Health inspection·February 24, 2026

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 staff interviews, clinical record review, and select guidelines, it was determined that the facility failed to discontinue/alter medication dosage and/or to ensure the risks were known with refusal of monitoring to prevent hyperkalemia (elevated potassium level) for one of three residents reviewed (Resident 1). Findings include: A review of Food and Drug Administration guideline, last approved October 27, 2025, for use of Potassium Chloride ER (extended release) tablets stated, the use of potassium salts in patients with chronic renal disease, or any other condition which impairs potassium excretion, requires particularly careful monitoring of the serum potassium concentration and appropriate dosage adjustment. Based on National Institutes of Health guidelines, dated October 5, 2024, severe hypokalemia (<3mEq/L): For oral administration initiate at 40 mEq (milliequivalents- a unit of measure for concentration of electrolytes in body) 3 to 4 times daily or 20 mEq every 2 to 3 hours. The dose should be adjusted based on serum potassium levels, which should be rechecked every 2 to 4 hours. For patients with renal impairment: Starting at the lower end of the dosing range is recommended for patients with reduced renal function. Review of Resident 1's clinical record revealed diagnoses that include chronic kidney disease (progressive loss of kidney function), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of blood against the artery walls is too high). Further review revealed Resident 1 was admitted to the facility on [DATE], post-surgery for a right hip fracture. Review of Resident 1's admission MDS (Minimum Data Set, periodic assessment of care needs) dated December 21, 2025, Section C0500 a Brief Interview for Mental Status test (BIMS -brief interview of mental status) indicated a score of 13, indicating the Resident was cognitively intact. On December 17, 2025, laboratory results revealed Resident 1 had hypokalemia (low potassium level) of 2.8 (normal 3.5-5.3). Other lab results included:BUN (blood urea nitrogen [Normal level 7-20. High levels often indicate kidney dysfunction, dehydration, or heart failure]) -28 Creatinine (waste product from muscle metabolism and protein digestion, filtered from the blood by the kidneys [Normal level for women is 0.59 to 1.04]) -1.29. eGFR (estimated Glomerular Filtration Rate - a blood test calculating how well kidneys filter waste, primarily used to diagnose and monitor chronic kidney disease [Normal level is 90 or higher, with levels below 60 for 3 months indicating chronic kidney disease]) -40.9 On December 18, 2025, Potassium Chloride ER (extended release) orders were written for 20 mEq tablets and to administer 40 mEq (2 tablets) three times a day without an end date. On December 19, 2025, a repeat laboratory result revealed a normal potassium level of 4.5 (normal level).Other Lab results included:BUN -36 (high)Creatinine -1.33 (high)eGFR -39.5 (low) There were no laboratory tests ordered for December 20 or 21, 2025. A laboratory test was ordered for December 22, 2025, and the Resident refused two attempts to obtain a specimen for the potassium level. There was no documentation that the facility ensured Resident 1 was made aware of the risk of declining the laboratory test. When the physician was notified that Resident 1 Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395348 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 02/24/2026 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)