Health inspection·April 30, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 facility policy review, observations, review of select facility documentation, and resident and staff interviews, it was determined that the facility failed to maintain a clean, comfortable and home-like environment in one of 35 resident rooms reviewed. Findings include: Review of facility policy, titled Resident Rights Under Federal Law last revised February 1, 2023, read, in part, The resident has a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Interview with Resident 368 on April 27, 2025, at 12:29 PM, revealed he was disappointed about the condition of the wallpaper in his bathroom, and it had been that was since he was admitted to the room on April 21, 2025. Observation in Resident 368's bathroom on April 27, 2025, at 12:32 PM, revealed the wallpaper was coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. Interview with the Nursing Home Administrator (NHA) on April 29, 2025, at 2:11 PM, revealed it is the responsibility of staff to identify environmental concerns in resident rooms on a daily basis to be communicated to maintenance staff to be fixed. Review of facility maintenance work order report from April 22-29, 2025, failed to reveal an active work order in place for Resident 368's bathroom. Follow-up observation in Resident 368's bathroom on April 30, 2025, at 10:20 AM, revealed the wallpaper remained in the same condition as it was on April 27, 2025; coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. During an interview with the NHA on April 30, 2025, at 11:44 AM, she revealed she would speak with Employee 4 (Maintenance Director) to address the issues in Resident 368's bathroom. She further revealed they have hired a third maintenance employee whose sole responsibility will be identifying and fixing physical issues such as the wallpaper around the facility. Follow-up interview with the NHA on April 30, 2025, at 1:32 PM, revealed Employee 4 is currently addressing the concerns in Resident 368's bathroom, and she would expect residents to be provided with a clean, comfortable and home-like environment Page 1 of 6 395348 395348 04/30/2025 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

F 0584 28 Pa. Code 201.18(b)(3) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395348 Page 2 of 6 395348 04/30/2025 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 35 residents reviewed (Residents 48 and 82). Residents Affected - Few Findings include: Review of Resident 48's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), and difficulty walking. Review of Resident 48's clinical record revealed that he had experienced a fall with no injuries on January 24, 2025. Review of Resident 48's Medicare Quarterly/5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of January 30, 2025, indicated in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on January 17, 2025. During a staff interview with Employee 2 (Registered Nurse Assessment Coordinator) on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 48's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 48. Review of Resident 82's clinical record revealed diagnoses that included muscle weakness, difficulty walking, and history of a traumatic brain injury (an injury to the brain caused by an external force). Review of Resident 82's clinical record revealed that he had experienced a fall with an injury on February 8, 2025, and was sent to the emergency room for evaluation of the injury. Review of Resident 82's Discharge Return Anticipated MDS with the assessment reference date of February 9, 2025, revealed in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on February 2, 2025. During a staff interview with Employee 2 on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 82's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the NHA and the DON on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 82. 28 Pa Code 211.12 (d)(3)(5) Nursing services 395348 Page 3 of 6 395348 04/30/2025 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

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 Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of 38 residents reviewed (Resident 84). Residents Affected - Few Findings include: Review of Resident 84's clinical record revealed diagnoses that included congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and atrial fibrillation (irregular heart beat). Review of Resident 84's physician order summary revealed an order for daily weights and to notify the doctor of a gain of 2 pounds or greater in a day or 5 pounds in a week for congestive heart failure, starting February 17, 2025. Review of Resident 84's daily weight documentation revealed that no weights, or refusals to be weighed, were documented for eight days in February 2025; for 15 days in March 2025; and for three days in April 2025. Further review of Resident 84's weight documentation revealed that a weight of 176.1 pounds was recorded on April 24, 2025, and that a weight of 187.8 pounds was recorded on April 25, 2025. This represented a weight gain of 11.7 pounds in one day. Review of Resident 84's clinical record failed to reveal that the practitioner was notified of this change in weight or that a reweigh was obtained. During an interview with the Director of Nursing on April 30, 2025, at 2:28 PM, she revealed the expectation that Resident 84's daily weights should have been recorded, and that follow-up should have occurred when a weight gain was recorded on April 25, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395348 Page 4 of 6 395348 04/30/2025 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, observations, product label, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Findings include: Review of facility policy, titled Food Brought in for Patients/Residents last revised January 26, 2024, read, in part, Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. Food will be held in refrigerator for three days following the date on the label and will be discarded by staff upon notification to resident. Observation in Reach-in Refrigerator 1 on April 27, 2025, at 9:52 AM, revealed one container of thickened lemon water open and not dated with an open date; and one container of thickened lemon water open with an open date of April 2, 2025. Further observation of the thickened beverage containers read After opening, may be kept up to 7 days under refrigeration. Observation in the Station II Pantry Area on April 27, 2025, at 10:28 AM, revealed one thickened apple juice open with an open date of April 18, 2025. Interview with Employee 3 (Food Service Director) on April 27, 2025, at 10:28 AM, revealed that container should have been discarded after seven days. Observation in the Medbridge Pantry Area on April 27, 2025, at 10:30 AM, revealed one thickened lemon water open and not dated with an open date; and one container of food from an outside source not dated. Observation in the Arcadia Pantry Area on April 27, 2025, at 10:32 AM, revealed a box of food from an outside source dated April 21, 2025; one container of thickened apple juice open and not dated with an open date; one thickened lemon water open and not dated with an open date; one thickened lemon water open with an open date of March 25, 2025; one pudding prepared for medication pass with a use by date of April 26, 2025; and one bag of food from an outside source not dated. Interview with Employee 3 on April 27, 2025, at 10:33 AM, revealed the beverages should have been labeled properly and discarded after seven days of being open; and refrigerated food from outside sources should be labeled properly and discarded after three days. Interview with the Nursing Home Administrator on April 28, 2025, at 1:32 PM, revealed it was the facility's expectation that expired items are discarded, foods items and beverages are labeled and dated per facility policy, and food items and beverages are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 395348 Page 5 of 6 395348 04/30/2025 Chambersburg Skilled Nursing and Rehabilitation Ce 1070 Stouffer Avenue Chambersburg, PA 17201

F 0812 28 Pa. Code 211.12(d)(3) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395348 Page 6 of 6