Inspection·February 28, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 19 residents reviewed (Residents 17, 24). Residents Affected - Few Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0451K was to be coded if the resident received an anti-convulsant during the seven-day assessment period. Physician's orders for Resident 17, dated January 24, 2025, included orders for the resident to receive 300 mg Gabapentin (anti-convulsant) three times a day. Review of the January MAR revealed that the resident received Gabapentin during the assessment period. However, an admission MDS assessment for Resident 17, dated January 30, 2025, revealed that Sections N0415K was coded to indicate that the resident had not received the anti-convulsant. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that MDS assessment for Resident 17 was coded inaccurately. The Long-Term Care Facility Resident Assessment Instrument User's Manual, dated October 2024, indicated that Section B-Hearing, Speech, and Vision (B0100-B1200) was to be completed to indicate the resident's ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. Section C-Cognitive Patterns (C0100-C1000) of the MDS was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The RAI User's Manual also indicated that if a resident did not answer a question, then the question should be coded as a zero for an incorrect answer. If there were no responses, or the responses were nonsensical, then the BIMS interview was to be stopped after Section C0300 (day of the week), a dash was to be coded in the remaining sections of the individual interview, a (99) was to be entered in Section C0500, and then a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. A quarterly MDS assessment for Resident 24, dated February 6, 2025, revealed that section B0700 was coded (3) indicating that the resident was rarely or never understood, and section B0800 was coded (3) indicating the resident could rarely or never understand others. However, according to Section C0100, attempt to conduct interview, was coded (1) indicating yes, interview the resident. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 2 of 4 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 02/28/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Section C0100 of Resident 24's February 6, 2025, MDS assessment was not accurate and should have been coded zero (0). 28 Pa. Code 211.5(f) Clinical Records. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 3 of 4 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 02/28/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of 19 residents reviewed (Resident 17). Residents Affected - Few Findings include: The facility's policy regarding pain management, dated February 20, 2025, indicated that the facility would ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences. When pain medications were administered the facility would follow up monitoring the effectiveness. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated January 30, 2025, revealed that the resident was alert and oriented, received pain medication routinely and as needed, received an opioid (a controlled pain medication), and was receiving hospice services. Physician's orders for Resident 17, dated January 30, 2025, included orders for the resident to receive 0.5 milliliters (mL) of morphine sulfate solution (a narcotic pain medication) 20 milligrams/milliliter (mg/mL) every two hours as needed for shortness of breath or pain. Resident 17's Medication Administration Record for February 2025 revealed that 0.5 mL morphine sulfate was administered on February 6 at 1:13 p.m. There was no documented evidence of the effectiveness of pain relief after the administration of the morphine sulfate until 4:17 p.m., at which time the effectiveness was documented as ineffective and 0.5 mL of morphine sulfate was administered at that time. Resident 17's Medication Administration Record for February 2025 revealed that 0.5 mL morphine sulfate was administered on February 7 at 6:55 a.m. There was no documented evidence of the effectiveness of pain relief after the administration of the morphine sulfate until 10:03 a.m., at which time the effectiveness was documented as ineffective and 0.5 mL of morphine sulfate was administered at 10:07 a.m. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that there was no follow up regarding the effectiveness of the morphine sulfate after administration on February 6 and 7, 2025. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395944 If continuation sheet Page 4 of 4