Health inspection·May 8, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 52's clinical record revealed that Resident 52 was admitted to the facility on [DATE]. After admission, on February 28, 2024, facility staff identified a pressure injury to Resident 52's right heel that presented as a fluid filled blister measuring 5.0 centimeters (cm - metric unit of measure) by 5.0 cm. On March 6, 2024, a progress note stated that Resident 52's blister had opened with visible wound base. Review of wound tracking for Resident 52's pressure injury revealed the wound base developed slough (yellow/white accumulation of dead cells that usually presents as soft and wet but can be dry) on March 27, 2024 and necrotic skin (eschar - brown to black hard area of dead skin/tissue) was present upon an April 4, 2024 assessment. Review of the wound tracking revealed that Resident 52's pressure injury continued to have varying amounts of necrotic skin during assessments conducted on April 11, 19, 26, 2024, and May 3, 2024. Review of Resident 52's Discharge Return Anticipated Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) with an assessment reference date of April 14, 2024, revealed that Section M Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, was coded to reflect that Resident 52 had an Unstageable - Slough and/or eschar pressure injury, and that the pressure injury was present upon admission or reentry to the facility. Review of Resident 52's Quarterly MDS with an assessment reference date of April 20, 2024, revealed that section K, subsection K0300 Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in the last 6 month, was answered as Yes, not on prescribed weight-loss regimen. However, review of Resident 52's weight documentation during the look back of 30 days (or closest) and 180 days (or closest) revealed Resident 52 did not have a weight loss of 5% in 30 days nor 10% in 6 months. Further review of the Quarterly MDS revealed that section M - Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage, subsection G1, was coded to reflect that Resident 52 had one unstageable deep tissue injury (purple or maroon area of discolored intact skin due to damage of the underlying soft tissue). Finally, the pressure ulcer coded under section M of the Quarterly MDS was identified as present upon admission or reentry, however; the pressure injury was sustained after Resident 52 had entered the facility. Review of aforementioned wound tracking revealed that, at the time of the Quarterly MDS with assessment reference date of April 20, 2024, Resident 52's pressure injury was acquired at the facility and presented with necrotic tissue/eschar and was not considered a deep tissue injury at that time. During a staff interview on May 8, 2024, at approximately 3:05 PM, the Director of Nursing confirmed that Resident 52's Discharge Return Anticipated MDS section M and Quarterly MDS section K and section M were coded incorrectly. During the staff interview the Director of Nursing revealed corrections were being made to the MDS errors identified. Review of Resident 80's clinical record on May 7, 2024, at 11:52 AM, revealed diagnoses that included epileptic seizures (a sudden alteration of behavior due to a temporary change in the electrical functioning in the brain) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 2 of 11 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 05/08/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 80's physician orders revealed Resident 80 was admitted to hospice services December 12, 2022. Review of Resident 80's minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 80 was receiving hospice services while a resident for two quarterly MDS assessments with dates of September 20, 2023 and March 18, 2024 and one annual MDS assessment dated [DATE]. During an interview on May 7, 2024, at 2:04 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor made the NHA and DON aware of the aforementioned MDS concerns. During an additional interview on May 8, 2024, at 1:15 PM, with the NHA and DON it was revealed that Resident 80's two quarterly and one annual MDS assessments where coded incorrectly and corrections had been completed. The DON stated that it was the facility's expectation that MDS assessments be completed accurately. 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 3 of 11 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 05/08/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on policy review, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for three of 6 residents reviewed for pressure ulcers (Residents 11, 72 and 110). Residents Affected - Few Findings Include: Review of policy, Wound Dressings: Aseptic, revised December 1, 2021, revealed that following application of a wound treatment, staff should document the treatment on the Treatment Administration Record (TARform used to document physician orders as well as when and how treatments are administered to a resident). Review of Resident 11'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 muscle weakness. Review of nursing progress note dated March 14, 2024, revealed that staff discovered an open area at the top of Resident 11's sacrum on that date. Review of a skin integrity report revealed that Resident 11's open area was classified as a stage III pressure injury (involves the full thickness of the skin and may extend into the subcutaneous tissue layer). Review of Resident 11's March 2024 TAR revealed an order to cleanse the sacrum with saline solution, apply skin prep (liquid that forms a protective film or barrier) to the peri wound (skin around the wound), let dry, apply hydrogel to the wound bed (creates moist environment to promote healing) and cover with a dry dressing every evening shift. This order was effective March 16, 2024. Further review of Resident 11's March 2024 TAR revealed that it was not documented that this treatment was completed on March 18, 22, and 25, 2024. Review of Resident 11's May 2024 TAR revealed an order to cleanse the sacrum with wound cleanser and apply a wet to dry dressing each evening shift, effective April 29, 2024. Further review revealed that this treatment was not documented as being completed on May 3, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:41 PM, she acknowledged the missing documentation and revealed the expectation that treatments should be documented. Review of Resident 72's clinical record revealed diagnoses that included dementia and moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of nursing progress note dated April 30, 2024, revealed Resident 72 had stage III pressure injuries on his left heel, right heel, and right ankle. Review of Resident 72's April 2024 TAR revealed an order to cleanse the left heel with wound cleanser, apply skinprep to the periwound, apply hydrogel to the wound bed, and cover with an optifoam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 4 of 11 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 05/08/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressing (has a silicone border, waterproof backing and high absorbency) on day shift every Tuesday and Friday, effective April 12, 2024. Further review revealed that it was not documented that this treatment was completed on April 19, 2024. Resident 72's April 2024 also contained an order, effective April 5, 2024, to cleanse the right heel with wound cleanser, apply hydrogel to the wound bed, and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. Lastly, Resident 72's April 2024 TAR revealed an order, effective April 5, 2024, to cleanse the right lateral ankle with wound cleanser, apply therahoney (wound filler made of 100% medical grade Manuka honey that promotes healing and reduces odor) to the wound base and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM, she revealed that she had no additional information, and stated she would expect that wound treatments would be documented. Review of Resident 110's clinical record revealed diagnoses that included: pressure ulcer of left heel (wound that occurs due to prolonged pressure), peripheral vascular disease (a disorder of the blood vessels outside the heart), and muscle weakness. Review of Resident 110's November 2023 TAR revealed a physician order for, Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's November 2023 TAR failed to reveal documentation that this treatment was completed on November 22 day shift and November 27 evening shift. Review of Resident 110's December 2023 TAR revealed a physician order for, Treatment: Buttocks: cleanse with soap and water, pat dry, apply Hydraguard (blue top tube) every shift and as needed, with a start date of December 20, 2023, and a discontinued date of January 3, 2024. Further review of Resident 110's December 2023 TAR failed to reveal documentation that this treatment was completed on December 23 night shift and December 29 day shift. Review of Resident 110's January 2024 TAR revealed a physician order for, Treatment: Buttocks: cleanse with normal saline solution, apply hydrogel to wound base and cover with Opti foam every evening shift, with a start date of January 4, 2023, and a discontinued date of January 26, 2024; and a physician order for Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's January 2024 TAR failed to reveal documentation that the aforementioned treatments were completed on January 5 and 8 evening shifts. Review of Resident 110's February 2024 TAR revealed a physician order for, Treatment: sacrum: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 5 of 11 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 05/08/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleanse with normal saline solution, Apply wet to dry dressing to wound bed, cover with ABD pad and secure with tape. Apply Hydraguard (blue top tube) to periwound every day and evening shift, with a start date of February 2, 2024, and a discontinued date of March 1, 2024. Further review of Resident 110's February 2024 TAR failed to reveal documentation that this treatment was completed on February 10 day and evening shifts. Review of Resident 110's May 2024 TAR revealed a physician order for, Treatment bilateral buttocks: Cleanse with soap and water, pat dry, Apply a thin layer of Zguard and cover with Nystatin Powder to every day and evening shift for wound care, with a start date of April 19, 2024. Further review of Resident 110's May 2024 TAR failed to reveal documentation that this treatment was completed on May 3 evening shift. Email correspondence with the DON on May 7, 2024, at 5:21 PM, revealed she was unable to provide additional information for Resident 110's missing TAR documentation. During a follow-up interview with the DON on May 8, 2024, at 12:54 PM, she revealed she would expect wound treatments to be documented as completed. 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 6 of 11 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 05/08/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, record review, and staff and resident interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for two of 4 residents reviewed for nutritional status (Residents 60 and 72). Residents Affected - Some Findings include: Review of facility policy titled Procedure: Weights and Heights last revised February 1, 2023, read, in part, A licensed nurse or designee will weigh the patient. If the body weight is not as expected, re-weigh the patient. Review of Resident 60's clinical record revealed diagnoses that included: muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). During an interview with Resident 60 on May 5, 2024, at 9:58 AM, he revealed he had lost a lot of weight at the facility. Further review of Resident 60's physician orders revealed an order for a weight every month with a start date of November 30, 2023, that was discontinued on November 30, 2023, noting the reason to be Resident on [nurse aide] task to weigh each month the 1st-7th. Review of Resident 60's weight measures revealed he had an unplanned weight loss of 8.6 pounds (4.9%) from March 4, 2024, to his next weight measure on April 11, 2024. Further review of Resident 60's weight measures failed to reveal monthly weight measures for November 2023, and January 2024; and failed to reveal a re-weigh was obtained for the weight change on April 11, 2024. Review of Resident 60's clinical record failed to reveal a nutrition assessment between the dates of March 22, 2024, and April 26, 2024. During an interview with the Director of Nursing on May 8, 2024, at 1:02 PM, she revealed she has identified problems with weight orders and weight monitoring at the facility; she revealed Resident 60 should have had a monthly weight obtained in November, and should have had an order in place and a monthly weight obtained in January; furthermore, she revealed she would expect him to have a re-weigh for his weight measure on April 11, 2024, and a nutrition assessment in response to his weight loss prior to two weeks later. Review of Resident 72'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 moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of Resident 72's recorded weights revealed he experienced an unplanned significant weight loss of 16 pounds (approximately a 10% loss) between March 9, 2024, and April 2, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 7 of 11 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 05/08/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a dietician progress note dated April 3, 2024, revealed that this weight loss was noted and reviewed. Further review revealed instructions to monitor weekly weights due to the significant weight change. Review of Resident 72's clinical record failed to reveal that weekly weights were obtained or recorded between April 2, 2024, and May 1, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM she revealed the expectation that weekly weights should have been obtained as recommended by the dietician following Resident 72's significant weight loss. 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 8 of 11 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 05/08/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on policy review, observation, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 32 residents reviewed (Resident 36). Residents Affected - Few Findings include: Review of the facility policy titled Procedure: Nebulizer: Small Volume, last reviewed April 23, 2024, stated 21. Rinse SVN, mouthpiece, and T piece with sterile water and dry and 21.1 Place in treatment bag labeled with patient name and date. 21.2 Replace and date the setup daily, if used. Review of Resident 36's clinical record revealed diagnoses that included pulmonary embolism (blood clot in the lungs) with acute pulmonale (right-sided heart failure caused by an issue with the lungs) and chronic obstructive pulmonary disease (condition involving constriction of the airways causing difficulty breathing). Review of Resident 36's physician orders revealed an order for Ipratropium-Albuterol Solution (medication used to treat and prevent symptoms caused by ongoing lung disease) 0.5-2.5 (3) MG/3ML one application inhale orally four times a day for cough and one vial inhale orally every four hours as needed for cough. Review of Resident 36's April 2024 and May 2024 Medication Administration Record (MAR- documentation of medications administered) revealed Resident 36 received Ipratropium-Albuterol every four hours (9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM) daily. An observation on May 6, 2024 at 10:37 AM, revealed the nebulizer mask lying uncovered on Resident 36's nightstand. The medication reservoir was still attached to the mask and clear liquid droplets were visualized in the reservoir. The attached tubing was dated April 4. Resident 36 stated she receives the nebulizer treatment four times a day and that staff use to clean it and change the mask frequently, but they don't anymore. An additional observation was made May 7, 2024, at 10:39 AM, of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated April 4. During a staff interview with Employee 4 (Registered Nurse) on May 7, 2024, at 10:43 AM, it was revealed that nebulizer tubing is to be changed weekly by respiratory therapy. During a staff interview in Resident 36's room with Employee 5 (Respiratory Therapist) on May 7, 2024, at 10:56 AM, the surveyor informed Employee 5 of the aforementioned observations. Employee 5 revealed that she started here recently was waiting on a list of nebulizers in the building. Prior to her starting nursing was responsible for tubing changes. Employee 5 stated she changes oxygen tubing weekly and cleans filters and is planning to change nebulizer tubing weekly with the oxygen tubing changes. Employee 5 also revealed nebulizer masks are to be cleaned after each treatment and all should be bagged when not in use. Employee 5 stated was going to replace the nebulizer mask and tubing and get a bag to store it in when not in use. During an additional interview with Resident 36 on May 7, 2024, at 1:30 PM, she reported her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 9 of 11 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 05/08/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm nebulizer mask and tubing had been replaced. Resident 36 also revealed she received nebulizer treatment at 1:00 PM but staff never came back to remove it, so she had to do it herself and no one had cleaned the mask after the treatment. An observation was made of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated May 7. Residents Affected - Few During a staff interview on May 7, 2024, at 1:56 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON) the surveyor made them aware of the multiple observations of Resident 36's nebulizer mask and tubing and of Resident 36's statement that staff do not clean the mask and reservoir after administering the treatment. 28 Pa code 211.12(d)(1)(2)(3) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 10 of 11 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 05/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of the review of clinical records, and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 32 residents reviewed (Resident 107). Residents Affected - Few Findings include: A review of the clinical record for Resident 107 on May 6, 2024, revealed diagnoses that include neurogenic bladder (lack of bladder control due to spinal cord problem and nerve problem) and spina bifida (a birth defect when the developing baby's spinal cord fails to develop properly). A review of Resident 107's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 20, 2024, revealed that the resident had a brief interview for mental status with a score of 15, indicating Resident 107 is cognitively intact. Further review of Resident R107's clinical records revealed, and he had moisture associated skin damage (MASD) on his buttock and scrotum and was ordered to have a thin layer of zinc paste applied every shift. Observation during wound care on May 7, 2024, revealed zinc paste was observed prior to the start of the observation and was applied post wound care. During an interview with Resident 107 on May 6, 2024, Resident 107 confirmed that he was receiving treatments every shift for both his chronic wounds and some white paste (referring to zinc paste was confirmed) to protect his buttock and scrotal area from damage. The resident also confirmed that he was receiving Ketoconazole cream 2% (treatment for skin condition, dermatitis) applied to his head, face, and neck to prevent dry, flaky skin every shift. A review of Resident 107's Treatment Administration Record (TAR) on May 7, 2024, revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the Ketoconazole cream 2% on April 8, 2024, on dayshift, April 11, 2024, on dayshift, and on April 14, 2024, on evening shift. Further review of Resident 107's TAR revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the zinc past on April 5, 2024, on evening shift, April 7, 2024, on night shift, and April 14, 2024, on evening shift. During an interview with the Director of Nursing (DON) on May 8, 2024, at approximately 2:27 PM, the DON confirmed that all treatments should be signed off as completed on the TAR. 28 Pa Code 211.5(f) Medical records. 28 Pa Code 211.12(d)(1) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395348 If continuation sheet Page 11 of 11