Health inspection·February 20, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior for three of four nursing units observed (Stations 1, 2, and 3). Residents Affected - Some Findings include: Observations made on February 20, 2024, at the noted times and locations revealed the following: - 9:03 AM in the dining room outside of the main kitchen (corner of Station 1 and 2) - the air vent was noted to be covered in a black, speckled substance. - 9:32 AM in Resident 1's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:37 AM in Resident 2's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:41 AM in the Station 3 lounge - presence of a black substance on the grates of the wall heating/cooling unit. - 9:42 AM in Resident 3's room (Station 3) - the wall above the heating/cooling unit appeared to be crumbling with debris noted in and on the heating/cooling unit. - 9:44 AM in Resident 4's room (Station 3) - the plastic grate was missing from the heating/cooling unit. Food and other debris were noted in the unit. - 9:45 AM in Resident 5's room (Station 3) - dried spill/splash spots on the front grill panel of the heating/cooling unit. Food and other debris were observed inside of the unit. A black substance was present on the air vent grates. - 9:47 AM in Resident 6's room (Station 3) - an accumulation of debris was noted in the heating/cooling unit. Additionally, the air vent grates were noted to be soiled. - 9:57 AM in Resident 7's room (Station 2) - a black substance was present in the corner near the heating unit vent. - 9:59 AM in the Chapel Dining Room (located at the corner of Station 1 and 2) - black film on the Page 1 of 2 395348 395348 02/20/2024 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

F 0584 wall around the vent/heating unit. Level of Harm - Minimal harm or potential for actual harm - 10:01 AM in Resident 8's room (Station 1) - a black substance was present along the seam of the wallpaper in the corner near the heating unit. Residents Affected - Some During a tour with the Nursing Home Administrator and Director of Nursing (DON) on February 20, 2024, at 10:30 AM, they acknowledged the aforementioned concerns. During a later interview with the DON on February 20, 2024, at 1:33 PM, she revealed that work orders had been submitted to have required repairs completed, and staff were in the process of going room to room to audit for cleanliness. 28 Pa. Code 201.14(a) Responsibility of licensee 395348 Page 2 of 2