Health inspection·November 29, 2023

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few Based on review of policies and clinical records, as well as observations and 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 of residents for two of three residents reviewed (Residents 1, 3), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. Recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's plan of care. The facility's care plan policy, dated September 14, 2023, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, and described the services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, revealed that the resident was cognitively impaired, required extensive assistance with transfers, had limited range of motion to his upper extremities, used a wheelchair, had a history of falls, and had diagnoses that included dementia and traumatic brain injury (sudden injury that causes damage to the brain). The resident's care plan, dated September 14, 2023, revealed that he was at risk for falls and used a wheelchair. Investigative documents for Resident 1, dated November 15, 2023, revealed that the resident was on the floor lying in front of his wheelchair with the nurse aide standing beside him. The resident was stabilized, the bleeding was stopped from the laceration, and he was assessed by the registered nurse. A statement from Registered Nurse 1, dated November 15, 2023, revealed that when she came upon the situation to help staff, it was noted that Resident 1's foot rests for his wheelchair were in the bag hanging on the back of the wheelchair. There was no documented evidence that a care plan was developed to address Resident 1's specific and individualized interventions and care needs related to using foot rests on his wheelchair prior to falling from his wheelchair. However, the foot rests were hanging on the back of the chair and (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 4 Event ID: 395944 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 11/29/2023 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)