Health inspection·April 3, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of facility policy, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 52). Findings include: Review of facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, revised June 14, 2023, revealed, This facility's policy is to immediately report and investigate all allegations of mistreatment, neglect, abuse, misappropriation of a resident's property or any injury of unknown origin .Facility staff will be trained to report any oral or written reports of alleged neglect, abuse, mistreatment, and misappropriation of resident's property .Any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor .The Administrator and the Director of Nursing are to be notified immediately by the charge nurse/supervisor who receives the report. The Administrator or his designated person will notify the Licensing and Regulatory Agency (Department of Health/DHS), Protective Services, Local Police Department, and other state designated agencies as required. Review of Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, revealed that on December 12, 2024, Resident 52 stated she wanted to attend a church activity, but Employee 3 (Nurse Aide) told her she was going to bed and not the activity. Further review of this form revealed that this incident was reported to Employee 2 (Registered Nurse) on December 13, 2024, who reported it to Employee 4 (Social Worker) on that date. It also stated that the investigation into this alleged incident of abuse did not start until December 16, 2024, and was not reported to the state regulatory agency until December 17, 2024. Review of Employee 2's witness statement (undated) revealed, [Resident 52] reported to this writer on the afternoon of 12/13/24 she wanted to attend the evening activity after supper to listen to a group of Christmas carolers singing in the activity room. [Resident 52] said that a tall colored girl asked her 'where do you think you are going' when [Resident 52] was waiting to go down to the activity. [Resident 52] told the tall colored girl that she wanted to go to the activity to listen to Christmas carolers. [Resident 52] said that 'the tall colored girl then said no you're not doing that you are going to bed.' [Resident 52] was very upset and crying at the time when she shared this with this writer. Review of Employee 4's witness statement (undated) revealed, Spoke to resident on 12/16 about incident on 12/12 (Thursday). Resident stated she was not allowed to go to activities to watch the Christmas carolers sing because she had to go to bed and it was 6 pm. She began to cry because she said she did not want to go to bed and was waiting for activities. I asked her who told her this she said her aide, she didn't know the name, only that it was a 'tall black girl.' During an interview with the Director of Nursing (DON) on April 3, 2025, at 11:03 AM, she acknowledged that there was a delay in reporting the aforementioned allegation of abuse. She revealed that the incident took place on December 12, 2024. The Resident reported the incident to Employee 2 during a care plan meeting on December 13, 2024. Employee 2 passed it along to Employee 4 for follow-up, but Employee 4 was not working that day. Administration did not become aware of the incident until December 16, 2024. The DON also revealed that verbal education was provided to Employee 2 regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 2 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 0609 required timeframes and process for reporting allegations of potential abuse/neglect. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 3 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide a notice of transfer that included the required information for three of four resident records reviewed for hospitalizations (Residents 47, 50, and 58). Findings include: Review of Resident 47's clinical record revealed diagnoses that included atrial fibrillation (irregular and rapid heartbeats on the upper chamber of the heart) and acute kidney failure (a sudden and significant decrease in kidney function). Further review of Resident 47's clinical record revealed that she had been transferred and admitted to the hospital on [DATE]. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the Nursing Home Administrator (NHA) on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation, and chronic respiratory failure with hypoxia (long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed that she had been transferred and admitted to the hospital on [DATE]; November 13, 2024; and February 8, 2025. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the NHA on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. Review of Resident 58's clinical record revealed diagnoses that included paroxysmal atrial fibrillation and acute kidney failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 4 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 Residents Affected - Some Further review of Resident 58's clinical record revealed that he had been transferred and admitted to the hospital on [DATE]. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the NHA on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 5 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 17 residents reviewed (Residents 13 and 24). Findings include: Review of facility policy, titled Care Plan - Comprehensive, last reviewed December 2024, revealed, Each resident will have a comprehensive care plan developed that is individualized, included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. Review of Resident 13's clinical record revealed diagnoses that included atrial fibrillation (upper chambers of the heartbeat irregularly and rapidly) and heart failure (the heart cannot pump effectively enough to meet the body's needs). Review of Resident 13's physician orders revealed an order for Apixaban (anticoagulant medication) 2.5 milligrams two times a day, with a start date of June 11, 2024. Review of Resident 13's comprehensive care plan failed to reveal any care planning for Resident 13's anticoagulant medication use or side effect monitoring. During a staff interview on April 3, 2025 at 11:09 AM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the NHA stated Resident 13's care plan had been updated and it was the expectation of the facility that comprehensive care plans be developed accurately. Review of Resident 24'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 obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Further review of Resident 24's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident 24's hospital Discharge summary dated [DATE], revealed that dementia associated with other underlying disease was noted as one of the problems addressed during her stay. Review of Resident 24's practitioner visit notes dated March 25, 2025, revealed that Resident 24 was discharged home from the facility in January 2025, but had been seen in the emergency room four times since then. Two of the visits were related to increased episodes of confusion, and her MoCA score (Montreal Cognitive Assessment - a highly sensitive tool for early detection of mild cognitive impairment) indicated significant cognitive impairment. Further review revealed that when examined, Resident 24 confirmed she did have confusion and stated she was unsure where she was. Review of Resident 24's care plan failed to reveal any information related to her cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 6 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 0656 impairment or dementia diagnosis. Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA on April 3, 2025, at 11:02 AM, he revealed the expectation that Resident 24's cognitive impairment/dementia diagnosis should have been included in her plan of care. Residents Affected - Few 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 7 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 - Few 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 facility policy review, review of facility admission agreement, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 21 residents reviewed (Residents 48 and 55). Findings include: Review of facility policy, titled Care Plan - Comprehensive, revised September 28, 2022, revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 48's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. Review of Resident 48's clinical record progress notes revealed a nurse's note dated March 17, 2025, at 1:52 PM, that indicated he had edema (swelling caused by too much fluid trapped in the body's tissues) in both of his lower legs. Review of Resident 48's physician orders revealed an order for TED stockings (compression stockings used to reduce chance of blood clots and to promote increased blood flow velocity in the legs), apply in AM and remove in PM, dated March 17, 2025. Review of Resident 48's care plan failed to reveal a focus for his edema or the use of TED hose. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 3, 2025, at 10:45 AM, the DON confirmed that Resident 48's care plan should have been updated to reflect his edema and the use of TED hose. Review of the facility admission agreement, effective July 27, 2015, revealed, The facility does not permit smoking anywhere on its premises. Review of Resident 55'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 other symptoms and signs involving cognitive functions and awareness. Review of Resident 55's care plan revealed a focus area of, [Resident 55] wishes to be a smoker; smoking evaluation has determined resident's degree of independence for safe smoking, initiated February 20, 2025. Further review revealed an intervention to inform and orient resident to smoking areas. Review of Resident 55's clinical record failed to reveal that she was an active smoker. During an interview with the NHA on April 1, 2025, at 9:43 AM, he confirmed that the facility was non-smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 8 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 During an interview with the DON on April 3, 2025, at 11:10 AM, she revealed the expectation that smoking should have been removed from Resident 55's care plan. Level of Harm - Minimal harm or potential for actual harm 42 CFR 483.21(b)(2) Comprehensive Care Plans Residents Affected - Few 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 9 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 Based on clinical record review and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure each resident's highest level of well-being for one of three residents reviewed for advanced directives (Resident 51). Residents Affected - Few Findings Include: Review of Resident 51's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Further review of Resident 51's clinical record revealed a POLST form (Pennsylvania Orders for Life Sustaining Treatment), dated December 23, 2024, stating that if Resident 51 was found with no pulse and not breathing, Resident 51 did not wish to be resuscitated. Review of Resident 51's physician orders revealed an order dated July 3, 2024, for Full Code, meaning resuscitation should be attempted if she was found without a pulse and not breathing. During an interview with the Nursing Home Administrator on April 3, 2025, at 10:59 AM, he confirmed that Resident 51's orders should have reflected her DNR (Do Not Resuscitate) status. He also revealed that a whole house audit was completed to ensure accuracy of code statuses. 28 Pa. Code 211.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 10 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 review of facility policy, record review, observation, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of one resident reviewed (Resident 49). Residents Affected - Few Findings Include: Review of facility policy, titled CLIN-046 Dressing Changes, Revised March 28, 2016, revealed in step 11. Write the date, time, and initials on the dressing. Review of facility policy, titled IC- Enhanced Barrier Precautions, with a revision date of April 1, 2024, indicated that residents on enhanced barrier precautions require the use of gloves and a protective gown for high contact resident care activities, including wound care and any skin opening requiring a dressing. Review of Resident 49's clinical record revealed diagnoses that included pressure ulcer of right heel (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time) and diabetes (a disease that effects how the body utilizes and regulates blood sugar). Review of Resident 49's current physician orders revealed an order to cleanse Resident 49's right heel with wound cleanser, apply medihoney (wound medication) and apply gauze to cover, with a start date of February 25, 2025. Another order revealed Resident 49 required enhanced barrier precautions related to her right heel, starting on February 11, 2025. Observation of Resident 49's dressing change to right heel on April 2, 2025, at 10:41 AM, revealed Employee 1(Registered Nurse) was completing Resident 49's right heel. When Employee 1 removed the dressing from Resident 49's heel, she confirmed that the dressing was not dated or timed, and she could not tell when it was applied. For the duration of the dressing change, Employee 1 was not wearing a gown at any time during the procedure. Interview with the Director of Nursing on April 3, 2025, at 12:51 PM, revealed that Resident 49's dressing should have been dated and Employee 1 should have followed the enhanced barrier precautions policy. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 11 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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, clinical record review, and staff interview, it was determined that the facility failed to monitor hydration to ensure proper hydration for one of two residents reviewed for hydration (Resident 50). Residents Affected - Some Findings include: Review of facility policy, titled CLIN-054 Fluid Intake with a last review date of December 2024, failed to reveal how the facility would manage fluid intake for residents with physician ordered restrictions. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and chronic respiratory failure with hypoxia (long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed a physician order for no added salt /1500 CC (cubic centimeters) FR [fluid restriction] diet Regular texture, Regular Liquids consistency, small portions at meals, dated November 16, 2024. Further review of Resident 50's clinical record failed to reveal how the Resident's fluid restrictions would be distributed throughout a 24-hour time period or how the facility would monitor Resident 50's overall fluid intakes on a daily basis. Review of Resident 50's clinical record nurse aide task documentation for fluid intake with meals and additional fluids provided from March 4, 2025 -April 1, 2025, revealed that Resident 50's was documented as consuming a total of 3370 cc on March 7, 2025; and 1560 cc's on March 25, 2025. Review of Resident 50's Medication Administration Records from November 2024 through April 1, 2025, failed to include any documentation of how much fluid was provided to Resident 50 during medication administrations on any shift. Review of Resident 50's clinical record progress notes failed to reveal documentation that her physician was made aware of her exceeding her ordered fluid restrictions on March 7 and 25, 2025. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on April 3, 2025, at 11:08 AM, the DON confirmed that there was no documentation of how many fluids were being provided by nursing staff with medication passes or nurse monitoring of total fluids consumed in a 24-hour period. She indicated that on March 7, 2025, she believed her fluid intake was a documentation error as Resident 50 does not generally consume that amount of fluid and that there were no notes indicating any change in her status. She confirmed that there was no documentation that Resident 50's physician was notified of her exceeding her fluid restriction on March 25, 2025. In addition, she confirmed that Resident 50 should have had a fluid breakdown in a 24-hour period to include meals, medication passes, and other offerings, established with nurse monitoring of fluids on a daily basis when the order was initially given for the fluid restriction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 12 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 28 Pa. Code 211.10(c) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 13 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 50). Residents Affected - Few Findings include: Review of facility policy titled CLIN-009 Aerosol Therapy, with a last review date of December 2024, revealed: Following the treatment remove any medication left in the medication cup of the nebulizer. Wash the nebulizer with tap water after shaking excess medication from assembly, then disassemble nebulizer and place on a paper towel and allow to air dry. Rinse the mask and/or mouthpiece with warm water for 30 seconds. Also air dry on a clean paper or towel. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag. Once a week, replace all disposable parts. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and chronic respiratory failure with hypoxia (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed a physician order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams/3 milliliters inhale orally via nebulizer four times a day, dated February 11, 2025. Further review of orders failed to include frequency of nebulizer tubing/mask change or frequency of cleaning of medication chamber/mask. Observations of Resident 50's room on April 1, 2025, at 10:25 AM, and April 2, 2025, at 11:48 AM, revealed that the tubing connected to her nebulizer machine was not dated and that the mask was laying on top of the machine with a plastic storage bag located beside the nebulizer. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on April 2, 2025, at 12:55 PM, the DON indicated that she would expect the nebulizer tubing to be dated and mask to be bagged when not in use. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 14 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 - Few 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 policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor psychotropic medications to ensure that residents were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy, Use of Psychotropic medications, revised January 21, 2025, revealed, Complete 'Behavior/Interventions' Sheet or other behavior tracking pharmacy form to include : All relevant resident data, target behavior, record the number of episodes, intervention code and outcome by shift, if side effects observed enter code, otherwise leave blank. Review of Resident 24'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 anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 24's physician orders revealed an order for risperidone (antipsychotic medication) for dementia, effective March 20, 2025. Review of Resident 24's clinical record failed to reveal evidence of side effect monitoring related to use of her antipsychotic medication or monitoring of the target behaviors the medication was to address. During an interview with the Director of Nursing on April 3, 2025, at 12:55 PM, she confirmed that behavior and side effect monitoring was not in place related to Resident 24's use of risperidone, but should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 15 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to ensure that residents were served food that accommodated their allergies and intolerances for one of 17 residents reviewed (Resident 32). Findings include: Review of Resident 32'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 obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 32's physician's orders revealed an order for a gluten free, lactose free diet effective July 7, 2023., Observation of Resident 32 on March 31, 2025, at 12:51 PM, revealed she was served and consumed a cheeseburger on a bun. During an interview with Employee 5 (Dietary Aide) on March 31, 2025, at 12:58 PM, she confirmed that she had not served Resident 32's burger on a gluten free bun. She also confirmed that she has mistakenly served Resident 32 cheese on her burger. Review of Resident 32's meal ticket (paper slip that accompanies resident's meal tray that indicates allergies, preferences, and food/drink items to be received) for lunch on March 31, 2025, revealed that she was to be served a gluten free, lactose free diet. During an interview with the Nursing Home Administrator on April 3, 2025, at 10:56 AM, he revealed the expectation that Resident 32 should have been served the appropriate diet. He also revealed that education was provided to staff. 28 Pa. Code 201.18(b)(1)(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 16 of 17 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 395918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Shook Home 55 South Second Street 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 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 observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure food was prepared and served under sanitary conditions in two of two dining rooms observed (1st and 2nd floor). Findings include: Review of facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, dated 2021, revealed, Bare hand contact with food is prohibited .Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single-use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single-use gloves. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Observation of tray line service on second floor on March 31, 2025, at 12:38 PM, revealed Employee 7 (Dietary Aide) wearing gloves, touching the paper meal tickets, then reaching into the bag of hamburger buns to retrieve them wearing the same gloves, and touching cheese slices wearing the same gloves. Observation during lunch meal service on second floor on March 31, 2025, at approximately 12:40 PM, Employee 8 (Nurse Aide) brought a resident's plate back up to the serving line to have Employee 7 add a slice of cheese to the burger. Employee 8 was noted to use the tip of her right index finger to slide the top bun off the burger for Employee 7 to add the cheese. Employee 8 then slid the top bun back onto the burger using her same finger. Employee 8 was not wearing gloves. Observation in the first floor dining room on March 31, 2025, starting at approximately 12:40 PM, revealed Employee 6 (Nurse Aide) touching the sandwiches of Residents 26, 27, and 45 with her bare hands while assisting them with cutting and/or placing condiments on their sandwiches. Observation of tray line on first floor on March 31, 2025, at 12:44 PM, revealed Employee 5 (Cook) wearing gloves, touching the paper meal tickets, then reaching into the bag of hamburger buns to retrieve them wearing the same gloves, and touching cheese slices wearing the same gloves. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 2, 2025, at 12:43 PM, the DON confirmed that staff should have used tongs to serve hamburger buns and cheese slices, and that nursing staff should wear gloves when touching residents' food. During an interview with the NHA on April 3, 2025, at 10:56 AM, he revealed the expectation that staff should not be touching resident food with bare hands. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 17 of 17