Health inspection·June 15, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for one of three residents reviewed (Resident 49). Residents Affected - Few Findings include: Review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on June 13, 2023, revealed that Medicare coverage for Resident 49 started on January 4, 2023, and that Resident 49's last covered day was February 16, 2023. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the Resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide form CMS-10055, SNF ABN (Advanced Beneficiary Notice - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) to the Resident or the Resident's Representative as required at the time that Medicare Part A was discontinued. On June 15, 2023, at 10:11 AM, the Nursing Home Administrator (NHA) stated that form CMS-10055 was not one of the forms that was presented to Resident 49. On June 15, 2023, at 10:21 AM, NHA stated that form CMS-10055 has been sent to the social workers to start using immediately. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 2 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident family and staff interviews, it was determined that the facility failed to maintain a safe, clean comfortable, and home-like interior on four of six units observed (Arcadia, A Hall, B Hall, and D Hall). Findings include: Observations on the Arcadia unit revealed the following: - On June 12, 2023, at 10:20 AM, armchairs present in front of the nursing station had an accumulation of dried debris and liquid present on the sides and rungs of the chairs. - On June 12, 2023, at 11:08 AM, large, dried liquid rings were present on the couch located in the unit lounge. Additionally, two wheelchairs (one with cushions and leg rests stored in the seat of the chair), two walkers, and a chair scale were stored in the lounge. The lounge was being utilized for visitation with Resident 125 at the time of the observation. - On June 12, 2023, at 11:11 AM, Resident 117 was observed standing in the parlor. The lights were off in the room. Two wheelchairs and two mechanical lifts were being stored in the room at the time. - On June 13, 2023, at 12:36 PM, the stains remained present on the lounge couch. Two wheelchairs were stored in the lounge. In the parlor, it was observed that two mechanical lifts, one wheelchair, an overbed table, and wheelchair legs were being stored. In the dining room, it was observed that multiple dining chairs had an accumulation of dried debris and liquid on the sides and rungs of the chairs. - On June 14, 2023, at 12:28 PM, two mechanical lifts, a chair scale, and one wheelchair were stored in the lounge. The stains remained present on the lounge couch. In the parlor, it was observed that two wheelchairs, wheelchair legs, a mechanical lift, and an overbed table were being stored. A staff person was sitting with Resident 86 in the parlor at the time of the observation. At 12:41 PM on that date, it was observed that Resident 125 was served his lunch in the parlor. - On June 15, 2023, at 10:25 AM, it was observed that lifts and a wheelchair were still stored in the lounge and the parlor. The couch in the lounge remained stained. Chairs present in the dining room were observed to have an accumulation of dried debris and liquid on the sides and rungs of the chairs. During an interview with a family member of Resident 125 on June 12, 2023, at 12:08 PM, she revealed a concern with the cleanliness of the lounge and the furniture in the lounge. Additionally, she expressed a concern with the amount of items stored in the lounge, noting that Resident 125 often mistakes the wheelchair (stacked with cushions and leg rests) for a car. Observations of A Hall Unit revealed the following: - On June 12, 2023, at 12:14 PM, a mechanical stand-aide lift was observed in Resident 81's room near their bed, impeding their access to sit beside the bed in their wheelchair. Resident 81 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 3 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0584 observed attempting to maneuver their wheelchair around the lift when Employee 6 intervened. Level of Harm - Minimal harm or potential for actual harm - On June 13, 2023, at 8:56 AM, it was observed in the lounge that a mechanical lift, a chair scale, two broda chairs, and three wheelchairs were being stored. Residents Affected - Some -On June 14, 2023, at 9:16 AM, it was observed in the lounge that three wheelchairs and a chair scale were being stored. -On June 14, 2023, at 1:00 PM, it was observed in Resident 81's room that a mechanical stand-aide lift was stored at the foot of their roommates bed. Observation of B Hall Unit revealed on June 13, 2023, at 8:58 AM, revealed that a mechanical lift was being stored in the lounge. Observation of D Hall Unit on June 14, 2023, at 9:14 AM, revealed that four mechanical lifts and one broda chair were being stored in the lounge. Findings of all observations were shared with the Nursing Home Administrator (NHA) and Director of Nursing on June 14, 2023, at 2:03 PM, for further follow-up. During an interview with the NHA on June 15, 2023, at 12:58 PM, she acknowledged the aforementioned concerns. She revealed that the furniture that could not be cleaned would be disposed of. She also revealed that she identified storage concerns upon her arrival at the facility, and that she plans to work on finding additonal storage and educating staff on where to store things. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 4 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to provide a notice of transfer for two of nine residents reviewed for hospitalization (Residents 42 and 60). Residents Affected - Few Findings include: Review of Resident 42's clinical record on June 12, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 42's clinical record revealed that on February 21, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a notice of transfer. Review of Resident 42's clinical record revealed that on March 1, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a notice of transfer, nor was there notification of the transfer sent to a Representative of the State Ombudsman for the transfer on March 1, 2023. Review of Resident 60's clinical record on June 13, 2023, at approximately 10:00 AM, revealed diagnoses including diabetes mellitus type 2 and quadriplegia (partial or full loss of function in both arms and both legs). Review of Resident 60's clinical record revealed that Resident 60 was transferred to a hospital emergency room after a change in condition on February 8, 2023, and March 21, 2023. Review of available documention revealed that no transfer notice was provided to Resident 60 and/or Resident 60's Representative for neither the February 8, 2023, and March 21, 2023, transfers. During a staff interview on June 15, 2023, at approximately 12:30 PM, Director of Nursing revealed that, prior to May 1, 2023, transfer notices were not consistently provided in response to resident transfers to a hospital. 28 Pa. code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 5 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident and/or resident representative received written notice of the facility bed-hold policy at the time of transfer for three of nine residents reviewed for hospitalization (Residents 42, 106, and 123). Findings Include: Review of facility policy and process, titled Bed Hold Notice - Deliver Upon Transfer, last revised August 2022, revealed section titled, Process stated, Bed hold notification is required per Federal regulation [Title 42, Chapter IV, Subchapter G, Part 483.15(d)(2)]. To meet Federal and survey requirements, Genesis follows Accounts Receivable Policy 102 Bed Holds, which states: Prior to a resident transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and representative, if applicable, with the Bed Hold Policy Notice & Authorization form (Smartworks form # GHC-4731) .Notice must be given regardless of payer .Resident copy is given directly to the resident prior to transfer and noted in the medical record .Representative copy can be delivered electronically via email/secure fax or hard copy via mail if the representative is not present at the time of transfer. (Must be done within 24 hours.) Review of Resident 42's clinical record on June 12, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 42's clinical record revealed that on March 1, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a copy of the facility's bed-hold policy in response to the hospital transfer. During a staff interview on June 15, 2023, at approximately 12:30 PM, Director of Nursing (DON) revealed that the facility had identified multiple concerns with required documents being provided upon transfer in regards to resident transfers that took place prior to May 1, 2023. During a staff interview on June 15, 2023, at approximately 1:45 PM, Nursing Home Administrator (NHA) revealed that the facility had no further information to provide regarding a bed-hold notice being provided to Resident 42 in response to the hospital transfer on March 1, 2023. A review of Resident 106's clinical record on June 13, 2023, revealed diagnoses that included hypertension (elevated blood pressure) and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of Resident 106's clinical record revealed that Resident 106 was transferred to the hospital on April 18, 2023, and returned to the facility on May 1, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 6 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the NHA and DON on June 15, 2023, at approximately 10:51 AM, the NHA indicated that she could not provide a copy of the bed-hold notice for Resident 106's hospitalization. The NHA further indicated that bed-hold notices were not being rendered prior to her assuming the role of NHA on May 1, 2023. Review of Resident 123's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and chronic combined systolic and diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly). Review of clinical record further revealed that Resident 123 was transferred to the hospital on April 17, 2023, and returned to the facility on April 20, 2023. Resident 123 was again transferred to the hospital on April 26, 2023, and returned to the facility on May 1, 2023. During an interview with the NHA and DON on June 15, 2023, at approximately 10:51 AM, the NHA indicated that she could not provide a copy of the bed-hold notices for Resident 123's hospitalizations. She further indicated that bed-hold notices were not being rendered prior to her assuming the role of NHA on May 1, 2023. 28 Pa. Code 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 7 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observations, staff interviews, and clinical record review, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised to reflect the resident's current status for eight of 29 residents reviewed, (Residents 30, 72, 81, 83, 86, 106, 118, and 125). Findings include: Review of Resident 30's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic pain. Review of Resident 30's care plan revealed that she was to be out of bed for all meals, effective February 10, 2023. Observation on June 12, 2023, at 12:38 PM, and June 13, 2023, at 12:42 PM, revealed Resident 30 eating her meal in bed. During an interview with the Director of Nursing (DON) on June 15, 2023, at 1:45 PM, she revealed that the intervention for Resident 30 to be out of bed for all meals was no longer applicable since she has had a decline in functioning since that time. She confirmed that the care plan was not accurate. Review of nursing progress notes and physician orders revealed that Resident 30 was admitted to hospice services (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness)on March 3, 2023, for dementia and kidney disease. Review of Resident 30's current care plan failed to reveal that it was noted that Resident 30 was receiving hospice services. During an additional interview with the DON on June 15, 2023, at 1:25 PM, she acknowledged that hospice should have been on Resident 30's plan of care. She provided an updated care plan. A review of the clinical record for Resident 72 on June 12, 2023, at 1:00 PM, revealed diagnoses that included congestive heart failure (CHF-excessive body/lung fluid caused by a weakened heart) and chronic obstructive pulmonary disease (COPD- disease process that causes decreased ability of the lungs to perform). Observation of Resident 72 on June 12, 2023, at 10:30 AM, revealed oxygen was being administered at 2 liters per minute (lpm) via nasal cannula (NC). A review of Resident 72's physician orders dated June 2023 revealed oxygen to be administered at 2 lpm via NC every shift for shortness of breath. A review of Resident 72's care plan on June 13, 2023, failed to include a care plan for oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 8 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the DON on June 14, 2023, the DON confirmed Resident 72's care plan should have been revised to include oxygen administration. Review of Resident 81's clinical record revealed diagnoses that included anxiety and hypertension. Review of Resident 81's current physician orders revealed the following orders: Apply right thumb brace after AM care. Check skin integrity prior to application every day shift, dated March 2, 2023; and remove right thumb brace at HS (bedtime). Check skin integrity after removal at bedtime, dated March 1, 2023. Review of Resident 81's care plan revealed that the use of thumb brace was not included as part of their care plan. During an interview with the Nursing Home Administrator (NHA) and DON on June 15, 2023, at 10:56 AM, the DON confirmed that the brace was not mentioned on Resident 81's care plan and that she would have expected it to be on the care plan. She further indicated that she had updated the Resident's care plan to include the brace. A review of the clinical record for Resident 83 on June 12, 2023, at 1:00 PM, revealed diagnoses that included schizophrenia (mental disease characterized by loss of reality contact, delusions, hallucinations, and/or feelings of persecution) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of the clinical record for Resident 83 on June 12, 2023, at 1:00 PM, revealed the diagnosis of schizophrenia was added to the Resident's diagnoses list on August 17, 2022. A review of Resident 83's care plan dated June 2023, failed to include a focus area, goals, or interventions for the diagnosis of schizophrenia. During an interview with the DON on June 14, 2023, the DON confirmed Resident 83's care plan should have been revised to include the diagnosis of schizophrenia. Review of Resident 86's clinical record revealed diagnoses that included dementia with agitation and psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions). Review of Resident 86's current care plan revealed active plans of care for a laceration (deep cut) to the back of the head, effective December 26, 2022. Review of nursing progress notes dated January 1, 2023, indicated that staples were removed from Resident 86's head at that time. Review of physician orders revealed that treatment orders for the laceration/staples were discontinued on January 6, 2023. During an interview with the DON on June 15, 2023, at 12:43 PM, she revealed that she resolved the care plan associated with a head laceration. A review of the clinical record for Resident 106 on June 12, 2023, at 1:00 PM, revealed diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 9 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0657 Level of Harm - Minimal harm or potential for actual harm that included diabetes mellitus (DM- a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and schizophrenia. Observation of Resident 106 on June 12, 2023, at 11:00 AM, revealed oxygen was being administered at 3 lpm via NC. Residents Affected - Some A review of Resident 106's physician orders dated June 2023, revealed oxygen to be administered at 3 lpm via NC every shift for shortness of breath. A review of Resident 106's care plan dated June 2023, on June 13, 2023, failed to include a care plan for oxygen administration. During an interview with the DON on June 14, 2023, the DON confirmed the care plan for oxygen therapy should be developed. Review of Resident 118's clinical record revealed diagnoses that included hypertension and personal history of COVID-19. Review of Resident 118's current care plan revealed a care plan focus for: Has/At risk for respiratory impairment related to + COVID, with a date initiated of December 2, 2022, with a goal target date of September 6, 2023. During an interview with the NHA and DON on June 15, 2023, at 1:01 PM, the DON confirmed that Resident 118 did not have an active COVID-19 infection and that that the care plan should have been revised when their infection resolved in December 2022. Review of Resident 125's clinical record revealed diagnoses that included dementia with agitation and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 125's nursing progress notes revealed the following: - May 6, 2023 - Resident was noted to be swearing at staff and residents, swinging at other residents. - May 15, 2023 - Resident was verbally aggressive with staff and residents, attempting to hit staff and other residents. - May 17, 2023 - Resident picked up chair and threw it. - May 18, 2023 - Resident was using profanity. - May 20, 2023 - Resident was verbally and physically aggressive. - May 22, 2023 - Resident was noted to be agitated, beating on closed doors, attempting to leave the secured unit, grabbed staff person and put hand around their neck, swinging fists, cursing, pinching. Resident was sent to the emergency department on this date for evaluation due to behavioral concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 10 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0657 - May 23, 2023 - Resident was swearing and was agitated. Level of Harm - Minimal harm or potential for actual harm - May 25, 2023 - Resident was noted to be agitated. - May 26, 2023 - Resident was using profanity Residents Affected - Some - May 27, 2023 - Resident hit staff with his wheelchair, was attempting to hit/bite staff, using profanity. - May 29, 2023 - Resident was noted to be hitting his head on the wall. Further review of Resident 125's progress notes indicated that he was being followed by psychiatric services for mood and agitation concerns. Review of Resident 125's current care plan failed to reveal notation of specific behavioral concerns or personalized non-pharmacological interventions to manage the aforementioned behavioral concerns. During an interview with the DON on June 15, 2023, at approximately 12:45 PM, she acknowledged that care plan accuracy was an issue that she identified at the facility upon her arrival, and that the facility is currently working through a process improvement plan to address the concern. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plans 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 11 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 observation, clinical record review, and staff interview, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for two of 29 residents reviewed (Residents 93 and 126). Residents Affected - Few Findings include: Review of Resident 93's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and difficulty in walking. Review of nursing progress note dated June 11, 2023, revealed that Resident 93 obtained a skin tear to her left lower leg on this date. Further review revealed that it was documented that Resident 93 was to begin wearing leg protectors at all times, except for during care. Review of nursing progress note dated June 12, 2023, revealed that a skin tear was discovered on the back of Resident 93's right calf. It was again noted that the intervention to prevent future occurances was for Resident 93 to wear leg protectors. Observations on June 12, 2023, at 1:20 PM; June 13, 2023, at 12:39; and on June 14, 2023, at 1:20 PM, revealed that Resident 93 was not wearing leg protectors. During an interview with the Director of Nursing (DON) on June 15, 2023, at 12:46 PM, she revealed the she was unable to locate two padded leg protectors, so another type of sleeve was used in the meantime. She also revealed the expectation that Resident 93 should have been wearing some kind of leg protectors. Review of Resident 93's occupational therapy Discharge summary dated [DATE], revealed that she was seen and treated by occupational therapy for wheelchair positioning. Further review revealed, upon discharge from services, it was noted that Resident 93 was utilizing assistive devices, including leg rests, to maintain proper wheelchair positioning. Review of Resident 93's care plan revealed that she was to be using leg rests on her wheelchair, effective February 10, 2023. Observations of Resident 93 on June 12, 2023, at 1:20 PM; June 13, 2023, at 12:39; and on June 14, 2023, at 1:20 PM, revealed her in her wheelchair. Resident 93 was slouched in her chair, with the back of her neck resting on the top of the back of her wheelchair. No leg rests were present on Resident 93's wheelchair. During an interview with the DON on June 15, 2023, at 12:49 PM, she revealed the expectation that Resident 93 should have had leg rests on her wheelchair. Review of Resident 126's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 12 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 Review of a practitioner progress note dated May 4, 2023, indicated that Resident 126 was seen on that date. It was noted that the Resident had a low grade temperature of 99.5 degrees. Further review revealed that the practitioner noted a plan to complete a urinalysis (test to examine the urine contents for any abnormalities that indicate a disease condition or infection). Review of a physician order form dated May 4, 2023, revealed an order for urinalysis with culture and sensitivity (a test to identify bacteria and their antibiotic susceptibility). The form was signed by both the practitioner and nurse. Review of a nursing progress note dated May 7, 2023, revealed that a urine sample was successfully obtained on May 6, 2023. Review of Resident 126's clinical record failed to indicate any documentation of the results of the urinalysis. During an interview with the DON on June 15, 2023, at 12:43 PM, she revealed that, when she called the laboratory for the results of the urinalysis, she was informed that the lab did not have them. The DON revealed that she was unable to provide any information about what happened to the urine sample. She revealed the expectation that someone should have caught this and followed-up. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 13 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 Based on review of facility policy, clinical record review, observations, and interviews with resident and staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed (Resident 123). Residents Affected - Few Findings include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) Communication and Documentation with a last revision date of June 15, 2022, revealed, in part: Center staff will communicate with the certified dialysis center regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments; prior to leaving the facility a licensed nurse will complete the top portion of the Hemodialysis Communication Record and send with the patient to his/her HD facility visit; and upon return of the patient to the facility, a licensed nurse will review the dialysis center communication, evaluate the resident, and complete the post-hemodialysis treatment section of the Hemodialysis Communication Record; and maintain the Hemodialysis Communication Record in the patient's medical record. Review of Resident 123's clinical record revealed diagnoses that included end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for long-term dialysis or a kidney transplant) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 123's current physician orders included Hemodialysis per physician order, with a start date of May 22, 2023; and Dialysis site observation-left upper arm every shift and as needed, dated May 22, 2023. During an interview with Resident 123 on June 13, 2023, at 9:08 AM, Resident 123 revealed that they currently attend dialysis on Mondays, Wednesdays, and Fridays. During this interview, it was observed that Resident 123 had a dialysis catheter to their right chest. Review of Resident 123's dialysis communication book located at the nurses' station revealed the presence of only one completed facility Hemodialysis Communication Form, which was dated June 7, 2023. There were, however, computer generated communication sheets from the dialysis center, except for June 9, 2023. Review of Resident 123's clinical record progress notes revealed that they did attend dialysis on June 9, 2023. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 15, 2023, at 10:58 AM, the NHA confirmed that the staff should have been completing the Hemodialysis Communication Form consistently as per facility policy. She further indicated that they had ordered more forms and will be educating staff. During an interview with the NHA and DON on June 15, 2023, at 1:01 PM, the DON confirmed that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 14 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 would expect Resident 123's order to be accurate in regards to their hemodialysis catheter site location for proper monitoring. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.5(f) Clinical 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: 395348 If continuation sheet Page 15 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for four of five nurse aides reviewed (Employee 1, 2, 3, and 5), and failed to ensure that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 1, 2, 3, 4, and 5). Residents Affected - Some Findings Include: Review of select facility documentation revealed that Employee 1 was hired on October 15, 2016 ; Employee 2 was hired on September 25, 2005; Employee 3 was hired on December 2, 2021; Employee 4 was hired on August 31, 1998; and Employee 5 was hired on June 1, 2022. During an interview with the Nursing Home Administrator on June 15, 2023, at 2:40 PM, she confirmed that Employee 4's performance evaluation was the only one able to be found, and she confirmed that she could not provide any documentation of completed education for all Employees selected for review. She further indicated this was due to the change in ownership in January. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 16 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 125). Findings include: Review of facility policy, titled Medication Regimen Review revised March 3, 2020, revealed that the consultant pharmacist will conduct medication regimen reviews (MRRs) and make recommendations based on the information available in the resident's health record. Copies of residents' MRRs will be provided to the Director of Nursing (DON) and/or the attending physician and to the Medical Director. The facility will then encourage the physician/prescriber or other responsible parties to act upon the recommendations contained in the MRR. For the issues requiring intervention, the practitioner/prescriber should accept and act upon the recommendations, or reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected. The attending practitioner should document in the residents' health records that the identified irregularity was reviewed and what, if any, action was taken to address it. If the attending physician decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Review of Resident 125's clinical record revealed diagnoses that included severe dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Further review of Resident 125's clinical record revealed that medication regimen reviews were completed on April 12, 2023, May 11, 2023, and on May 19, 2023. Irregularities were noted by the consultant pharmacist, and recommendations were made on those dates. Additional review failed to reveal what recommendations were made or the physician's response to these recommendations. During an interview with the DON on June 15, 2023, at 1:46 PM, she revealed that she did not have any additional information to provide. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 17 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 interviews, it was determined that the facility failed to ensure that the resident medication regimen was free from unnecessary psychotropic medication as evidenced by failure to monitor for target behaviors and/or adverse side effects for six of 26 residents reviewed (Residents 30, 86, 102, 118, 125, and 126), and for failure to act upon a physician's order to reduce a psychotropic medication in a timely manner for one of 26 residents reviewed (Resident 126). Findings include: Review of Resident 30's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions). Review of Resident 30's current physician orders revealed orders for Fluoxetine (antidepressant) twice a day for depression, effective January 21, 2023; and Seroquel (antipsychotic medication) for psychotic disorder in the morning, effective May 10, 2022, and at bedtime, effective May 9, 2022. Review of Resident 30's clinical record failed to reveal that behavior monitoring was in place to track or document behaviors related to depression or psychosis. During an interview with the Director of Nursing (DON) on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done. Review of Resident 86's clinical record revealed diagnoses that included Alzheimer's disease and psychotic disorder. Review of Resident 86's current physician orders revealed orders for Ativan (antianxiety medication) as needed for anxiety (sense of uneasiness, distress, or dread), effective June 7, 2023; Rexulti (antipsychotic medication) daily for dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), effective June 10, 2023; Depakote (anticonvulsant also used to treat certain psychiatric disorders) twice a day and at bedtime for delusional disorder (unshakable belief in something that's untrue), effective October 2, 2021; Paxil (antidepressant) daily for adjustment disorder (difficulty in managing stressful life changes), effective December 11, 2021; and buspirone (antianxiety medication) every eight hours for anxiety, effective June 9, 2023. Review of Resident 86's clinical record failed to reveal that behavior monitoring was in place to track or document behaviors related to anxiety, delusional disorder, dementia with agitation, or adjustment disorder. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done, and that it was added to Resident 86's orders for Depakote and Rexulti. Review of Resident 102's clinical record on June 12, 2023, at approximately 12:30 PM, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 18 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transfer of glucose from the blood stream into the cells for nourishment) and obsessive compulsive disorder (OCD mental health disorder characterized by obsessive thoughts that contribute to compulsive often repetitive behaviors). Review of Resident 102's physician orders on June 13, 2023, at approximately 1:30 PM, revealed a physician order for fluvoxamine maleate (psychotropic medication used to treat obsessive compulsive disorder), 50 milligrams once a day at bedtime with the identified indication of hoarding (chronic and persistent inability to discard/part with possessions because of a pervasive perception that the items need to be saved). Review of Resident 102's clinical record revealed no behavior monitoring was in place to monitor Resident 102's behavior of hoarding or any other behavior associated with Resident 102's OCD. During a staff interview on June 15, 2023, DON confirmed that there was no behavior monitoring in place for Resident 102 at that time. Review of 118's clinical record revealed diagnoses that included depression and adjustment disorder with anxiety (an emotional or behavioral reaction to a stressful event or a change in a person's life with symptoms that may include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed). Review of 118's current physician orders revealed the following orders: busPIRone HCl Tablet (an antianxiety medication) 30 MG Give one tablet by mouth two times a day for anxiety, dated August 8, 2022; and Lexapro oral tablet (antidepressant medication) 10 MG (escitalopram oxalate) Give 10 milligrams by mouth one time a day for Depression, dated April 21, 2023. Review of Resident 118's care plan revealed the following care plan focus items: 1) Resistive/noncompliant with treatment/care (refusing showers) related to: Belief that treatment is not needed/working, Cognitive Impairment, with date initiated of February 20, 2023, and last revision date of June 13, 2023; 2) At risk for changes in mood related to diagnosis of adjustment disorder with mixed anxiety, with date initiated of August 3, 2022, and last revision date of June 13, 2023; and 3) At risk for adverse effects related to adjustment disorder: use of antianxiety/depression medication, with date initiated of August 2, 2023, and last revision date of June 13, 2023. Further review of Resident 118's clinical record failed to reveal documentation of monitoring of their identified target behaviors or documentation of medication side effect monitoring. During an interview with the Nursing Home Administrator and DON on June 15, 2023, at 12:38 PM, the DON confirmed that there was no documentation that they could provide for Resident 118's identified target behavior monitoring or medication side effect monitoring. She indicated that she is updating orders for psychotropic medications to include Resident specific target behaviors to monitor for as well as appropriate side effect monitoring. Review of Resident 125's clinical record revealed diagnoses that included Alzheimer's disease and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 19 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 125's current physician orders revealed orders for Rexulti daily for dementia with aggression, effective June 5, 2023; olanzapine (antipsychotic medication) at bedtime for severe dementia with agitation, effective May 26, 2023; and Citalopram (antidepressant) daily for depression, effective April 7, 2023. Review of Resident 125's clinical record failed to reveal evidence of behavior monitor for behaviors related to dementia with aggression/agitation or depression. Further review also failed to reveal monitoring for adverse medication side effects. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior/side effect monitoring was not being done. Review of Resident 126's clinical record revealed diagnoses that included severe dementia with agitation, and alcohol induced persisting amnestic disorder (disorder of the central nervous system characterized by amnesia and memory deficits caused by a deficiency of thiamine [vitamin B1] in the brain typically associated with prolonged, excessive ingestion of alcohol). Review of Resident 126's current physician orders revealed orders for Haldol (antipsychotic medication) every eight hours for dementia with agitation, effective May 19, 2023; Quetiapine (antipsychotic) three times a day for dementia with behavioral disturbance, effective May 25, 2023; and Trazadone (antidepressant) at bedtime for depression, effective May 3, 2023. Review of Resident 126's clinical record failed to reveal evidence of behavior monitoring for behaviors related to dementia with agitation or depression. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done, and that it was added to Resident 126's orders for Haldol and quetiapine. Review of Resident 126's medical practitioner progress note dated May 15, 2023, revealed, On exam he is noted to have some decreased range of motion in neck. Patient denies pain, he is on Haldol. Discussed with PGS [geropsychiatric service provider] for concerns of dystonia [movement disorder that causes the muscles to contract involuntarily causing repetitive or twisting movements - can be a potential medication side effect]. Will decrease Haldol to 1.5 mg PO [by mouth] TID [three times a day]. Review of physician order form dated May 15, 2023, revealed a written order to decrease Resident 126's Haldol to 1.5 mg every eight hours. The order form was signed by the practitioner and nurse. Review of geropsychiatric medical practitioner progress note dated May 19, 2023, revealed, CRNP [Certified Registered Nurse Practitioner] expressed concerns r/t [related to] possible dystonia vs [versus] neuroleptic malignant syndrome [rare but life-threatening reaction that can occur in response to neuroleptic or antipsychotic medication] on 5/15. Reported pt [patient] to have increasing temperatures 99.5, skin flush/red, neck stiffness, he was able to rotate head left/right, unable to flex neck. Discussed reduction of Haldol and increase of Cogentin [used to treat symptoms of involuntary movements due to the side effects of certain psychiatric drugs] for 7 days. After review of MAR [Medication Administration Record] Haldol was not reduced. Further review of this progress noted indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 20 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 a plan to reduce Haldol to 1.5 mg every eight hours as previously noted. Level of Harm - Minimal harm or potential for actual harm Review of physician order dated May 19, 2023, revealed a second written order to decrease Haldol to 1.5 mg three times per day. The order form was signed by the practitioner and nurse. Residents Affected - Some Review of Resident 126's May 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that it was documented that Resident 126 continued to receive the higher dose of Haldol through May 19, 2023, at 1:00 PM. During an interview with the DON on June 15, 2023, at 12:42 PM, she confirmed that the order to reduce Resident 126's Haldol was not completed and carried out in a timely manner. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 21 of 22 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 395348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of the sign-in sheets for the facility's quarterly Quality Assurance (QA) Committee and staff interview, it was determined that the required members failed to attend one out of three quarterly meetings since the last Full Health Survey cleared date of September 1, 2022. Residents Affected - Few Findings include: Review of the QA Committee sign-in sheets revealed that the facility Infection Preventionist was not in attendance at the January 18, 2023, meeting. During an interview with Nursing Home Administrator (NHA) on June 15, 2023, at approximately 10:23 AM, the NHA confirmed that the Infection Preventionist was not at the meeting, and revealed the expectation that all required members should attend meetings quarterly. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.18(e)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 22 of 22