Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chambers Pointe Health Care Center during CMS and state inspections, most recent first.
Surveyors found that a resident with dementia and depression received multiple PRN doses of Lorazepam for anxiety/agitation over several months without any documented evidence that non-pharmacological interventions were attempted beforehand, despite a facility policy requiring such measures for residents on psychotropic drugs. The Nursing Home Administrator confirmed that documentation of these interventions was absent and should have been present.
The facility failed to serve meals at appetizing and policy-compliant temperatures. A resident reported that hot foods were often not hot when received. For a lunch meal including salmon, stir-fried rice, green beans, pickled beets, and cheesecake, food temperatures taken before service were within or above the facility’s specified ranges, but temperatures taken after plating on a unit test tray showed hot items below the required minimum and a cold item above the allowed maximum. When the test tray was tasted, the hot items were lukewarm and the beets were not cold, and the staff member who prepared the tray acknowledged that the temperatures were not within the recommended ranges.
Surveyors found that the facility did not follow its own food storage policy requiring all products to be labeled and dated, including an open date for items once opened. During an observation of the Dogwood unit reach-in freezer, two open half-gallon containers of ice cream (Butter Pecan and Chocolate) were found without any indication of when they had been opened. A homemaker and the Nursing Home Administrator both confirmed that these ice cream containers should have been dated upon opening, demonstrating noncompliance with established dietary service standards.
Two residents using alternating air mattresses did not have documented air mattress safety assessments, despite care plans identifying skin integrity concerns and hospice involvement for one resident. MDS assessments showed that one resident was cognitively intact and required staff assistance, while the other was cognitively impaired, dependent for care, and on hospice. Observations confirmed both residents were using air mattresses, and the NHA acknowledged that required safety assessments had not been completed or documented.
A resident who required assistance for transfers fell and sustained a right shoulder fracture when a nurse aide failed to use a gait belt during ambulation, as required by the care plan and facility policy. The aide turned away to adjust bed linens, resulting in the resident losing balance and falling. The incident was substantiated as neglect due to noncompliance with safety protocols.
A facility failed to maintain a clean environment for a resident with cerebral palsy, as evidenced by a buildup of food and dust on the resident's power wheelchair. Observations confirmed the lack of a cleaning schedule for power wheelchairs, unlike regular wheelchairs.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly indicated they had not received an anti-convulsant medication, despite records showing otherwise. Another resident's assessment inaccurately suggested a BIMS interview should be attempted, despite indications of communication difficulties. These errors were confirmed by the Nursing Home Administrator.
A resident receiving hospice services and opioid medication for pain management did not have timely follow-up documentation on the effectiveness of administered morphine sulfate. The facility's records showed delays in assessing pain relief, leading to additional doses being given without proper documentation of the initial dose's effectiveness.
A resident with dysphagia was not provided with the prescribed nectar thick liquids, receiving thin water during a luncheon and slightly thick Ensure Plus during a meal. The facility's policy requires thickened liquids as ordered, but staff interviews confirmed the oversight.
The facility failed to serve food items at proper temperatures. Initial food temperatures were within the required range, but the food was left uncovered in the steam table, causing it to become cold by the time it was served. Staff interviews confirmed that lids should have been closed when not plating food.
The facility failed to adhere to food service safety standards by not ensuring dietary staff wore proper hair coverings and by improperly storing food. Observations revealed uncovered hair on dietary staff and improperly stored, unlabeled, and undated food items in the freezer. These deficiencies were confirmed by the Executive Culinary Director.
The facility failed to resolve ongoing grievances related to cold food. Residents complained about cold, unappetizing meals, and grievances indicated that the issue persisted. Observations showed that while food temperatures were initially acceptable, a test tray revealed the food had become cold by the time it was served. The Nursing Home Administrator confirmed the ongoing concern.
The facility failed to respond timely to pharmacy recommendations for a resident with multiple diagnoses and medications. Despite the pharmacist's recommendations for periodic blood draws and laboratory testing, the physician did not review, respond to, or sign off on these recommendations, as confirmed by the DON.
The facility failed to notify a resident's representative in writing regarding the reason for hospitalization. Despite the resident being severely cognitively impaired and requiring assistance for daily care needs, there was no documented evidence that the resident's daughter, listed as the responsible party, was notified in writing about the hospitalizations.
The facility failed to update a resident's care plan to reflect their refusal of dinner trays, despite multiple documented instances and staff awareness. The resident, who was cognitively impaired and dependent on staff, had a care plan for inadequate oral intake and swallowing difficulty, but it did not include the refusals.
The facility failed to ensure controlled medications were stored in a permanently-affixed compartment in the Main medication room and did not discard expired medical supplies in the Evergreen medication room. Observations revealed a non-affixed narcotic storage box with Ativan and expired intravenous catheters and syringes. Staff confirmed these deficiencies.
Lack of Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s psychotropic medication regimen was free from unnecessary medication use and that non-pharmacological interventions were implemented as required by facility policy. The facility’s policy on psychotropic medications, dated February 12, 2026, stated that residents using psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of these drugs. Resident 42’s quarterly MDS assessment dated March 12, 2026, documented that the resident was cognitively intact, required staff assistance for daily care needs, and had diagnoses including dementia and depression. Physician orders for Resident 42 between early January and mid-March 2026 directed administration of 0.50 mg Lorazepam every eight hours as needed for anxiety/agitation for 14-day periods. The MARs for January, February, and March 2026 showed multiple administrations of 0.50 mg Lorazepam on specific dates and times across those months. However, there was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on any of those occasions. In an interview on March 25, 2026, the Nursing Home Administrator confirmed that there was no documentation of non-pharmacological interventions before the PRN Lorazepam doses and acknowledged that such documentation should have been present.
Failure to Serve Meals at Required Hot and Cold Holding Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at appetizing and policy-compliant temperatures. The facility’s policy dated February 12, 2026, required cold foods to be served between 33°F and 50°F and hot foods between 135°F and 155°F. A resident reported on March 23, 2026, that hot foods were often not hot when received. For the lunch meal on March 24, 2026, the planned menu included salmon fillet, stir-fried rice, green beans, pickled beets with onions, and cheesecake. Temperatures taken prior to meal service showed the salmon at 155°F, stir-fried rice at 168°F, green beans at 165°F, and pickled beets at 41°F, which were within or above the policy range at that point. During observation of the lunch meal service on the Dogwood unit on March 24, 2026, at 12:07 p.m., Homeworker 1 plated hot items directly from the steam table and cold items from containers on the counter for a test tray. When she took the temperatures of the foods once plated, the salmon measured 126°F, stir-fried rice 134°F, green beans 123.9°F, pickled beets 63.5°F, and cheesecake 50.3°F, showing that hot foods had fallen below the required minimum of 135°F and the pickled beets exceeded the maximum 50°F for cold foods. At 12:13 p.m., tasting of the test tray revealed the salmon and green beans were lukewarm and the pickled beets were not cold. Homeworker 1 acknowledged that the hot food temperatures were a little low and the beet temperature was a little high, and she referred to the tray line sheet for recommended temperatures.
Failure to Label and Date Opened Frozen Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards and its own policy by not properly labeling and dating opened frozen food items on the Dogwood unit. The facility’s food storage policy, dated February 12, 2026, required that all products be labeled and dated with the receiving date, and that all open items be labeled with the open date and resealed to prevent contamination. During an observation of the Dogwood unit reach-in freezer on March 23, 2026, surveyors found two half-gallon containers of ice cream (Butter Pecan and Chocolate) that were open and not labeled with the date they were opened. A homemaker interviewed at the time of the observation confirmed that the ice cream containers should have been dated when opened, and the Nursing Home Administrator later confirmed that the open containers should have been dated in accordance with policy.
Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete required air mattress safety assessments for two residents who were using air mattresses. For one resident, a significant change MDS dated February 13, 2026, showed that the resident was cognitively intact and required staff assistance for daily care. The resident’s care plan, dated December 12, 2025, identified potential or actual impairment to skin integrity and included an intervention for use of an alternating air mattress to maintain intact skin. Observation on March 23, 2026, confirmed that this resident was using an air mattress on the bed. Review of the clinical record revealed no documented evidence that an air mattress safety assessment had been completed, and the Nursing Home Administrator confirmed that such an assessment should have been performed but was not. For the second resident, a quarterly MDS dated January 27, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care, and receiving hospice services. A care plan dated February 3, 2026, documented that the resident had an alternating air mattress provided by hospice. Observation on March 23, 2026, showed that this resident was in bed with an air mattress in use. Review of the clinical record revealed no documented evidence of an air mattress safety assessment for this resident. In an interview, the Nursing Home Administrator confirmed there was no documented air mattress safety assessment for this resident, despite the use of the equipment. These findings were cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required assistance for transfers, experienced a fall resulting in a right proximal humerus fracture. The incident took place while the resident was being assisted from the bathroom to the bed by a nurse aide. The aide turned away to arrange bed linens, during which time the resident lost balance and fell backwards. Documentation and witness statements confirmed that a gait belt, which was required by the resident's care plan and facility policy for ambulation and transfers, was not used during this transfer. The nurse aide admitted to forgetting to use the gait belt, despite being aware of the policy. The facility's abuse and neglect policy mandates the use of appropriate safety measures to prevent harm, and defines neglect as the failure to provide necessary goods and services to avoid physical harm. The investigation substantiated that neglect occurred due to the failure to use a gait belt, directly leading to the resident's fall and subsequent injury. Clinical records indicated the resident required pain management and a sling for the shoulder fracture following the incident.
Failure to Maintain Cleanliness of Resident's Power Wheelchair
Penalty
Summary
The facility failed to ensure a clean environment for a resident, specifically regarding the cleanliness of a power wheelchair. A quarterly Minimum Data Set (MDS) assessment for a resident with cerebral palsy indicated that the resident was usually understood and could understand others. Observations on multiple occasions revealed a buildup of food and dust debris on the lower frames and an accumulation of dust on the black motor/battery cover of the resident's power wheelchair. An interview with the Director of Housekeeping confirmed these observations and revealed that while there is a regular cleaning schedule for standard wheelchairs, no such schedule exists for power wheelchairs.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For Resident 17, the deficiency involved the incorrect coding of Section N0415K, which should have indicated that the resident received an anti-convulsant medication, Gabapentin, during the assessment period. Despite physician's orders and the Medication Administration Record (MAR) confirming the administration of Gabapentin, the MDS assessment inaccurately reflected that the resident had not received the medication. This discrepancy was confirmed through an interview with the Nursing Home Administrator. For Resident 24, the deficiency was related to the incorrect coding of Section C0100, which pertains to the attempt to conduct a Brief Interview for Mental Status (BIMS). The quarterly MDS assessment inaccurately indicated that an interview should be attempted, despite Sections B0700 and B0800 showing that the resident was rarely or never understood and could rarely or never understand others. This inconsistency was also confirmed by the Nursing Home Administrator. These inaccuracies in the MDS assessments were identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews.
Failure in Pain Management Documentation
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident 17, who was receiving hospice services and required routine and as-needed pain medication. According to the facility's policy on pain management, they were to ensure pain management was consistent with professional standards, the comprehensive care plan, and the resident's goals and preferences. Resident 17's admission Minimum Data Set (MDS) assessment indicated that the resident was alert, oriented, and received opioid medication for pain management. Physician's orders specified that the resident was to receive morphine sulfate every two hours as needed for shortness of breath or pain. However, the Medication Administration Record for February 2025 showed that there was no documented follow-up on the effectiveness of the morphine sulfate administered on February 6 and 7, 2025. On both occasions, the effectiveness of the pain relief was not documented until several hours after administration, and it was noted as ineffective, leading to additional doses being administered. An interview with the Nursing Home Administrator confirmed the lack of follow-up regarding the effectiveness of the morphine sulfate after its administration on the specified dates.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided as ordered by the physician for a resident with dysphagia. The resident was prescribed a mechanically altered diet with nectar thick liquids due to swallowing difficulties. However, during a luncheon, the resident was given thin water instead of the prescribed thickened drink. Additionally, during a supper meal observation, the resident was provided with Ensure Plus, which was not thickened to the required nectar consistency, as confirmed by the dietitian and a registered nurse. The facility's policy on thickened liquids requires that they be provided only when ordered by a physician or delegated dietitian, and the resident's care plan specified the need for nectar thick liquids. Despite this, the resident received liquids that were not appropriately thickened, as the Ensure Plus was only slightly thick at room temperature, not meeting the required consistency. This oversight was confirmed through staff interviews, highlighting a failure to adhere to the prescribed dietary orders for the resident.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food items that were palatable and at proper temperatures. According to the facility's policy, hot foods should be served at 135-155 degrees Fahrenheit. On March 12, 2024, initial temperatures of the food items were within the required range when brought to the kitchenette. However, the food was left uncovered in the steam table throughout the lunch meal service. By the time lunch was served to the last resident, the temperatures of the food items had dropped below the required range, and the food was cold to taste. Interviews with a dietary aide and the nursing home administrator confirmed that the lids should have been closed when not plating food and that the food would be cold if lids were left open during service.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety. Observations in the main kitchen revealed that the Assistant Dietary Director was wearing a hair restraint that did not completely cover her hair, leaving approximately three inches of her bangs uncovered. Additionally, in the Evergreen and Dogwood kitchenettes, dietary aides were observed either without hairnets or with hair restraints that did not fully cover their hair. These observations were confirmed by the Executive Culinary Director, who acknowledged that staff should have had all hair covered with hair restraints. Further deficiencies were noted in the storage of food. In the freezer, a tray containing 22 uncovered, unlabeled, and undated grey-colored, unidentifiable food patties was found. Additionally, 24 patties of pureed cranberry were uncovered, unlabeled, and undated, and a full box of an unspecified item was uncovered, undated, unlabeled, and open to the air. These findings were also confirmed by the Executive Culinary Director, who stated that the frozen patties and the box should have been covered and dated according to the facility's dietary policy on food storage.
Ongoing Grievances About Cold Food
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances related to cold food. A meeting with a group of residents revealed complaints about cold, unappetizing, and unpalatable food. Grievances filed on November 14, 2023, and February 7, 2024, indicated that residents continued to receive cold food. Observations of the lunch meal service on March 12, 2024, showed that while the food temperatures were initially within acceptable ranges, a test tray conducted after the last resident was served revealed that the food had become cold. An interview with the Nursing Home Administrator confirmed that cold food has been an ongoing concern and had not been resolved despite continued grievances and the cold test tray results.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to respond timely to pharmacy recommendations for a resident. The facility's policy, dated September 14, 2023, mandates that a licensed pharmacist collaborates with facility leadership to coordinate pharmaceutical services and resolve pharmaceutical concerns affecting resident care. However, for one resident, the facility did not adhere to this policy. The resident, who was cognitively impaired and had multiple diagnoses including atrial fibrillation, high blood pressure, high cholesterol, thyroid disorder, arthritis, and renal failure, had physician's orders for several medications including Meloxicam, potassium chloride, Losartan, Levothyroxine, Allopurinol, and Lasix. Despite the pharmacist's recommendations for periodic blood draws and laboratory testing to monitor the effects of these medications, the recommendations were not reviewed, responded to, or signed by the physician. Specifically, the pharmacy medication regime review (MRR) for the resident, dated September 27, 2023, and November 6, 2023, included recommendations for various blood tests to monitor the resident's condition and medication effects. These recommendations were not addressed by the physician, as confirmed by the Director of Nursing during an interview on March 13, 2024. This failure to act on the pharmacist's recommendations constitutes a deficiency in the facility's pharmaceutical services, as it did not comply with its own policies and procedures, potentially impacting the resident's care and medical outcomes.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 30 residents reviewed. Resident 38, who was severely cognitively impaired and required assistance for daily care needs, was transferred to the hospital on multiple occasions. Despite the resident's daughter being listed as the responsible party and first emergency contact, there was no documented evidence that she was notified in writing about the hospitalizations in October and November 2023. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 12, 2024.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs. Resident 21, who was cognitively impaired and dependent on staff for daily care, had a care plan indicating inadequate oral intake with swallowing difficulty and unintended weight loss. However, the care plan did not include information about the resident's refusal of dinner trays, despite multiple instances of refusal documented in nursing notes and dietary records. A speech therapy note indicated that Resident 21 could have a mechanically soft diet if alert, out of bed, and in the dining room. Despite this, the resident continued to refuse dinner trays on several occasions. Interviews with speech therapists and the nursing home administrator confirmed that the care plan needed to be updated to reflect these refusals, but this had not been done. This failure to update the care plan was a violation of the facility's policy and regulatory requirements.
Deficiencies in Medication Storage and Expired Medical Supplies
Penalty
Summary
The facility failed to ensure that controlled medications were stored in a separately-locked, permanently-affixed compartment in the Main medication room. During an observation, a narcotic storage box containing an unopened bottle of liquid Ativan was found in the refrigerator, but the box was not permanently affixed. This was confirmed by an interview with a registered nurse who acknowledged that the narcotic storage box should have been permanently affixed inside the refrigerator. Additionally, the facility failed to discard expired medical supplies in the Evergreen medication room. Observations revealed multiple intravenous catheters and syringes that had expired in various months of 2023. A registered nurse confirmed that these expired medical supplies should not have been in circulation. The Nursing Home Administrator also confirmed the absence of a policy regarding expired medical supplies and the permanent affixing of narcotic boxes in the medication refrigerator.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chambersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menno Haven Rehabilitation Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Brookview Health Care Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Transitions Healthcare Shook Home | 1.3 mi | ★★★★★ | 8 | 0 |
| Laurel Lakes Rehabilitation And Wellness Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Chambersburg Skilled Nursing And Rehabilitation Ce | 2.5 mi | ★★★★★ | 15 | 0 |
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