Inspection·February 16, 2024

F 0600 that date. Level of Harm - Actual harm A review of a hospital Xray report dated January 9, 2024, revealed the resident had a displaced angulated fracture (two ends of the broken bone are at an angle to each other) of the left hip. Residents Affected - Few A review of the facility's investigation report dated January 9, 2024, revealed Resident CR1 reported to Employee 1 LPN (license practical nurse) that Employee 2, a nurse aide (NA), on night shift took her to the bathroom when Resident CR1 requested to use the bedpan to relieve herself. Employee 2 got the resident up into the wheelchair and took her to the bathroom to use the toilet instead of providing the bedpan as the resident requested. Employee 2 transferred the resident by herself to the wheelchair when the resident's plan of care indicated that the resident is to be transferred with the assistance of two staff. Employee 2 then transferred the resident by herself onto the toilet. The employee was unable to transfer the resident back to the wheelchair from the toilet, so Employee 2 used a sit to stand lift, without the assistance of another staff member, to transfer the resident back into the wheelchair. Resident CR1 reported to Employee 1 that she heard snapping while Employee 2 was transferring her to the toilet. The facility concluded that Employee 2 neglected to follow Resident CR1's plan of care to ensure the proper staff assistance was provided to safely transfer the resident. Employee 2 was terminated from employment at the facility. A review of Resident CR1's statement regarding the event dated January 9, 2024, revealed that the resident stated Employee 2, NA, transferred her to the wheelchair to take her to the bathroom by herself. The resident stated that she was yelling out in pain during the transfer. The resident stated that Employee 2 told her to stop yelling so people don't think she is hurting the resident. The resident stated that Employee 2 took her to the bathroom and had her pivot and sit on the toilet. The resident stated while she was having her do that, she was yelling out in pain again. Resident CR1 stated Employee 2 transferred her off the toilet using a lift and that is when she heard two snaps. The resident stated Employed 2 then transferred her to the wheelchair as the resident continued to yell out in pain. The resident then stated Employee 2 brought the wheelchair to the side of the bed and the resident stated, oh no not again. The resident stated at that time Employee 2 left the room to get Employee 3, another nurse aide. The resident stated the Employee 2 and Employee 3 then placed the resident back in bed. The resident further indicated that Employee 4, LPN, came into the room after Employee 2 and Employee 3 left and administered her the scheduled pain medication. The resident then stated she called her daughter around 7:20 AM that morning to inform her of what happened during the night shift on January 9, 2024. A review of a statement from Employee 2 dated January 9, 2024, revealed that the employee reported that Resident CR1 rang the call bell and indicated that she needed to be toileted. The employee stated that she transferred the resident by herself to the wheelchair. When asked about the resident's transfer status, the employee stated she did not know the resident was an assist of two. The employee stated when the resident sat down on the toilet it sounded like a crunch. When the employee was asked if she notified the LPN, or the RN (registered nurse) supervisor, Employee 2 stated no. Employee 2 indicated that she had a difficult time getting the resident up from the toilet and stated that she told Employee 4 she was going to have to use the lift to get her up. Employee 2 stated that she used the sit to stand lift by herself to get the resident up and on the side of her bed. Employee 2 then stated Employee 3 came into the room to help lift the resident's legs into bed. Employee 2 was asked if the resident complained of pain during these transfers, the employee stated yes, but I thought it was normal for her. A review of a statement from Employee 3 dated January 9, 2024, revealed that Employee 2 came to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 2 of 4 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 02/16/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few Employee 3 for help with Resident CR1. Employee 3 indicated that when she entered the room Resident CR1 was already sitting on the side of the bed. Employee 3 revealed that Employee 2 stated to her, I keep trying to lay her down and she keeps screaming that her legs hurt. Employee 3 stated she helped assist her legs into bed. Further Employee 3 indicated she was not aware that Employee 2 had transferred the resident to and from the bathroom. A review of a statement from Employee 4 dated January 9, 2024, revealed that a little after 6:00 AM he administered Resident CR1's scheduled pain medications. The employee stated at that time she did not appear at ease and assumed pain was the culprit. The employee indicated that Employee 2 had cared for the resident that night (tour of duty). Employee 4's statement did not indicate awareness that Employee 2 had transferred to the toilet and needed a sit to stand lift to be transferred off the toilet and back to bed. An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed that prior to the incident Employee 2 was educated on abuse, neglect and following a resident's plan of care in August 2023, and she knew where to find the information regarding the resident's transfer status. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, difficulty walking, and need for assistance with personal care. An Annual MDS dated [DATE], indicated the resident was moderately cognitively impaired. A review of the resident's plan of care, initially dated June 8, 2020, revealed that the resident had limited physical mobility related to osteoarthritis with planned interventions initially dated August 3, 2023, for the resident to be transferred with the assistance of two staff members with a walker. A nursing progress note dated January 12, 2024, at 7:38 PM revealed staff was assisting Resident 2 to the toilet when the resident's right knee buckled causing the resident to lose balance. Staff assisted the resident to a chair. The resident complained of pain to the right ankle. The physician was made aware, and x-rays were ordered. A review of a facility investigation report dated January 12, 2024, revealed that at 4:15 PM Employee 5, a nurse aide, took Resident 2 to the bathroom. Employee 5 was transferring the resident, without the assistance of another staff member, to the toilet when the resident's knee gave out causing the resident to fall to her knees and her ankle to turn outward. Employee 5 called out for assistance from other staff and the resident was placed back into the wheelchair. The resident was required an assist of two staff members for all transfers. Upon assessment the resident's right ankle was swollen, painful, and bruised. X-rays were ordered. The facility's investigation concluded that Employee 5 neglected to follow the resident's plan of care and transferred the resident alone when the resident required assistance of two staff. The facility notified the employee's nurse staffing agency, and she was placed on the do not return list. A review of an x-ray report dated January 12, 2024, revealed the resident had a mildly displaced acute oblique fracture (break in the bone at an angle that does not line up) of the right ankle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 3 of 4 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 02/16/2024 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 0600 The resident was transferred out to the hospital on January 12, 2024, for further treatment. Level of Harm - Actual harm A review of a statement from Employee 5 dated January 12, 2024, revealed that the employee stated she was trying to toilet the resident. As the employee was assisting her turn, the resident screamed out, oh my god my legs hurt. The employee indicated that she then assisted the resident to the floor and yelled for help. Residents Affected - Few An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed Employee 5 was just educated on January 12, 2024, prior to her shift on the importance of reviewing resident's [NAME] and transfer status prior to performing any care involving resident transfers. This education was completed in response to the prior incident with Resident CR1 on January 9, 2024. Employee 5 was educated on the abuse policy, resident rights policy, following resident transfer orders and plan of care due Employee 2's he neglect of Resident CR1. The Director of Nursing confirmed Employee 5 still failed to implement the resident's plan of care and use the correct amount of transfer assistance for Resident 2, and the facility's education failed to prevent another incident of neglect from happening. An interview with the Nursing Home Administrator and Director of Nursing on February 16, 2024, at approximately 1:45 PM confirmed that the facility failed to ensure that Resident CR1 and Resident 2 were provided the services necessary to avoid physical harm and Employee 2 and Employee 5 neglected to provide care planned for the resident, sufficient staff assistance with transfers, resulting in serious injuries. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395556 If continuation sheet Page 4 of 4