Inspection·October 4, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to stop the resident's dialysis and would like a hospice evaluation of the resident. Nursing noted that hospice choices were provided to the resident's son and that the resident's son chose an external hospice provider. There was no documented evidence that the facility fully informed had informed Resident 88 of the treatment decisions proposed regarding initiating hospice care and stopping dialysis and that the resident was afforded the opportunity to choose preferred treatment options, including hospice care prior to initiating hospice services on [DATE]. A nursing progress note dated [DATE], at 1:51 p.m. indicated that the external hospice provider would be sending an electronic consent to Resident 88's son and a nurse would be in to do an admission evaluation. A review of the external hospice provider form titled Hospice Election Statement, Notice of Patient Rights, and Informed Consent, indicated that Resident 88's son elected to initiate Medicare hospice benefits, indicated that Resident 88's son is the resident's representative, and indicated that Resident 88 was unable to sign due to confusion. The hospice provider form was dated as signed by Resident 88's son on [DATE], at 14:07 p.m. There was no documented evidence that Resident 88 had deferred healthcare decision making to her son, including initiation of hospice services on [DATE]. There was no documented evidence that the physician had deemed Resident 88 incapable of exercising her rights to participate in her healthcare decision making. There was no documented evidence that the facility afforded Resident 88 an opportunity to review the Hospice Election Statement, Notice of Patient Rights, and Informed Consent and allow the resident the opportunity to make a fully informed decision regarding initiating her Medicare hospice benefits. A clinical record review revealed a physician order for Resident 88, initiated on [DATE], for the resident to have a hospice evaluation, hospice treatment, and to discontinue dialysis treatment. A physician order for Resident 88 was initiated on [DATE], to admit the resident to hospice care The facility was unable to demonstrate that Resident 88 was fully informed, and had participated in the treatment decisions to end dialysis and receive hospice care. During an interview on [DATE], at approximately 10:00 a.m., the Director of Nursing and Nursing Home Administrator (NHA) were unable to provide evidence that Resident 88 was afforded the right to fully participate in treatment, including making healthcare decisions regarding the initiation of ending dialysis treatments and beginning hospice care. 28 Pa. Code 201.29 (a)(b) Resident rights. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 2 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of the minutes from Resident Council meetings and grievances filed with the facility, resident interviews and staff interviews, it was determined that the facility failed to put forth efforts to sustain resolution and prevent continued resident complaints expressed during Resident Council meetings, including those voiced by six (6) of six (6) residents attending a group meeting (Residents 1, 30, 37, 42, 56, and 58). Residents Affected - Few Findings Include: A review of resident council meeting minutes from July 21, 2023, indicated that the residents in attendance voiced complaints regarding snacks not being offered in the evenings. A review of resident council meeting minutes from August 18, 2023, indicated the resident complaints regarding snacks was resolved. However, during a group meeting conducted on October 2, 2023, at 10:00 a.m. with six alert and oriented residents, all residents in attendance (Residents 1, 30, 37, 42, 56, and 58) voiced concerns that evening snacks are not offered despite the noted resolution to the resident council's complaint regarding snacks in the August 18, 2023, meeting minutes. During an interview on October 2, 2023, at approximately 2:00 p.m., the Nursing Home Administrator (NHA) was unable to provide evidence that residents' complaints raised at their group meetings, of not receiving evening snacks, had been fully resolved and solutions sustained. 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 3 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, a review of the facility's grievance policy and resident and staff interviews it was determined that the facility failed to make current information readily available to residents on the facility's grievance policy and procedures to file a complaint and timeframe for resolution. Findings included: A review of the facility policy titled Grievance Policy, last reviewed by the facility on June 30, 2023, revealed the name and e-mail address of the facility's current grievance official was not accurate and did not reflect current staff employed in the facility. The policy also failed to include the reasonable expected time frame for completing a review of a grievance. During an observation on October 1, 2023, at 9:45 a.m. of the Yellow Wing bulletin board, a posted facility policy title, Grievance Policy, was observed that included inaccurate information regarding the name and e-mail address of the facility's current grievance official. During a group meeting conducted on October 2, 2023, at 10:00 a.m. with six alert and oriented residents, all six residents in attendance (Residents 1, 30, 37, 42, 56, and 58) stated that they were unaware of who was the facility's current grievance official, did not know how to file a grievance with the facility, did not know how to file a grievance anonymously with the facility, and did not know how to file a grievance with an independent entity. Interview with the NHA on October 2, 2023, confirmed that the current posting did not accurately identify the grievance official. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 4 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy - protocol, clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out of 20 sampled (Residents 8 and 68) to promote normal bowel activity to the extent practicable. Residents Affected - Few Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Protocol, last reviewed by the facility, June 30, 2023, indicated the purpose is to maintain or encourage regular bowel function in order to prevent constipation. If no bowel movement after two (2) days, the following protocol will be followed. Day 3, Milk of Magnesia (MOM) 30 ml, Day 4, Dulcolax Suppository, and Day 5, Fleets Enema. Notify physician after Day 5 if above interventions are ineffective. A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include, cerebral infarction (stroke), Alzheimer's disease, and disease of the anus and rectum. The resident had physician orders dated January 6, 2021, for the following bowel regimen: - Milk of Magnesia Suspension 7.75% (Magnesium Hydroxide), give 30 ml by mouth as needed for constipation. Give 30 ml if no BM (bowel movement) by day 3 days on evening shift; -Biscolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally as needed for constipation. Give at bedtime if no BM by day 4 if MOM (milk of magnesia) is not effective; -Fleet Bisacodyl Enema 10 MG/30 ML (Bisacodyl), insert 1 applicator full rectally as needed for constipation. Give at hours of sleep on day 5 if suppository is not effective. If fleets is not effective call MD for further orders. Review of Resident 8's report of bowel activity from the Documentation Survey Report v2 for June 2023, revealed that the resident did not have a bowel movement on June 23, 2023, June 24, 2023, June 25, 2023, June 26, 2023, June 27, 2023, June 27, 2023, June 28, 2023, and June 29, 2023. Review of Resident 8's Medication Administration Record (MAR) for June 2023, revealed that on June 27, 2023, milk of magnesia was administered and noted as ineffective. There was no documented evidence that nursing administered prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. There was no documented evidence that the physician was notified of the eight (8) consecutive days without a bowel movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 5 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the clinical record revealed that Resident 68 was admitted to the facility on [DATE], with diagnoses of diabetes, Parkinson's Disease, and Gastro-Esophageal Reflux Disease (GERD). The resident had physician orders dated May 5, 2023, for the following bowel regimen: - Milk of Magnesia Suspension 7.75% (Magnesium Hydroxide), give 30 ml by mouth as needed for constipation. Give 30 ml if no BM (bowel movement) by day 3 days on evening shift; -Biscolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally as needed for constipation. Give at bedtime if no BM by day 4 if MOM (milk of magnesia) is not effective; -Fleet Bisacodyl Enema 10 MG/30 ML (Bisacodyl), insert 1 applicator full rectally as needed for constipation. Give at hours of sleep on day 5 if suppository is not effective. If fleets is not effective call MD for further orders. Review of Resident 68's report of bowel activity from the Documentation Survey Report v2 for June 2023, revealed that the resident did not have a bowel movement on June 3, 4, 5, 6, and 7, 2023. Review of Resident 68's Medication Administration Record (MAR) for June 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. There was no documented evidence that the physician was notified of the five (5) consecutive days, June 3, 4, 5, 6, and 7, 2023, without a bowel movement. During an interview with the Director of Nursing (DON) on October 3, 2023, at 12:27 PM, the DON was unable to provide evidence that physician ordered bowel protocol was followed for Residents 8 and 68, and that the physician was notified as ordered. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 6 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to consistently provide restorative nursing services as planned to maintain mobility, range of motion and to ensure the application of splinting devices for three residents of 20 sampled (Residents 1, 27, and 54). Findings include: A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis, paraplegia (paralysis of the lower body), stiffness of elbow, and contracture of muscle (abnormal shortening of muscle tissue). A physician order dated May 27, 2021, was noted for the application of a bean bag splint to resident's knee when in bed, during hours of sleep. Alternate splint between right and left knee daily. Review of Resident 1's care plan revealed a restorative nursing program (RNP) to apply a splint or brace to resident's bilateral (both) elbows and knees during hours of sleep, with the resident to determine, which elbow/knee and to alternate each night, date-initiated May 27, 2021. The resident's Documentation Survey Report v2 (general care nursing tasks completed for the resident) dated September 2023, revealed no evidence that the daily restorative program (RNP) for splint application was provided 10 times out of the ordered 30 times. Staff documented NA during the shift when the application of the splints were ordered. During an interview with Resident 1 on October 1, 2023, at 1:44 PM the resident expressed concern that staff are not applying the elbow and knee splints (to help prevent contracture or worsening contracture) that he is supposed to wear every night. He voiced concern that his elbow and knees feel like they are getting tighter. A review of Resident 54's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia, difficulty in walking and muscle weakness. Resident 54's clinical record revealed that the resident was discharged from physical therapy on April 5, 2023. Discharge recommendations were for the resident to receive a RNP for ambulation to walk daily, 50 feet as able, with the use of a rolling walker, contact guard assistance (touch support from staff), and a wheelchair follow. A Documentation Survey Report v2 dated September 2023, revealed that the restorative program for ambulation was not provided to the resident on 15 times out of the ordered 30 times, with staff documenting NA as a response. Interview with the Director of Nursing (DON) on October 3, 2023, at 12:30 PM, verified that NA was not an appropriate response to document in the Documentation Survey Report v2. The DON confirmed that the facility failed to consistently implement the planned restorative nursing programs for residents to maintain functional abilities and deter declines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 7 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 Residents Affected - Some A clinical record review revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses of dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), heart failure (a condition in which the heart cannot pump enough blood to meet the body's requirements), and hypertensive heart disease (abnormalities of the heart involving structure and function as a result of long-standing high blood pressure). A review of Resident 27's (MDS assessment dated [DATE], revealed that Resident 27 is severely impaired. The resident received Occupational Therapy Services between May 24, 2023, and June 15, 2023, for physical rehabilitation that included a contracture (prolonged shortening of the muscle or other soft tissue around a joint, preventing movement of the joint) of the right hand. The Occupational Therapy Evaluation and Plan of Treatment document dated June 15, 2023, included recommendations for Resident 27 to have a restorative nursing program for right hand splinting with a washcloth or palm roll. A physician order, initially dated, October 28, 2022, was noted for Resident 27 to wear a finger separator (a type of hand orthotic) on the left hand at all times as tolerated. A review of Resident 27's current plan of care included an intervention for the resident to wear a finger separator on the left hand at all times as tolerated. An observation on October 1, 2023, at 11:35 a.m. revealed that Resident 27 was not wearing a finger separator, washcloth, palm roll, or other orthotic in either hand. There was no documented evidence in the clinical record or care plan that Resident 27 declined the use of the therapeutic devices. An observation on October 3, 2023, at 9:35 a.m. revealed that Resident 27 was not wearing a finger separator, washcloth, palm roll, or other orthotic in either hand. Interview with Employee 1 at the time of this observation, revealed that the employee stated that the devices, should be in place. There was no documented evidence in the clinical record or care plan that Resident 27 declined the use of the therapeutic devices on this date. During an interview on October 3, 2023, at approximately 2:00 p.m., the Director of Nursing failed to provide evidence that staff consistently applied the devices planned and prescribed for Resident 27's use. 28 Pa. Code: 211.5(f) Medical records 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 8 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, information submitted by the facility, and select facility reports and staff interviews it was determined that the facility failed to provide effective safety measures planned to prevent falls for one resident out of four reviewed for falls (Resident 82). Findings included: A review of the clinical record revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include cerebrovascular disease (condition that affects blood flow and blood vessels in the brain), cognitive communication deficit, difficulty in walking, and muscle weakness. A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated September 21, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 9 (8-12 represents moderate cognitive impairment), required extensive assist of two people to perform bed mobility tasks and transfers, and extensive assist of one person to walk in room. A review of Resident 82's Fall Risk Evaluation, dated June 29, 2023, revealed that the resident was identified as a high risk for falls. A review of Resident 82's care plan revealed that the resident was at risk for falls due to gait and balance issues and impaired safety awareness, with a planned intervention for a bed alarm to be intact at all times, date initiated on April 30, 2023. A review of incident/accident reports revealed that the resident had three unwitnessed falls in his room, which occurred on June 29, 2023, July 24, 2023, and September 21, 2023, during which the resident was attempting to get out of bed without staff assistance. According to the reports, at the time of each fall, the resident's bed alarm was plugged in and in place on the bed but was did not sound to alert staff that resident was attempting to get out of bed without assistance. Interview with the Director of Nursing (DON) on September 4, 2023, at 8:40 AM confirmed that the planned intervention of a bed alarm was not functioning properly at the time of the resident's falls while attempting self-transfers from bed on June 29, 2023, July 24, 2023, and September 21, 2023. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 9 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to ensure that residents received appropriate treatment and services to prevent potential complications for residents with indwelling catheters for three out of the 20 residents sampled (Residents 83, 191, and 193). Findings include: Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. The Centers for Disease Control and Prevention released guidance on the implementation of personal protective equipment in nursing homes to prevent the spread of multidrug-resistant organisms (MDROs). Updated on July 12, 2022, the guidance expanded recommendations for enhanced barrier precautions in nursing homes to include residents with indwelling medical devices. Enhanced barrier precautions expand the use of personal protective equipment (PPE) to include the use of gowns and gloves during high-contact resident care activities. The guidance identifies residents with indwelling medical devices at especially high risk of both acquisition and colonization with MDROs. Recommendations include posting clear signage on the door or wall outside of the resident room indicating the type of precautions and the required PPE, identifying high-contact resident care activities that require the use of gowns and gloves, making PPE available immediately outside of the resident room, ensuring access to alcohol-based hand rub in every resident room, positioning a trash can inside the resident room and near the exit for discarding PPE after removal, and providing education to residents and visitors. Observations of the facility from October 1, 2023, through October 4, 2023, revealed that the facility failed to implement enhanced barrier precautions for residents with indwelling medical devices, including Yellow Wing room [ROOM NUMBER] (Resident 83), Blue Wing room [ROOM NUMBER] (Resident 191), and Yellow Wing room [ROOM NUMBER] (Resident 193). The facility failed to post signage on the door or wall outside of residents' rooms indicating the type of precautions, required types of PPE, and types of high-contact activities that would require PPE. Observation revealed that the facility failed to have PPE available immediately outside of resident rooms that had indwelling medical devices. A clinical record review revealed that Resident 191 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and tubulointerstitial nephritis (inflammation that affects the tubules of the kidneys and surrounding tissue). The resident had a current physician order to care for and maintain Resident 191's nephrostomy tube (a tube that is put into the kidney to drain urine directly from the kidney). An observation on October 1, 2023, at 9:31 a.m. revealed Resident 191 self-propelling in a wheelchair near the blue hall nursing station. The resident's nephrostomy urinary collection bag containing urine was visible, dragging behind the resident in contact with the floor. The resident was observed for about 30 seconds when Employee 2 secured the bag to the resident's wheelchair. Employee 2 stated that the urine collection bag should be covered and not in direct contact with the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 10 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A clinical record review revealed Resident 193 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (brain damage that results from a lack of blood) and diabetes. The resident had an active physician order dated September 26, 2023, for a 16-Fr Foley urinary catheter with a 10-cc balloon and a drainage bag. An observation on October 1, 2023, at 11:52 a.m. in Yellow Wing room [ROOM NUMBER] revealed Resident 193 in bed with a urinary catheter bag and catheter tube directly on the floor. Urine was visible within the tube. A clinical record review revealed Resident 83 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and calculus in the bladder (bladder stones). The resident had a current physician order initially dated June 15, 2023, for a 24-Fr Foley catheter with a 30 cc balloon and a drainage bag. An observation on October 1, 2023, at 12:00 p.m. in Yellow Wing room [ROOM NUMBER] revealed Resident 83 in bed with a urinary catheter bag directly on the floor. An observation on October 2, 2023, at 9:40 a.m. in Yellow Wing room [ROOM NUMBER] revealed Resident 83 in bed with a urinary catheter bag directly on the floor. During this observation, Employee 1 confirmed that the urinary catheter bag should be placed in a protective bag and not in direct contact with the floor. Employee 1 was observed removing Resident 83's catheter bag from direct contact with the floor following surveyor inquiry. An observation on October 2, 2023, at 12:56 p.m. in Yellow Wing room [ROOM NUMBER] revealed Resident 83 in bed with a urinary catheter bag directly on the floor. During an interview on October 3, 2023, at approximately 2:00 p.m., the Director of Nursing and Nursing Home Administrator confirmed that the urinary catheter and nephrostomy bags should not be in direct contact with the floor. The Director of Nursing and Nurse Home Administrator confirmed that the facility failed to implement enhanced barrier precautions for the residents with indwelling medical devices. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 11 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff interview it was determined that the facility failed to plan individualized care for resident receiving hemodialysis and failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis (Resident 71). Residents Affected - Few Findings include: According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand. A review of the clinical record revealed that Resident 71 was admitted to the facility on [DATE], with a diagnosis to include diabetes, end stage renal disease, and Parkinson's Disease. A review of physician orders dated August 11, 2023, indicated the resident is to receive Hemodialysis (HD), Monday, Wednesday, and Friday. The resident was receiving hemodialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood), every Monday, Wednesday, and Friday. A review of the resident's current plan of care revealed no indication of emergency procedures, and or location, presence of an emergency kit available. Observations of Resident 71's room was conducted on October 1, 2023, at approximately 12:08 PM, October 2, 2023, at approximately 9:08 AM, and October 3, 2023, at approximately 8:20 AM, revealed no emergency supplies available for use. An additional observation on October 3, 2023, at approximately 8:30 AM, in the presence of the Director of Nursing (DON), confirmed the absence of emergency supplies available for use. Interview with the DON on October 3, 2023, at approximately 8:30 AM, confirmed the facility failed to assure an emergency kit was readily available and that the resident's plan of care addressed emergency procedures, and or the emergency kit. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 12 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy, controlled drug usage records, medication administration records and clinical records and staff interviews it was determined that the facility failed to implement procedures to promote accurate medication administration, and accurate records of medication administration for four of four medication carts, (Blue A, B Hall, Yellow C, D Hall), and one residents out of 20 sampled (Resident 69). Findings include: The facility policy entitled Controlled Substances, last reviewed by the facility, June 30, 2023, indicated that Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together, they must document, and report discrepancies. A review of the Controlled Substance Accountability Record, for the Blue, A Hall medication cart on October 1, 2023, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: September 1, 10, 13, and 14, 2023 A review of the Controlled Substance Accountability Record, for the Blue, B Hall medication cart on October 1, 2023, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: September 1, and 22, 2023 A review of the Shift Change Narcotic Audit, for the Yellow, C Hall medication cart on October 1, 2023, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: September 8, and 21, 2023 A review of the Shift Change Narcotic Audit, for the Yellow, D Hall medication cart on October 1, 2023, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: September 25, and 27, 2023. A review of the clinical record revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses to include fracture of the right femur, fracture of the 2nd lumbar vertebra (low back) and difficulty in walking. Resident 69 had a physician order, initially dated August 16, 2023, for Oxycodone HCL (a narcotic opioid pain medication) 5 mg by mouth every 8 hours as needed for moderate pain 4-6 severity level. A review of the controlled medication record accounting for the above narcotic medication revealed that on August 21, 2023, at 7:00 PM nursing signed out a dose of the resident's supply of Oxycodone HCL 5 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record on that date and time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 13 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0755 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON), on October 1, 2023, at approximately 10:50 AM, indicated that her expectation is that the controlled substance records be signed at each change of shift, and confirmed the findings above. She further acknowledged that the facility failed to accurately document the controlled substance accountability records to decrease the risk for misappropriation of resident property/drug diversion. Residents Affected - Some 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 14 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and staff interview, the facility failed to ensure that the attending timely acted upon physician irregularities reported by the pharmacist for two out of 20 residents sampled (Residents 22 and 27). Findings include: A clinical record review revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), heart failure (a condition in which the heart cannot pump enough blood to meet the body's requirements), and hypertensive heart disease (abnormalities of the heart involving structure and function as a result of long-standing high blood pressure). A monthly medication review dated December 7, 2022, revealed that the pharmacist reported to the physician that resident currently receives a proton pump inhibitor (PPI), Pantoprazole 40 mg daily (initially ordered on April 20, 2019). The pharmacist noted that current guidelines and recent literature recommended duration of treatment with PPIs to be 4 to 12 weeks. PPIs are generally not indicated for continuous use beyond 3 months. The pharmacist asked the that physician Please evaluate if a trial reduction or discontinuation would be appropriate. The physician did not respond to the pharmacist's identified irregularity until February 23, 2023, when an order was noted to discontinue the pantoprazole 40 mg. A clinical record review revealed that Resident 22 was admitted to the facility on [DATE] with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). On November 9, 2022, the pharmacist monthly medication review noted that the American Geriatrics Society defines a sliding-scale insulin regimen as insulin regimens containing only short or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. As defined, sliding scale insulin is on the Beers Criteria list (a list of potentially harmful medications or medications with side effects that outweigh the benefit of taking the medication); this indicates that sliding scale insulin should be avoided in adults [AGE] years of age and older. It is associated with a higher risk of hypoglycemia without improvement in hyperglycemia management, regardless of the care setting. Please assess this resident's current insulin therapy and consider the addition of basal or long-acting insulin and/or the discontinuation of sliding-scale coverage. The physician indicated agreement with the pharmacist's medication recommendation on November 11, 2022. However, there was no evidence of the physician's actions with respect to the assessing this resident's current insulin therapy and considering the addition of basal or long-acting insulin and/or the discontinuation of sliding-scale coverage. A monthly medication regimen review note from pharmacist to physician dated May 5, 2023 again requested that the physician assess Resident 22's current insulin therapy and consider the addition of basal or long-acting insulin and/or the discontinuation of sliding scale coverage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 15 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 - Few However, a clinical record review revealed no physician action taken on the pharmacist's recommendations August 18, 2023, at 11:08 a.m. On that date nursing noted that the physician initiated a new order for laboratory work prior to changing orders for Resident 22's current insulin therapy. During an interview on October 4, 2023, at approximately 9:00 a.m., the Director of Nursing confirmed that the physician failed to act upon pharmacy identified irregularities and recommendations. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 16 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, select facility policy review and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on one of two medication carts observed (Blue B hall - Resident 28) Findings include: A review of facility policy entitled Insulin Administration last reviewed by the facility June 30, 2023, indicates the purpose is to provide guidelines for the safe administration of insulin to residents with diabetes. It further states to check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). Observation of medication administration pass, on October 1, 2023, at approximately 9:28 AM, revealed Employee 3, Licensed Practical Nurse (LPN), on the Blue B Hall medication cart. Observation of the Blue B Hall medication cart on October 1, 2023, at approximately 9:28 AM, revealed two (2) Novolin R vials (medication used for diabetes) belonging to Resident 28, opened and available for use, the first dated August 28, 2023, and the second dated August 29, 2023. Manufacturers' instructions for use indicated that these insulins should be used within 28 days of opening. The above observations where in the presence of Employee 3, LPN, who confirmed these observations and stated that the insulin vials where open and in use and should have been discarded. Interview with the Director of Nursing (DON) on October 3, 2023, at approximately 8:30 AM, confirmed that the facility failed to assure the implementation of procedures to ensure acceptable storage and use by dates for multi-dose medications. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 17 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations of the resident pantry areas and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in foods and conditions, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of the resident food pantry located on the Yellow nursing unit on October 2, 2023, at 9:05 AM, revealed a clear plastic container with a red lid containing leftover food without a date or name, an opened 16 ounce sour cream container without a date when opened, an opened 10 ounce Coffeemate container without a date and name, an opened salad dressing without a date and name, a Ziplock bag containing a baked item without a date or name, a shaker bottle filled with brown liquid without a date or name, and four opened half-consumed water bottles without a name in the refrigerator. Observation of the freezer revealed two frozen meals without a date or name, two containers of ice cream sandwiches without a date or name and an opened one-half gallon of vanilla ice cream without a date or name. Observation of the resident food pantry located on the Blue nursing unit on October 2, 2023, at 9:34 AM revealed an opened 32-ounce Coffeemate container without a date or name, an opened one-half gallon Guers iced tea without a date or name, Bubbly sparkling water without a name, and an opened one-half gallon Tropicana orange juice without a date or name in the refrigerator. Observation of the cabinet above the sink revealed two opened peanut butter jars without a date or name, and two opened packages of cookies without a date or name. Interview with the certified dietary manager on October 4, 2023, at 9:20 AM confirmed that the food in the resident pantry was to be labeled with an open date and name of the resident and that acceptable practices for food storage were to be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 18 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement established procedures to assure safe smoking ability for one resident out of one resident identified as a current smoker (Resident 38). Residents Affected - Few Findings include: A review of the facility's policy entitled Smoking Policy last reviewed by the facility June 30, 2023, indicated that on admission, change in condition, and at least quarterly the Safe Smoking Assessment Form must be completed on a resident requesting to smoke. Upon completion of the assessment form the individualized Care Plan will be completed to reflect appropriate interventions for each resident. During entrance conference meeting on October 1, 2023, at approximately 11:00 A.M., the Director of Nursing (DON) provided a list of residents at the facility that currently smoke, which included Resident 38. A review of Resident 38's clinical record revealed he was most recently admitted to the facility on [DATE], with diagnoses to have include cerebral infarction (stroke), left non-dominant hemiplegia and hemiparesis, and severe protein - calorie malnutrition. The most recently completed smoking evaluation was dated November 16, 2022, at 12:57 PM, and indicated that Resident 38 is to be supervised by staff at all times when smoking tobacco products. Review of the resident's plan of care revealed no indication that the resident smoked. Observation on October 1, 2023, at approximately 1:15 PM, revealed Resident 38 in a wheelchair in front of the building with other residents smoking, without any staff supervision. A second observation on October 1, 2023, at approximately 1:37 PM, in the presence of Employee 2 Registered Nurse Supervisor (RNS), confirmed Resident 38 was in a wheelchair in front of the building smoking without any staff supervision. In questioning, the (RNS) indicated that Resident 38 is independent - unsupervised, with smoking. An additional observation on October 1, 2023, at approximately 1:50 PM, in the presence of the Director of Nursing (DON), confirmed Resident 38 smoking, unsupervised. Interview with the DON on October 1, 2023, at approximately 2:30 PM, confirmed the last Smoking Evaluation was completed on November 15, 2022, and indicated that the resident is to be supervised by staff at all times when smoking tobacco products, and that the resident's plan of care revealed no indication of smoking. The DON stated that a Nursing Evaluation is also completed at different intervals and includes a smoking evaluation section. A review of facility provided Nursing Evaluations, Section 17, Smoking Evaluation, Summary, revealed the following: December 24, 2022, indicated the resident must request smoking material, however made no indication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 19 of 20 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 395556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shenandoah Senior Living Community 101 E. Washington St Shenandoah, PA 17976 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the resident's smoking ability was fully addressed to include independence, supervision, or any equipment required for safe smoking, any restrictions as to time for smoking and the resident's possession and storage of smoking materials. March 24, 2023, Section 17, smoking summary was blank. June 26, 2023, Section 17, smoking summary was not completed. September 5, 2023, indicated the resident does not smoke. Interview with the DON on October 3, 2023, at approximately 8:30 AM, confirmed Resident 38 did not have a smoking care plan, and that the facility did not have a current assessment to ensure that independent smoking was safe and appropriate for the resident. 28 Pa. Code 209.3 (a)(c) Smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 20 of 20