Health inspection·July 22, 2025

F 0760 Level of Harm - Actual harm Residents Affected - Few indicated that, upon arriving to Resident 1's room, he was noted to be unresponsive in his wheelchair. His heart rate palpable to bilateral radial [wrists]- regular rate. Bilateral pupils equal and reactive to light. Resident warm/dry to touch. Blood sugar 142. At this time, resident was going in and out of responsiveness, resident laid to floor. BP [blood pressure] 135/52, HR [heart rate] 85. Sterum rub performed by this nurse - effective. BP 84/46 HR 59. Resident continues to come in and out of consciousness, BP 137/90. Resident becomes more aroused, lightly speaking with staff prior to EMS [Emergency Medical Services] arriving BP 87/52 HR 61. EMS arrived in residents' room. Review of Resident 1's clinical record progress notes revealed that he was transferred to the hospital on July 12, 2025, at 8:29 AM. Review of Resident 1's clinical record progress notes revealed a nurse's note by Employee 1 on July 12, 2025, at 4:36 PM, that indicated when she entered Resident 1's room, she said his name as Resident 2's name and that Resident 1 stated yes. The note indicated that Employee 1 administered the medications at 7:13 AM, realized incorrect medications were administered to Resident 1 at 7:19 AM, and she reported the occurrence to Employee 2 at 7:20 AM. The note further indicated that at 8:05 AM, Resident 1's Blood sugar was 142; Blood pressure was 103/66; Pulse was 71; and Respirations were 16. Review of Resident 1's clinical record revealed that his last documented vital signs prior to the medication administration error were completed on July 12, 2025, at 12:46 AM, and were recorded as blood pressure 167/87, pulse 108, respirations 20, and an oxygen saturation of 95%. His last recorded blood sugar was 232 and was noted to be recorded July 12, 2025, at 7:20 AM. Review of Resident 1's hospital emergency department record dated July 12, 2025, at 8:52 AM, revealed that he presented to the hospital with a chief complaint of medication error and that he had no specific complaints but was not able to provide much history. Patient apparently does have some mild dementia. According to paramedics patient was able to stand and answer questions. Because he was somewhat hypotensive with a pressure in 70s systolic, IV fluids were started. Physical assessment findings indicated that he was drowsy but arousable and that he was alert and oriented to person and place with no other abnormal findings. His initial glucose (blood sugar) was greater than 90. Additional notes on timeline indicated the following: at 9:11 AM Resident 1 remained somewhat hypotensive (low blood pressure) and bradycardic (low heart rate/pulse), drowsy but arousable, will be given some intravenous fluids, will closely monitor his blood sugar on recheck 93; and at 10:43 AM Resident 1 was drowsy but arousable; remained relatively hypotensive and bradycardic; had received a liter of normal saline and was receiving D5 [Dextrose 5%] normal saline infusion; and that the plan would be to hold off on any further boluses unless necessary due to concern for developing congestive heart failure, and that Resident 1 was not exhibiting any respiratory distress and oxygen saturation was 97%. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 22, 2025, at 9:40 AM, the NHA indicated that Resident 1's and Resident 2's rooms were directly across the hall from one another and that Employee 1 turned the wrong direction in the hallway and ended up in wrong room. He further indicated that Resident 1 was a new resident at the facility, only being admitted on [DATE], and the event occurred on July 12, 2025. The NHA said that Resident 1 remained at the hospital for 3 days under observation and was then discharged to another facility. He further revealed that on-the-spot education on the 5 Rights of Medication Pass was completed immediately with Employee 1. He said that the facility began educating all licensed nursing staff and started medication pass observations of all nursing staff and that the education and observations were being completed on all shifts. He said that there have been no issues were noted with any of the observations. He said that they are continuing these observations as part of the Performance Improvement Plan, they developed when the event occurred. He said that they had achieved compliance on July 14, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395918 If continuation sheet Page 2 of 3 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 07/22/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of facility provided Performance Improvement Plan (PIP) for Medication Error- Med Pass Accuracy revealed the following:1) Immediate education was provided to the nurse involved on July 12, 20252) Immediate audit was completed to identify if any other residents were affected on July 12, 2025. Immediate audit completed that residents have the correct name, room number, and other identifiers in place. 3) All full time and part time licensed nursing staff were educated on the 5 Rights of Medication Administration beginning on July 12, 2025, and concluding July 14, 2025. 4) Medication Pass Observations will be completed on all nurses to ensure they are following the techniques of 5 Rights of Medication Administration. After 2 weeks of daily audits with 100% pass rate, the frequency will move to 3 days a week for 2 weeks, then weekly for 2 weeks, and then monthly for one month. During a staff interview with Employee 3 (Licensed Practical Nurse) on July 22, 2025, at 9:30 AM, Employee 3 confirmed she had received training on the 5 Rights of Medication Administration. Employee 3 indicated that she uses the picture in the electronic health record to identify residents. She said that if there was no picture or she was not sure, she would seek assistance from another staff member. During a staff interview with Employee 4 (Registered Nurse) on July 22, 2025, at 9:35 AM, Employee 4 confirmed she had received training on the 5 Rights of Medication Administration. Employee 4 indicated that she asks resident to state their name and uses the picture in the electronic health record to identify residents. She said if she had any doubt she would seek assistance from another staff member. She also indicated that she does not pass medications very often maybe, one to two times per month. During a staff interview with Employee 5 (Registered Nurse) on July 22, 2025, at 9:35 AM, Employee 5 confirmed she had received training on the 5 Rights of Medication Administration. Employee 5 said she uses the picture in the electronic health record to identify residents as well as asking them to state their name. She said if she had any doubt about a resident's identity, she would seek assistance from another staff member. She further indicated that she always verifies medications twice before administering them to a resident. She said medications are in blister packs and are labeled with each resident's name and room number. She said that insulin vials and pens are also labeled with resident's name and room number. She said that she also places the medication cart in front of the resident room for which she is preparing medications. Review of the POC documentation and interviews with staff revealed no concerns with medication administration. During a final staff interview with the NHA and DON on July 22, 2025, at 12:30 PM, they both confirmed they would expect nurses to follow the facility policy and practice the 5 Rights of Medication Administration with each medication administration to prevent significant medication errors from occurring. The NHA indicated that the facility was in compliance as of July 14, 2025, and that the PIP and audits will be reviewed at the next Quality Assurance Performance Improvement Committee Meeting on August 12, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Event ID: Facility ID: 395918 If continuation sheet Page 3 of 3