist since a confirmed dental visit on August 26, 2019. The Nursing Home Administrator confirmed in an interview on January 31, 2025, at 10:38 AM there was no evidence Resident 20 had services coordinated to see a dentist since 2019. Facility staff provided an email notification with the facility's dental provided dated January 30, 2025, indicating Resident 20 was added to the list to be seen with the next dentist visit to the facility, after it was brought to the facility staff's attention. 483.55(b)(1)(3)(5) Routine/emergency Dental Services Previously cited deficiency 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 23 of 28 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 02/04/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 23 residents reviewed (Resident 108). Residents Affected - Few Findings include: Physician orders for Resident 108 revealed an order for a Prenatal Oral Tablet (6.75-0.2 milligrams), prenatal vitamin with ferrous fumarate-folic acid (a multivitamin that contains different concentrations of vitamins and minerals), give one table by mouth in the afternoon. Review of the Medication Administration Record (MAR) for Resident 108 for January 2025, revealed the Prenatal Oral Tablet was documented by staff as being administered on January 4-9, 13, 17, 19, 21-29, 2025. Clinical documentation for Resident 108 revealed the following MAR notes regarding the Prenatal Oral Tablet: January 11, 2025, at 11:13 AM: This medication is not available to give; we do not carry this as house stock. FYI (for your information) to doctor was written to switch this medication to multi-vitamin with minerals instead. RN (registered nurse) aware. January 12, 2025, at 1:31 PM: Medication not available to give- not available as house stock. Doctor notified to switch medication to a multivitamin with minerals. RN aware. January 14, 2025, at 12:46 PM: Not available from pharmacy. Will call to see when it will be delivered. MD (physician) aware. January 15, 2025, at 1:16 PM: Medication is not available to give, FYI was written to doctor for a substitution, and RN was made aware. January 16, 2025, at 1:15PM: Medication not available to give. Not available as house stock. RN and MD were made aware to switch to multivitamins with minerals. January 20, 2025, at 12:21 PM: Medication is not available to give. Medication is not available in-house stock. MD has been made aware to switch medication to a multivitamin. RN was notified also. Multiple facility staff documented the medication as administered for Resident 108 on the above days while other staff noted the medication was unavailable for administration. The above information for Resident 108 was reviewed with the Nursing Home Administrator and Director of Nursing on January 29, 2025, at 1:45 PM. Further review of the MAR for Resident 108 revealed the Prenatal Oral Tablet was discontinued on January 29, 2025, at 2:52 PM (after the surveyor spoke to the facility) and an order was placed on the same date for Multivitamin-Minerals Oral Tablet (Multiple Vitamins with Minerals) give one tablet by mouth one time a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 24 of 28 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 02/04/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm A follow-up interview on January 31, 2025, at 2:25 PM with Employee 13, licensed practical nurse, revealed that the above information for Resident 108 was due to a documentation issue and the order was not previously changed in the electronic health record. 28 Pa. Code 211.5(i) Medical records 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: 395172 If continuation sheet Page 25 of 28 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 02/04/2025 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)

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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for three of five residents reviewed for immunizations (Resident 21, 53, and 85). Residents Affected - Few Findings include: The policy entitled Pneumococcal Vaccine, last reviewed December 16, 2024, indicates that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine within 30 days of admission. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccinations. Review of Resident 21's clinical record revealed that the facility admitted her on June 20, 2021. Documentation in Resident 21's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2016. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated April 1, 2022, Resident 21's pneumococcal vaccinations would not be complete until she received a PPSV23 or Pneumovax one year after she received her Prevnar 13. There was no documented evidence to indicate that the facility offered Resident 21 an updated pneumococcal vaccination. Review of Resident 53's clinical record revealed that the facility admitted him on October 18, 2022. There was no documented evidence in Resident 53's clinical record to indicate that the facility determined his eligibility to receive a pneumococcal vaccine or offered the vaccine within 30 days of admission. Review of Resident 85's clinical record revealed that the facility admitted her on August 18, 2024. Documentation in Resident 85's clinical record revealed that she received a pneumococcal vaccine (PPSV23 or Pneumovax) prior to her admission to the facility on July 1, 2008. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated April 1, 2022, Resident 85's pneumococcal vaccinations would not be complete until she received a PCV15 or PCV20 one year after she received her PPSV23. There was no documented evidence to indicate that the facility offered Resident 85 an updated pneumococcal vaccination. Interview with Employee 1, infection control preventionist, on January 31, 2025, at 10:33 AM confirmed the above findings for Resident 21, 53, and 85. 483.80(d) Influenza and Pneumococcal Immunizations Previously cited 1/26/24 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 26 of 28 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 02/04/2025 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)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented for five of five residents reviewed for immunizations (Residents 4, 16, 21, 53, and 85) and failed to screen, educate, and offer the COVID-19 vaccine for one of one employee reviewed (Employee 12). Findings include: The policy entitled, COVID-19 Vaccine, Resident, last reviewed on December 16, 2024, indicates that residents or their representatives will be educated about and offered the COVID-19 vaccine. The vaccines will be offered to residents per CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) guidelines unless such an immunization is medically contraindicated, the individual has already been immunized during this time or the individual refuses to receive the vaccine. The policy entitled COVID-19 Vaccine, Staff, last reviewed on December 16, 2024, indicates that employees will be offered the COVID-19 vaccine in accordance with state and local health departments and the CDC. The facility will screen new employees to determine their eligibility, offer the COVID-19 vaccine, and provide education including the risks and benefits of the vaccine. The CDC (Centers for Disease Control) recommendations for COVID-19 vaccines (https://www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf) indicate that for people [AGE] years of age and older should have one additional dose administered at least eight weeks following the last recommended dose of 2023-24 COVID-19 Vaccine. Review of Resident 4's clinical record revealed that her last COVID-19 vaccine was provided on November 10, 2022. There was no documented evidence that the facility offered Resident 4 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 16's clinical record revealed that her last COVID-19 vaccine was prior to her admission to the facility in 2022. There was no documented evidence that the facility offered Resident 16 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 21's clinical record revealed that her last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 21 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 53's clinical record revealed that his last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 53 or his responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 85's clinical record revealed that the facility admitted her on August 18, 2024. There was no documented evidence that the facility obtained a COVID-19 vaccination history, offered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 27 of 28 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 02/04/2025 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)

F 0887 Resident 85 the COVID-19 vaccine, or provided education regarding its risks and benefits. Level of Harm - Minimal harm or potential for actual harm Review of Employee 12's, registered nurse, personnel record revealed that she was hired on September 17, 2024. There was no documented evidence to indicate that the facility screened Employee 12 for eligibility of the vaccine, offered the vaccine, or educated her about the risks and benefits of the vaccine. Residents Affected - Some Interview with Employee 1, infection control preventionist, on January 31, 2025, at 10:33 AM confirmed the above findings for Residents 4, 16, 21, 53, 85, and for Employee 12. 483.80(d)(3) COVID-19 Immunization Previously cited 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395172 If continuation sheet Page 28 of 28