Health inspection·September 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility documentation, and staff interview, it was determined that the facility failed to implement interventions to decrease the potential for resident elopements for one of four residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a progress note date August 1, 2025, at 6:19 PM that indicated she was exit seeking twice during the shift. Clinical record review for Resident 1 revealed a nursing progress note dated August 17, 2025, at 10:11 PM that indicated Resident 1 was anxious and exit seeking. The physician was notified and a one time dose of Seroquel (a medication used to treat psychosis) 25 milligrams was ordered. A nursing progress note dated August 21, 2025, at 12:08 AM revealed that Resident 1 was pacing in the hallway and set off the wander guard system at the elevators once. A nursing progress note dated August 21, 2025, at 6:22 PM revealed that Resident 1 was restless and wandering. She wanted to leave. She was on the elevator twice and activated the alarm. Clinical record review for Resident 1 revealed a progress dated August 22, 2025, at 12:06 PM that indicated Resident 1 had eloped and walked out the front door of the building. Resident 1 was followed by staff and was on the grass at the right of the facility on the corner at the redlight near the highway. Staff redirected Resident 1 back into the facility. The note indicated that Resident 1's wander guard (a wearable bracelet that works with a wander guard system sounding an alarm to assist with elopement prevention) was working and sounded the alarm when she was brought back into the facility, and when she got off the elevator back onto the nursing unit. The note also indicated that Resident 1's physician was notified of the incident and new orders were received for lab work, an abdominal ultrasound, and urinalysis with culture and sensitivity. Review of the facility's investigation into Resident 1's elopement dated August 22, 2025, at 10:34 AM revealed that the facility initiated 15-minute checks on Resident 1 that would progressively lengthen in time over the weekend until they were hourly checks and then would remain in effect for 72 hours. Further clinical record review for Resident 1 revealed a progress note dated August 23, 2025, at 10:00 PM that indicated the alarm by the elevators activated and noted that Resident 1 was on the elevator as the elevator door closed. The nurse took the other elevator to the first floor and found Resident 1 near the front door with the wander guard alarm on that floor activated. Resident 1 was safely returned to her unit. The facility discontinued every one hours checks and initiated checks every 15-minutes. A nursing progress note dated September 1, 2025, at 9:49 PM revealed that Resident 1 attempted to leave the unit but was easily redirected. A nursing progress note dated September 3, 2025, at 2:29 PM revealed that Resident 1 attempted to get on the elevator one time that morning. A nursing progress note dated September 4, 2025, at 5:53 PM revealed that Resident 1 was exit seeking three times that shift. A nursing progress note dated September 6, 2025, at 3:23 PM revealed that Resident 1 was at the elevator with an arm full of clothes and pushed the elevator button and the alarm sounded, but the nurse intervened. A nursing progress note dated September 8, 2025, at 2:31 PM revealed that Resident 1 was walking down the (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 09/11/2025 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)