Health inspection·April 21, 2023

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. Based on facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for four of 29 residents reviewed (Residents 24, 39, 54, 57). Findings include: The facility's policy regarding care plans, dated April 13, 2023, indicated that the facility develops and implements a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days of the completion of the comprehensive MDS assessment. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated March 30, 2023, revealed that the resident was alert and oriented, had diagnoses that included diabetes, and received insulin (medication that lowers blood sugar levels). Physician's orders for Resident 24, dated March 23, 2023, included orders for the resident to receive 10 units of NPH Insulin (an intermediate-acting insulin that usually reaches the bloodstream about 1 to 3 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 16 hours) twice a day before meals, and physician's orders, dated April 17, 2023, included orders for the resident to receive 10 units of NPH Insulin three times a day before meals. The resident's Medication Administration Records (MAR's) for March and April 2023 revealed that the resident received NPH Insulin from March 24 through April 21, 2023. There was no documented evidence that a care plan was developed to address Resident 24's specific and individualized care needs related to receiving insulin. Interview with the Director of Nursing on April 21, 2023, at 7:46 a.m. confirmed that an individualized care plan and interventions were not developed related to Resident 24 receiving insulin. An admission MDS assessment for Resident 39, dated February 7, 2023, revealed that the resident was able to understand others and be understood, required extensive assistance for daily care needs, and had a diagnosis that included diabetes. There was no documented evidence that a care plan was developed to address Resident 39's specific and individualized care needs related his diabetes disease. An interview with the Nursing Home Administrator on April 20, 2023, at 3:43 p.m. revealed that an individualized care plan was not developed for Resident 39 related to his diabetes. Physician's orders for Resident 54, dated March 30, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of Apixaban (an anticoagulant medication) every morning and bedtime related to atrial fibrillation (irregular heartbeat). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 2 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0656 Level of Harm - Minimal harm or potential for actual harm Medication Administration Records (MARs) for Resident 54, dated March and April 2023, revealed that the resident received the 2.5 mg of Apixaban from March 30 through April 21, 2023. There was no documented evidence that a care plan was developed to address Resident 54's specific and individualized care needs related to receiving an anticoagulant medication. Residents Affected - Few Interview with the Director of Nursing on April 21, 2023, at 7:50 a.m. confirmed that an individualized care plan and interventions were not developed related to Resident 54 receiving anticoagulant medication. Physician's orders for Resident 57, dated April 9, 2023, included orders for the resident to receive 2.5 mg of Xarelto (an anticoagulant medication) twice a day related to atrial fibrillation, and the resident's MARs for April 2023 revealed that the resident received 2.5 mg of Xarelto on April 11 through 21, 2023. There was no documented evidence that a care plan was developed to address Resident 57's specific and individualized care needs related to receiving an anticoagulant medication. Interview with the Nursing Home Administrator on April 21, 2023, at 2:54 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 57 receiving anticoagulant medication. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 3 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 29 residents reviewed (Resident 2) and failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 29 residents reviewed (Residents 39). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 15, 2023, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included heart disease. Physician's orders for Resident 2, dated June 22, 2022, included orders for the resident to receive 125 micrograms (mcg) of Digoxin at bedtime every Monday, Wednesday, and Friday related to long-term use of anticoagulants and staff were to hold the medication if the resident's pulse was greater than 60 and to notify the physician. There was no documented evidence that the physician's order to hold the Digoxin for a pulse of greater than 60 was clarified with the physician. Resident 2's Medication Administration Record (MAR) for February, March, and April 2023 revealed that staff administered the Digoxin on Mondays, Wednesdays, and Fridays when the resident's pulse was greater than 60. Interview with the Director of Nursing on April 21, 2023, at 7:46 a.m. confirmed that Resident 2's physician's order for Digoxin to be held for a pulse greater than 60 should have been clarified. The facility's bowel protocol policy, dated April 13, 2023, revealed that licensed staff will review bowel records daily and are responsible for initiating bowel protocol. Standard bowel protocol includes on the third day without a bowel movement the nurse will offer 30 cubic centimeters (cc) of Milk of Magnesia. If the resident declines the Milk of Magnesia, a Dulcolax suppository will be offered. On the fourth day without a bowel movement, the licensed staff will offer a Dulcolax suppository. If the resident declines the suppository, 30 cc of Milk of Magnesia will be offered to the resident. If there is no bowel movement by the evening of day four, a bowel assessment will be completed and the results reported to the provider. The resident will receive a focused bowel assessment every shift until a bowel movement has occurred. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated February 7, 2023, revealed that the resident was able to understand others and be understood, required extensive assistance for daily care needs, received routine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 4 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0658 and as-needed pain medication, and had a diagnosis that included diabetes. Level of Harm - Minimal harm or potential for actual harm Review of bowel records for Resident 39 revealed that the resident did not have bowel movement for five days between March 2, 2023, and March 7, 2023. There was no documented evidence that a focused bowel assessment was completed and reported to the provider per the facility's policy on the evening of Day 4 without a bowel movement. Residents Affected - Few Interview with the Director of Nursing on April 21, 2023, at 7:48 a.m. confirmed that a bowel assessment was not completed as of March 7, 2023, after Day 4 of not having a bowel movement per facility policy and should have been. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 5 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 29 residents reviewed (Resident 15) and failed to ensure that physician's orders for medications were followed for two of 29 residents reviewed (Residents 22, 39). Residents Affected - Some The facility's bowel protocol, dated April 13, 2023, revealed licensed staff would review bowel records daily and were responsible for initiating the bowel protocol. The standard bowel protocol included on the third day without a bowel movement, the nurse will offer 30 cubic centimeters (cc) of Milk of Magnesia. If the resident declined the Milk of Magnesia, a Dulcolax suppository would be offered. On the fourth day without a bowel movement, the licensed staff would offer a Dulcolax suppository. If the resident declined the suppository, 30 cc's of Milk of Magnesia would be offered to the resident. If there is no bowel movement by the evening of Day 4, a bowel assessment will be completed and the results reported to the provider. The resident would receive a focused bowel assessment every shift until a bowel movement had occurred. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated February 15, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, was continent of bowel, and had diagnoses that included dementia. Physician's orders for Resident 15, dated June 8 and 16, 2022, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) as needed on Day 3 if there was no bowel movement, a Bisacodyl suppository (a laxative inserted rectally) at bedtime on Day 4 if there was no bowel movement and the MOM was ineffective, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) as needed on Day 5 of no bowel movement and if the Bisacodyl suppository was ineffective. Resident 15's bowel movement records for January and February 2023 revealed that the resident did not have a bowel movement from January 12-15, 2023, (four days) and January 30 through February 2, 2023 (four days). The resident's Medication Administration Records (MAR's) for January and February 2023 revealed no documented evidence that staff administered, or offered to administer, MOM or Bisacodyl to Resident 15 during the above time periods. Interview with the Director of Nursing on April 21, 2023, at 7:46 a.m. confirmed that Resident 15's physician's orders for bowel medications were not followed. A Quarterly MDS for Resident 22, dated January 17, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis that included orthostatic hypotension (a drop in blood pressure that occurs when moving from a lying down position to a standing position). Physician's orders for Resident 22, dated December 14, 2022, included to administer 2.5 milligrams (mg) of Midodrine (used to treat orthostatic hypotension) two times a day. If the resident refuses the supper time dose, a dose should be offered at bedtime. Review of the Medication Administration Record (MAR) for Resident 22 dated March and April 2023 revealed that the resident refused the supper time dose of Midodrine on March 6, 8, 9, 10, 11, 12, 15, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 6 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 16, 20, 21, 22, 24, 25, 26, 28, 29, and 31, 2023, and April 5, 7, 8, 9, 12, 14, and 19, 2023. There is no documented evidence that a Midodrine dose was offered at bedtime on these dates as ordered by the physician. An admission MDS assessment for Resident 39, dated February 7, 2023, revealed that the resident was able to understand others and be understood, required extensive assistance for daily care needs, received routine and as-needed pain medication, and had a diagnosis that included diabetes. Physician orders for Resident 39, dated January 31, 2023, included to administer one 10 mg Bisacodyl suppository (a laxative administered rectally) as needed for constipation every three days the resident is without a bowel movement. Review of bowel records for Resident 39 revealed that the resident had no bowel movement for five days between February 17-22, 2023; for five days between March 10-15, 2023; for five days between March 2-7, 2023; and for six days between April 11-17, 2023. Nurse's notes for Resident 39 dated February 22, 2023, and March 15, 2023, revealed that the resident had not had a bowel movement in five days. A nurse's note, dated April 15, 2023, revealed that the resident had not had a bowel movement in four days. A review of the MAR for Resident 39 revealed no documentation that a Bisacodyl suppository was administered to the resident as ordered by the physician after going three days without a bowel movement. Interview with the Director of Nursing on April 21, 2023, at 7:48 a.m. confirmed that Resident 39 was not given a Bisacodyl suppository as ordered by the physician after not having a bowel movement in three days on the above-mentioned dates and should have been, and that Resident 22 was not offered a dose of Midodrine at bedtime when she refused the supper time dose on the above-mentioned dates, and she should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 7 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of clinical records, as well as interviews with staff, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 29 residents reviewed (Residents 22, 39). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 17, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, received routine and as-needed pain medication, and had diagnoses that included Parkinson's (a brain disorder that causes unintended or uncontrollable movements). Physician's orders for Resident 22, dated October 17, 2022, included an order for the resident to receive 25 milligrams (mg) of Tramadol (a narcotic pain medication) two times a day as needed for pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 22, dated February 2023 and March 2023, indicated that a Tramadol dose was signed out on January 17, 2023, at 6:00 a.m. and March 17, 2023, at 3:45 p.m. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out doses of Tramadol were administered to the resident on these dates and times. Interview with the Director of Nursing on April 21, 2023, at 11:00 a.m. confirmed that there was no documented evidence in Resident's 22's clinical records to indicate that the signed-out doses of Tramadol mentioned above were administered to the resident. An admission MDS assessment for Resident 39, dated February 7, 2023, revealed that the resident was able to understand others and be understood, required extensive assistance for daily care needs, received routine and as-needed pain medication, and had a diagnosis that included diabetes. Physician's orders for Resident 39, dated January 31, 2023, included an order for the resident to receive 0.25 milliliters (ml) of 20mg/mL Morphine Sulfate solution (a narcotic pain medication) every hour as needed for pain. Review of the controlled drug record for Resident 39 for March and April,2023 indicated that a Morphine Sulfate dose was signed out on March 11, 2023, at 1:30 a.m.; March 21, 2023, at 5:40 a.m.; and April 1, 2023, at 6:00 a.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out doses of Morphine Sulfate were administered to the resident on these dates and times. Interview with the Nursing Home Administrator on April 21, 2023, at 1:51 p.m. confirmed that there was no documented evidence in Resident 39's clinical records to indicate that the signed-out doses of Morphine Sulfate mentioned above were administered to the resident. 28 Pa. Code 211.9(h) Pharmacy services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 8 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0755 28 Pa. Code 211.12(d)(1) Nursing services. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 9 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on review of manufacturer's instructions and resident clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the medication error rate was less than five percent. Residents Affected - Few Findings include: Observations during medication administration on April 20, 2023, at 7:50 a.m. revealed that two medication administration errors were made during 33 opportunities for error, resulting in an error rate of 6.06 percent. The current manufacturer's instructions for Metoprolol extended life (treats high blood pressure) indicated that the medication was to be swallowed whole and not chewed or crushed. The manufacturer's instructions for pantoprazole extended release, dated May 2022, indicated that it should be swallowed whole and not chewed or crushed. Current physician's orders for Resident 16, dated June 8, 2022, included an order for the resident to receive one 40 milligram (mg) tablet of pantoprazole extended release daily and an order for one 100 mg tablet of metoprolol extended life daily. Observations during medication administration on April 20, 2023, at 7:50 a.m. revealed that Licensed Practical Nurse 1 crushed Resident 16's Protonix and metoprolol, put them in applesauce, and administered it to Resident 16. Interview with Licensed Practical Nurse 1 on April 20, 2023, at 8:04 a.m. confirmed that she should not have crushed the metoprolol or Protonix. Interview with the Director of Nursing on April 20, 2023, at 3:45 p.m. confirmed that Licensed Practical Nurse 1 should not have crushed Protonix or metoprolol prior to administering to Resident 16. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 10 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 29 residents reviewed (Residents 17). Findings include: A facility policy for oxygen administration, storage and maintenance, dated April 13, 2023, indicated that a physician's order is required for oxygen administration and that the licensed nurse will assume responsibility for documentation of saturation rates and oxygen administration. Physician orders for a continuous oxygen flow to maintain a certain saturation level, the medication administration record (MAR) will reflect the obtained saturation rate, liter of flow of oxygen, and initials of medication nurse every shift. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated February 28, 2023, revealed that the resident understood others and was sometimes understood, required extensive assist of staff for daily care needs, and had diagnoses that included sick sinus syndrome (a type of heart rhythm disorder). Physician's orders for Resident 17, dated January 9, 2023, included an order to use oxygen to maintain oxygen saturation (percent of oxygen carried by red blood cells through the arteries and delivered to internal organs) of greater than 90 percent. A care plan for the resident, dated January 11, 2023, included an intervention for the resident to receive oxygen at 2 liters per minute. A review of clinical records, including the MAR, Treatment Administration Records (TAR), and nursing notes, revealed no consistent documentation to reveal how many liters of oxygen the resident was receiving. An interview with the Director of Nursing on April 21, 2023, at 7:48 p.m. revealed that the physician's order for the amount of oxygen Resident 17 should receive was unclear and confirmed that there was no documentation to reveal how many liters of oxygen the resident was receiving daily. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 11 of 12 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 395944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chambers Pointe Health Care Center 1425 Philadelphia 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for an annual survey ending May 13, 2022, revealed that the facility developed a plan of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 21, 2023, identified a repeated deficiency related to pharmaceutical services/accountability of narcotics. The facility's plan of correction for a deficiency regarding pharmaceutical services, cited during the survey ending May 13, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure pharmaceutical services, such as accountability for narcotics, was followed. Refer to F755. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 12 of 12