Inspection·July 2, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent in reflecting a resident's elected code status for two of 23 residents reviewed (Residents 29 and 80). Findings include: A review of a facility policy titled Advanced Directives, last reviewed by the facility on [DATE], revealed it is the facility policy that the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment, and advanced directives are honored in accordance with state law and facility policy. Further review revealed Physician Orders for Life Sustaining Treatment, or POLST, is a form designed to improve resident care by creating a portable medical order form that records the resident's treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration. A review of the clinical record of Resident 29 revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and 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). A review of Resident 29's current physician orders, revealed an order dated [DATE], in the electronic health record, and identified the resident's code status as Full Code, indicating CPR (cardiopulmonary resuscitation) was to be performed in the event of cardiopulmonary arrest (if breathing stops or if the heart stops beating). Further review of Resident 29's clinical record revealed a completed and signed POLST dated [DATE]. The POLST indicated the resident elected DNR status (Do Not Resuscitate, a medical order directing that cardiopulmonary resuscitation, a life-saving procedure performed when the heart or breathing stops, should not be attempted), with a goal of allowing a natural death. Following surveyor questions, there was a physician's order dated [DATE], for DNR (Do Not Resuscitate-a medical order directing that CPR should not be attempted) for Resident 29. A review of the clinical record of Resident 80 revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia and urine retention (difficulty urinating and (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 11 Event ID: 395556 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 07/02/2025 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)