Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Chambersburg Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
The facility failed to ensure ordered treatments and medication administration were carried out and documented as required. A resident with dementia had multiple wound treatments missing from the TAR, another resident with dementia was observed in bed without the ordered heel device in place even though the TAR was signed, and an RN left tablets at a resident’s bedside before realizing the dose had not been fully ingested. The DON stated medications should never be left at the bedside and staff should observe ingestion before leaving the room.
Food and Nutrition Services staff did not participate in care plan meetings for two residents at nutritional risk. One resident with osteoarthritis and personal care needs reported dissatisfaction with breakfast and food concerns, while another resident with depression and muscle wasting said her food preferences were not being honored and wanted to meet with foodservice staff. Both care plans included honoring food preferences, but meeting notes and nutrition documentation did not show updates to those preferences or attendance by FNS staff.
The facility failed to document freezer temps in four nourishment pantries and failed to keep four pantry refrigerators clean, with debris and dried substances observed in the refrigerators and in three microwaves. The Dietary Mgr said Housekeeping cleaned these areas, but the logs showed the refrigerators were last cleaned on a prior monthly cycle and did not include PRN cleaning. The facility also left a resident-labeled food item in a pantry refrigerator beyond the 3-day holding period required by policy.
Inaccurate MDS assessments were completed for three residents. One resident with osteoarthritis and a right ankle impairment had two MDSs that incorrectly coded no ROM impairment, another resident with bilateral lower-extremity amputations had MDSs that incorrectly coded only one or no impaired lower extremity instead of bilateral impairment, and a third resident with major depressive disorder and dementia had an MDS that incorrectly listed schizophrenia as an active dx despite a psychiatry note stating it should not be active.
Failure to Document Ordered Pressure Ulcer Treatments: The facility failed to ensure ordered pressure ulcer-related treatments were documented for two residents. One resident had CKD stage 3B and protein-calorie malnutrition, with orders for bilateral buttock care, left heel skin prep, and a heelz up device; another resident had dementia and required heel floating with a heelz up device. The TAR lacked documentation for multiple day and evening shifts, and the NHA and DON stated an LPN failed to document the treatments.
Hand hygiene was not performed during medication administration for a resident. An RN prepared meds without washing hands or using sanitizer after disposing of another resident's medication cup, poured Tylenol and six additional pills onto her bare hand before placing them in the med cup, and did not perform hand hygiene after giving the meds. The NHA and DON confirmed staff should perform hand hygiene appropriately and not place pills onto bare hands.
A resident with vascular dementia, gait difficulty, and muscle weakness experienced falls resulting in hospitalization, yet nursing staff documented multiple neurological assessments on flow sheets during periods when the resident was not in the facility. Facility policy required detailed neurological evaluations and vital sign documentation after such events, and the NHA and DON confirmed that supervisors complete these flow sheets and that entries had been made despite the resident’s absence, contrary to professional standards and expectations for accurate documentation.
A resident with chronic kidney disease, diabetes, and hypertension was treated for hypokalemia with potassium chloride ER 40 mEq three times daily. After the potassium level normalized, the high-dose supplementation continued without an end date and without further lab monitoring for several days, despite ongoing evidence of impaired renal function. When a follow-up potassium lab was ordered, the resident refused twice, and there was no documentation that the resident was informed of the risks of refusing this monitoring. The facility continued administering the same potassium dose without checking levels, and the resident was later transferred to the hospital with altered mental status and was found to have severe hyperkalemia, along with worsened renal function.
Surveyors found that food and beverages, including thickened liquids and items from outside sources, were not consistently labeled with open dates or resident information, and some were kept beyond the allowed time frames. Staff interviews confirmed these items should have been labeled and discarded per facility policy and professional standards.
A resident's bathroom was found to have wallpaper coming away from the wall, rippling under the sink, and torn behind the toilet, with no active maintenance work order in place and the issue persisting for several days despite facility policy requiring a clean and comfortable environment.
Two residents with significant medical histories experienced falls that were not accurately documented in their MDS assessments. Staff interviews confirmed that the assessments failed to reflect these incidents, resulting in inaccurate resident records.
A resident with CHF and atrial fibrillation did not have daily weights consistently documented as ordered, and a significant one-day weight gain was not reported to the practitioner or rechecked. The DON confirmed that daily weights and follow-up were expected but not completed.
The facility failed to maintain and install emergency lighting as required by NFPA 101. There was no documentation of annual maintenance for battery-powered emergency lighting sources, and no battery-powered emergency lighting was installed at the automatic transfer switch, affecting all six smoke compartments. These issues were confirmed by the Assistant DON and Maintenance Director.
The facility was found non-compliant with NFPA 101 smoking regulations due to the absence of a documented smoking policy, lack of no smoking signs in hazardous areas, and failure to provide proper receptacles for cigarette disposal in designated smoking areas. These deficiencies were confirmed through document review, observations, and interviews with facility staff.
The facility did not perform required maintenance and testing of its Essential Electrical System, including missing monthly and annual generator tests. This was confirmed during a review and interview with the Assistant DON and Maintenance Director.
The facility was found non-compliant with GFI protection requirements for power receptacles within six feet of a water source in three smoke zones. Observations revealed non-GFI protected outlets in the D Hall Nurses' Station Nourishment Area, B Hall Beauty Shop, and Main Kitchen Prep Area. This was confirmed by the Assistant DON and Maintenance Director.
The facility failed to maintain smoke-tight doors in a hazardous area, specifically the Boiler Room, where a gap greater than 1/2-inch was observed due to a removed astragal. This was confirmed by the Assistant DON and Maintenance Director.
The facility did not conduct and document the owner's checks of the fixed chemical fire suppression system in one of the smoke compartments. During a review, it was found that the facility lacked documentation for the required quick checks on the kitchen's fire suppression system, which was confirmed by the Assistant DON and Maintenance Director.
The facility did not provide documentation verifying the semi-annual testing and inspection of the fire alarm system within the previous twelve months. This deficiency was confirmed during a document review and an exit conference with the Assistant DON and Maintenance Director.
The facility failed to conduct required fire drills, missing drills for the 2nd shift in the 1st quarter of 2025, and the 1st and 3rd shifts in the 3rd quarter of 2024. This was confirmed by the Assistant DON and Maintenance Director, acknowledging non-compliance with NFPA 101 standards.
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review, and the absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. The lack of documentation indicates non-compliance with NFPA 80 requirements.
Two residents experienced significant unplanned weight loss due to the facility's failure to monitor nutritional status adequately. One resident, with muscle wasting and depressive disorder, lost 8.6 pounds without proper monthly weight checks or a timely nutrition assessment. Another resident, with dementia and intellectual disabilities, lost 16 pounds, and despite a dietician's recommendation, weekly weights were not recorded. The DON acknowledged the lapses in monitoring.
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in care documentation. A resident with Alzheimer's and diabetes had unreported dental issues in their MDS due to off-site staff errors. Another resident developed a pressure injury post-admission, with incorrect MDS coding regarding the injury and weight loss. A third resident receiving hospice care was not accurately documented in MDS assessments. These issues were confirmed by facility staff during interviews.
The facility failed to document necessary wound care treatments for three residents with pressure ulcers, leading to potential lapses in care. A resident with dementia and muscle weakness had missing documentation for sacrum wound care, while another with dementia and intellectual disabilities had incomplete records for heel and ankle treatments. A third resident with peripheral vascular disease also had undocumented treatments for heel and buttocks wounds. The DON acknowledged the missing documentation and emphasized the expectation for proper record-keeping.
A facility failed to provide proper respiratory care for a resident with chronic lung conditions. The resident's nebulizer mask was left uncovered, and the tubing was not changed weekly as required. Staff interviews revealed that nebulizer equipment should be cleaned and changed regularly, but this was not consistently done. The resident reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so.
A resident with neurogenic bladder and spina bifida did not have complete clinical records maintained, as staff failed to document the administration of prescribed treatments, including zinc paste and Ketoconazole cream, on several occasions. The DON confirmed that all treatments should be signed off on the TAR.
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Observations included black substances on air vents, debris in heating/cooling units, and missing plastic grates. The Nursing Home Administrator and DON acknowledged the concerns during a tour.
Failure to Document Ordered Treatments and Observe Medication Ingestion
Penalty
Summary
The facility failed to ensure that residents received treatments and medications as ordered and that documentation reflected what was actually provided. Facility policy required residents to be observed after medication administration to ensure the dose was completely ingested, and wound dressing policy required treatments to be documented on the TAR. Review of records and interviews showed that these standards were not consistently followed for three residents reviewed. Resident 2 had diagnoses including dementia and needed assistance with personal care. Physician orders included multiple wound-related treatments for the right lateral thigh, right lower shin, and right lower extremity. The TAR did not show documentation for several ordered wound treatments on multiple dates in late 2025 and spring 2026. The NHA and DON stated that the nurse assigned to Resident 2 on those dates failed to document the wound treatments and that the nurse was a new LPN who needed additional education. Resident 23 also had dementia and needed assistance with personal care. She had an order to float her heels using a heelz up device while in bed as she accepted, and the care plan included the same intervention. Surveyor observations on multiple days showed Resident 23 in bed while the heelz up device was across the room next to her television, yet the TAR was signed as if the device was in place. There was no documentation that she refused the device. In addition, Resident 163 was observed with a medication cup containing three tablets left on the bedside table, and the resident could not recall why the medications were there. The RN passing medications stated, "I thought she took them all," and then gave the resident the missed medications with water after being called back into the room.
Food and Nutrition Services Staff Did Not Attend Care Plan Meetings
Penalty
Summary
The facility failed to ensure a member of the Food and Nutrition Services staff participated on the interdisciplinary team for two residents who were identified as being at nutritional risk. The facility assessment addressed dining and the need for systems to provide an enjoyable, dignified, and sanitary dining experience. Resident 7 had diagnoses including osteoarthritis and needed assistance with personal care; during an interview, she stated she did not care for what was served for breakfast and had concerns with the food. Her care plan included honoring food preferences within the meal plan, but care plan meeting notes from July 2025 through the survey date did not show attendance by Food and Nutrition Services staff, and nutritional assessment and progress notes did not show that her food preferences were updated. Resident 105 had diagnoses including depression and muscle wasting and atrophy. During an interview, she stated her food preferences were not being honored, needed to be updated, and she wanted to meet with foodservice staff because she had concerns with the food and dietary services. Her care plan also included honoring food preferences within the meal plan, but care plan meeting notes from September 2025 through the survey date did not show attendance by Food and Nutrition Services staff, and nutritional assessment and nutrition progress notes did not show that her food preferences were updated. The Dietary Manager stated she was unable to attend quarterly care plan meetings because the dietary department was short staffed and the dietitian typically only came onsite on weekends; the Social Worker stated care plan meetings were usually held on Tuesdays and Wednesdays; and the Dietary Manager later stated she would need an extra dietary aide or food preparation designee to attend care plan meetings because she was busy filling those roles.
Failure to Monitor Freezer Temperatures and Maintain Clean Nourishment Pantries
Penalty
Summary
The facility failed to monitor freezer temperatures in four nourishment pantries: Station 1, Station 2, Station 3, and Arcadia. Review of the facility’s refrigeration/freezer temperature policy showed that the Director of Dining Services/Director of Culinary Services or designee was to observe and record refrigerator and freezer temperatures daily on the temperature log, and that temperatures were not to be taken during the defrost cycle. However, review of the logs with the Dietary Manager showed no freezer temperatures documented for May, and no freezer temperatures documented from February 2026 through April 2026. The Dietary Manager stated that the facility had no freezer temperatures documented during that timeframe, and the NHA stated she expected the policy to be followed and freezer temperatures to be taken and recorded. The facility also failed to maintain clean refrigerators in four nourishment pantries and failed to discard a resident-labeled food item in Station 3 after the required holding period. Observation of the four pantries showed debris and dried substances in all pantry refrigerators and in three of four microwaves. The Dietary Manager stated Housekeeping cleaned these areas, and the refrigerator cleaning log showed the refrigerators were last cleaned on April 2, 2026; the log also showed monthly cleaning but no provision for PRN cleaning between monthly cleanings. In Station 3, a food container with a resident’s name and a date of April 29, 2026 was observed in the pantry refrigerator, while facility policy required food brought in for residents to be held for three days and then discarded by staff upon notification to the resident. The NHA stated she expected the policy to be followed and the food to have been discarded after 3 days.
Inaccurate MDS Assessments for Resident Functional Status and Diagnoses
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for three residents. For one resident with osteoarthritis and need for assistance with personal care, the clinical record and PT evaluation showed the right lower extremity was impaired at the ankle, but two Quarterly MDS assessments coded Section GG0115 Functional Limitation in Range of Motion as no impairment when impairment on one side should have been recorded. During interview, the NHA stated those MDS assessments were marked in error and were being modified. For another resident with a right leg above-the-knee amputation, a left leg below-the-knee amputation, and type 2 diabetes mellitus with hyperglycemia, multiple Quarterly and Annual MDS assessments coded Section GG0115 as either one lower extremity impaired or no impairment, although bilateral impairment should have been coded. The NHA confirmed the assessments since August 2025 were marked in error. For a third resident with major depressive disorder and dementia, a psychiatry note stated no psychotropic medications were necessary and that schizophrenia should not be made an active diagnosis, yet the Quarterly MDS marked schizophrenia as an active diagnosis. The NHA confirmed that MDS was marked in error.
Failure to Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that residents received necessary pressure ulcer treatment and services consistent with professional standards of practice, and failed to promote healing and prevent infection of a pressure ulcer for two residents reviewed. Resident 17 had diagnoses including chronic kidney disease stage 3B and protein-calorie malnutrition. Physician orders included cleansing and applying hydraguard to bilateral buttocks every day and evening shift, skin prep to the left heel and leaving it open to air every day and evening shift, and use of a heelz up device while in bed as accepted every shift. The treatment administration record did not document these ordered treatments on evening shift April 13, 2026, day shifts April 29 and 30, 2026, and day shifts May 1 and 2, 2026. Resident 23 had diagnoses including dementia and need for assistance with personal care. Physician orders included floating both heels using a heelz up device while in bed as accepted every shift, and the care plan included an intervention to float heels while in bed utilizing the heelz up device as accepted. The treatment administration record did not document use of the heelz up device on day shift April 27, 29, and 30, 2026, day shift May 1 and 2, 2026, and evening shift May 5, 2026. During interview, the NHA and DON stated the nurse assigned to both residents on the missing documentation dates failed to document the wound treatments and identified the nurse as a new LPN needing additional education.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
Failure to provide and implement an infection prevention and control program occurred during medication administration for one resident. Facility policy for hand hygiene stated that hand hygiene is to be performed before resident care and after contact with the resident's environment, and the medication administration policy stated that hands are to be washed with soap and water and gloves applied before administering topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications, with hand hygiene performed again after resident contact. During observation, a registered nurse prepared medications for the resident without using hand sanitizer or washing hands after disposing of the previous resident's medication cup. The same nurse was observed pouring Tylenol tablets from the stock bottle onto her bare hand and then placing the tablet into the medication cup, and she removed six additional pills onto her bare hand for the resident. No hand hygiene was performed during medication preparation. After administering the medications, the nurse again failed to perform hand hygiene. The Nursing Home Administrator and Director of Nursing later confirmed they would expect nursing staff to perform hand hygiene appropriately and not place pills onto bare hands before placing them in the medication cup.
Inaccurate Neurological Assessment Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of quality, specifically related to neurological evaluations after falls. Facility policy and procedure required that neurological evaluations include documentation of level of consciousness, orientation, ability to follow commands, response to sensation and/or pain, pupil reaction, motor function, and vital signs on a Neurological Assessment Flow Sheet. Resident 4, who had diagnoses including vascular dementia with mood disturbances, difficulty walking, and muscle weakness, experienced a fall on January 11, 2026, with complaints of left leg pain and a hematoma to the left side of the forehead. She was transferred to the hospital shortly after the fall and remained hospitalized until January 17, 2026. Despite Resident 4’s absence from the facility during this hospitalization, her neurological evaluation flow sheet contained multiple entries indicating that neurological assessments were completed at numerous times on January 11, 12, 13, and 14, 2026. Similarly, after another fall on March 25, 2026, Resident 4 was transferred to the hospital on March 26, 2026, and remained hospitalized until March 28, 2026, yet her neurological evaluation flow sheet documented an assessment on March 26, 2026, during the 3–11 shift when she was not present in the facility. During interviews, the NHA and DON explained that neurological flow sheets are placed on a clipboard for nursing supervisors to complete and confirmed that neurological evaluations had been documented as completed even though the resident was not in the facility, acknowledging that documentation was expected to be accurate.
Failure to Adjust Potassium Supplementation and Ensure Informed Refusal of Lab Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to discontinue or adjust potassium chloride ER dosing and to ensure a resident was informed of the risks of refusing laboratory monitoring, resulting in unmonitored treatment for hypokalemia in a resident with chronic kidney disease. The resident had diagnoses including chronic kidney disease, diabetes, and hypertension, and was cognitively intact per an admission BIMS score of 13. Laboratory results showed hypokalemia with a potassium level of 2.8, along with elevated BUN and creatinine and a reduced eGFR, indicating impaired renal function. In response, the physician ordered potassium chloride ER 20 mEq tablets, 40 mEq three times daily, without an end date. A repeat lab two days later showed a normal potassium level of 4.5, but BUN and creatinine remained elevated and eGFR remained low. No labs were ordered for the next two days. A lab was ordered for a subsequent date to recheck potassium, but the resident refused two attempts to obtain the specimen, and there was no documentation that the resident was made aware of the risks of declining the lab test. When the physician was notified of the refusal, the lab was simply reordered for a later date, and the facility continued administering potassium chloride ER 40 mEq three times daily over several days without any potassium level monitoring. The resident was later sent to the hospital for altered mental status, where admission labs revealed hyperkalemia with a potassium level of 7.1, along with further elevated BUN and creatinine and a lower eGFR. The hyperkalemia was treated in the emergency department, and the resident was admitted for continued monitoring and evaluation of altered mental status and possible infection. The deficiency was cited under 28 Pa. Code 211.2(d)(3)(9) Medical Director, 28 Pa. Code 211.10(c) Resident Care Policies, and 28 Pa. Code 211.12(c) Nursing Services.
Failure to Properly Store and Label Food and Beverages
Penalty
Summary
The facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Observations revealed multiple instances where thickened beverages and food items were either not labeled with an open date or were kept beyond the allowable time frames specified by both facility policy and product labeling. Specifically, containers of thickened lemon water and apple juice were found open and either undated or dated beyond the seven-day limit for use after opening. Additionally, food items brought in from outside sources were not consistently labeled with the resident's name and the date the food was brought in, nor were they always discarded after the three-day holding period as required by facility policy. Interviews with the Food Service Director confirmed that these items should have been properly labeled and discarded according to the established time frames. The Nursing Home Administrator also stated that it was the facility's expectation for expired items to be discarded and for all food and beverages to be labeled and stored per policy and professional standards. These findings indicate a failure to adhere to both internal policies and professional standards regarding the safe storage and handling of food and beverages.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in one of the resident rooms reviewed. Facility policy requires that residents have a right to a safe, clean, and comfortable environment, and that housekeeping and maintenance services are provided to maintain a sanitary and orderly interior. A resident reported disappointment with the condition of the wallpaper in his bathroom, which had been in poor condition since his admission to the room. Observations confirmed that the wallpaper was coming away from the wall in several areas, was rippling under the sink, and was torn behind the toilet. A review of the facility's maintenance work order report did not show any active work order for the bathroom in question, despite the issue being present for several days. The Nursing Home Administrator stated that staff are responsible for identifying and reporting environmental concerns in resident rooms daily, but there was no evidence that this process was followed for this resident's bathroom. Follow-up observations showed that the wallpaper remained in poor condition several days after the initial report and observation.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents. For one resident with diagnoses including COPD, end stage renal disease, and difficulty walking, clinical records showed a fall with no injuries occurred. However, the resident's Minimum Data Set (MDS) assessment did not document this fall, indicating inaccurately that no falls had occurred since the prior assessment. This discrepancy was confirmed during staff interviews. Another resident, with a history of muscle weakness, difficulty walking, and traumatic brain injury, experienced a fall with injury and was sent to the emergency room. Despite this, the resident's MDS assessment also failed to document the fall, incorrectly stating that no falls had occurred since the previous assessment. Staff interviews confirmed the inaccuracy in the MDS coding for this resident as well.
Failure to Document and Respond to Significant Weight Changes in Resident with CHF
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and atrial fibrillation. Physician orders required daily weights and notification of the practitioner if the resident gained 2 pounds or more in a day or 5 pounds in a week. Documentation showed that daily weights, or refusals, were not recorded for multiple days across three months. Additionally, a significant weight gain of 11.7 pounds in one day was documented, but there was no evidence that the practitioner was notified or that a reweigh was performed. The Director of Nursing confirmed that daily weights should have been recorded and appropriate follow-up should have occurred when the weight gain was identified.
Deficiency in Emergency Lighting Maintenance and Installation
Penalty
Summary
The facility was found to be deficient in maintaining and installing emergency lighting as required by NFPA 101. During a document review and observation, it was discovered that the facility lacked documentation verifying the annual maintenance of battery-powered emergency lighting sources. Additionally, it was observed that there was no installed battery-powered emergency lighting at the automatic transfer switch, affecting all six smoke compartments within the component. These findings were confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1. and 2. Maintenance Director has completed annual maintenance of battery-powered emergency lighting and installed battery-powered emergency lighting at the automatic transfer switch. 3. Maintenance department will be educated on the standards of ensuring the facility has completed the annual maintenance of battery-powered emergency lighting and ensuring there is a battery back-up emergency lighting at the automatic transfer switch. 4. Maintenance or facility designee will audit the facilities battery-powered emergency lighting weekly x2 for 2 months, then every 60 days throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations due to several deficiencies. During a document review, it was discovered that the facility did not have a documented smoking policy available for review. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. Additionally, the facility failed to post no smoking signs in areas where flammable liquids, combustible gases, or oxygen are used or stored, which was also confirmed during the exit conference interview. Furthermore, observations revealed that the facility did not provide metal containers with self-closing cover devices for ashtrays, nor did it have fire-resistant ashtrays in the designated smoking area behind the facility at the picnic table. This area was found to have an abundance of cigarette butts discarded on the ground, indicating a lack of proper receptacles. The absence of these required receptacles was confirmed during the exit conference interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1 and 2. Maintenance Director will print smoking policy for life safety binder, will post non-smoking signs in rooms, wards, or compartments where flammable liquids, combustible gases or oxygen is used or stored and will provide metal receptacles to be available where smoking is permitted. 3. Maintenance department will be educated on the standards of the facilities smoking policy, need for non-smoking signs, and providing metal receptacles where smoking is permitted. 4. Maintenance or facility designee will audit facilities smoking policy, metal receptacles, and non-smoking signs to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to perform the required maintenance and testing of its Essential Electrical System (EES), which is crucial for ensuring the safety and functionality of the power supply in emergency situations. Specifically, the facility did not conduct the necessary weekly, monthly, and annual inspections and testing of the generator and associated equipment. This includes the failure to perform a monthly 30-minute load test using the transfer switches and an annual 90-minute load bank test. During a document review and interview conducted on April 16, 2025, it was confirmed by the Assistant Director of Nursing and the Maintenance Director that these essential maintenance activities were not carried out as required. The lack of adherence to the maintenance schedule outlined in NFPA 101 and related standards indicates a significant oversight in the facility's operational procedures, potentially compromising the reliability of the emergency power system.
Plan Of Correction
1 and 2. 4 hour building load test performed 3/8/2024 by GenServ. Maintenance Director has performed the monthly 30 min. test and will complete the annual 90 minute load bank inspection and testing of the facilities generator. 3. Maintenance department will be educated on the standards of completing weekly, monthly and annual inspections and testing of generator. 4. Maintenance or facility designee will audit facilities generator weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in three of six smoke zones. During an observation on April 16, 2025, between 12:30 PM and 12:45 PM, it was noted that various outlets were not GFI protected. Specifically, at 12:30 PM, one outlet in the D Hall Nurses' Station Nourishment Area was found to be non-compliant. At 12:40 PM, three outlets in the B Hall Beauty Shop, located by sinks, were also not GFI protected. Additionally, at 12:45 PM, two outlets in the Main Kitchen Prep Area, near the coffee machine and ice machine, were identified as lacking GFI protection. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
1 and 2. Maintenance Director has updated GFI's in D hall nurses station nourishment room (1 outlet), B hall beauty shop (3 outlets), and main kitchen prep area (2 outlets). 3. Maintenance department will be educated on the standards of maintaining power receptacles to be GFI within six feet of a water source. 4. Maintenance or facility designee will audit facilities GFI receptacles weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Deficiency in Smoke-Tight Integrity of Boiler Room Doors
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of hazardous area doors in one of six smoke compartments. During an observation on April 16, 2025, at 11:55 AM, it was noted that there was a gap greater than 1/2-inch between the double doors of the Boiler Room due to a removed astragal. This deficiency was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM.
Plan Of Correction
1 and 2. Maintenance Director installed astragal between the double doors in the boiler room. 3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors do not have a gap greater than 1/2in. and to not remove astragal. 4. Maintenance or facility designee will audit the facilities corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Suppression System Checks
Penalty
Summary
The facility failed to conduct and document the owner's checks of the fixed chemical fire suppression system in one of the six smoke compartments within the component. During a document review and interview conducted on April 16, 2025, it was revealed that the facility could not provide documentation of the owner's quick check for the fixed chemical fire suppression system installed in the kitchen. This deficiency was confirmed during an exit conference with the Assistant Director of Nursing and the Maintenance Director, who acknowledged the lack of documentation for the required quick checks on the kitchen's fire suppression system.
Plan Of Correction
1 and 2. Maintenance Director completed the monthly check of the chemical fire suppression system. 3. Maintenance department will be educated on the standards to ensure we are checking the chemical fire suppression system monthly. 4. Maintenance or facility designee will audit facilities chemical fire suppression system to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide documentation verifying that the semi-annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 1:45 PM, the Assistant Director of Nursing and the Maintenance Director confirmed the lack of documentation for the required semi-annual testing and inspection of the fire alarm system.
Plan Of Correction
1 and 2. Maintenance Director contracted Eastern Time, Inc. to revisit facility to complete semi-annual fire alarm system testing. 3. Maintenance department will be educated on the standards of the facilities fire alarm system inspection. 4. Maintenance or facility designee will audit facilities fire alarm system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm fire alarm reports are still available for review and results of the audit will be reported to the QA Committee.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform fire drills as required, with deficiencies noted in the documentation review. Specifically, the facility did not perform fire drills for the 2nd shift in the 1st quarter of 2025, the 1st shift in the 3rd quarter of 2024, and the 3rd shift in the 3rd quarter of 2024. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director, who acknowledged that the fire drills were not conducted as mandated by the NFPA 101 standards, which require fire drills to be held at least quarterly on each shift under varying conditions.
Plan Of Correction
1 and 2. Maintenance Director will complete monthly fire drills, one per shift, per quarter. 3. Maintenance department will be educated on the standards of the facilities monthly fire drill policy ensuring they are being conducted one per shift, per quarter. 4. Maintenance or facility designee will audit facilities fire drills to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM. The lack of documentation indicates that the required annual inspections of fire door assemblies, as mandated by NFPA 80, were not properly recorded or possibly not conducted, leading to non-compliance with the Life Safety Code requirements.
Plan Of Correction
1 and 2. Maintenance Director has completed the annual fire door inspection in six of six smoke compartments. 3. Maintenance department will be educated on the standards of the facility's annual fire door inspection. 4. Maintenance or facility designee will audit facilities annual fire door inspection in life safety binder weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status for two residents, leading to significant unplanned weight loss. Resident 60, diagnosed with muscle wasting, atrophy, muscle weakness, and major depressive disorder, experienced an unplanned weight loss of 8.6 pounds (4.9%) between March and April 2024. The facility did not obtain monthly weight measures for November 2023 and January 2024, nor did they conduct a re-weigh for the weight change in April 2024. Additionally, there was no nutrition assessment conducted between March 22, 2024, and April 26, 2024, despite the resident's weight loss. Resident 72, diagnosed with dementia and moderate intellectual disabilities, experienced an unplanned significant weight loss of 16 pounds (approximately 10%) between March and April 2024. Although a dietician noted the weight loss and recommended weekly weight monitoring, the facility failed to obtain or record these weekly weights between April and May 2024. The Director of Nursing acknowledged the expectation for weekly weights following the significant weight loss, which was not met.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in care documentation. Resident 12, diagnosed with Alzheimer's disease and type II diabetes mellitus, reported tooth pain due to poor dentition, which was confirmed by dental consults and a speech therapy evaluation. However, the comprehensive annual MDS for Resident 12 did not reflect the presence of obvious or likely cavities or broken teeth. This discrepancy arose because the MDS was completed by an off-site staff member who relied on an admission evaluation that inaccurately indicated the resident had dentures without other dental concerns. Resident 52, with diagnoses of dementia and type 2 diabetes, developed a pressure injury on the right heel after admission, which progressed to include necrotic tissue. The Discharge Return Anticipated MDS and Quarterly MDS for Resident 52 were incorrectly coded, indicating the pressure injury was present upon admission and misreporting weight loss. The Director of Nursing confirmed these coding errors during a staff interview. Resident 80, diagnosed with epileptic seizures and Alzheimer's disease, was admitted to hospice services, but the facility failed to indicate hospice care in two quarterly and one annual MDS assessments. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during interviews with the surveyor, who highlighted the expectation for accurate MDS assessments.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to promote healing and prevent infection of pressure ulcers, as evidenced by missing documentation of wound care treatments for three residents. Resident 11, diagnosed with dementia and muscle weakness, had a stage III pressure injury on the sacrum. The treatment orders included cleansing with saline, applying skin prep, hydrogel, and a dry dressing. However, documentation was missing for several dates in March and May 2024, indicating that the treatments may not have been completed as ordered. Resident 72, with dementia and moderate intellectual disabilities, had stage III pressure injuries on the left heel, right heel, and right ankle. The treatment orders involved cleansing with wound cleanser, applying skin prep, hydrogel, and optifoam dressing. Documentation was missing for multiple dates in April 2024, suggesting a lack of adherence to the prescribed treatment schedule. The Director of Nursing acknowledged the missing documentation and expressed the expectation that treatments should be documented. Resident 110, diagnosed with a pressure ulcer of the left heel, peripheral vascular disease, and muscle weakness, also had missing documentation for wound care treatments. The treatment orders included cleansing with saline, applying wet gauze, and covering with ABD and kerlex. Documentation was absent for several dates from November 2023 to May 2024. The Director of Nursing was unable to provide additional information regarding the missing documentation and reiterated the expectation for wound treatments to be documented.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for a resident with a history of pulmonary embolism, acute pulmonale, and chronic obstructive pulmonary disease. The resident had physician orders for Ipratropium-Albuterol Solution to be administered four times daily and as needed. Observations revealed that the nebulizer mask was left uncovered on the resident's nightstand with the medication reservoir still attached, and the tubing was not changed weekly as required. The resident reported that staff no longer cleaned or changed the mask frequently. Interviews with staff, including a registered nurse and a respiratory therapist, confirmed that nebulizer tubing should be changed weekly and masks should be cleaned after each treatment. However, the respiratory therapist, who had recently started working at the facility, was unaware of the current status of nebulizer equipment and was waiting for a list of nebulizers in the building. The resident also reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so, and the mask was not cleaned afterward. The facility's nursing home administrator and director of nursing were informed of these observations and the resident's statements.
Incomplete Clinical Records for Resident Treatments
Penalty
Summary
The facility failed to maintain complete clinical records for a resident, identified as Resident 107, who has diagnoses including neurogenic bladder and spina bifida. The resident was cognitively intact and required specific treatments for moisture-associated skin damage (MASD) on his buttock and scrotum, which included the application of zinc paste every shift. Additionally, the resident was receiving Ketoconazole cream 2% for a skin condition on his head, face, and neck every shift. However, the Treatment Administration Record (TAR) for Resident 107 showed that staff did not initial and check the block confirming the administration of the Ketoconazole cream on three specific dates and shifts in April 2024. Similarly, the TAR also revealed that staff failed to document the administration of the zinc paste on three different dates and shifts in April 2024. During an interview, the Director of Nursing (DON) confirmed that all treatments should be signed off as completed on the TAR. This deficiency was identified through a review of clinical records and staff interviews, indicating a lapse in maintaining complete and accurate medical records in accordance with accepted professional standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Specific observations included the presence of a black, speckled substance on air vents in the dining room outside the main kitchen, black substance accumulations along the corners of walls beside heating vents/units in multiple residents' rooms, and debris in heating/cooling units. Additionally, some heating/cooling units had missing plastic grates, dried spill/splash spots, and crumbling walls with debris noted in and on the units. During a tour with the Nursing Home Administrator and Director of Nursing, they acknowledged the concerns. The Director of Nursing later revealed that work orders had been submitted for the required repairs, and staff were in the process of auditing rooms for cleanliness.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 258 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chambersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare Shook Home | 1.5 mi | ★★★★★ | 8 | 0 |
| Laurel Lakes Rehabilitation And Wellness Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Chambers Pointe Health Care Center | 2.5 mi | ★★★★★ | 4 | 0 |
| Menno Haven Rehabilitation Center | 3 mi | ★★★★★ | 3 | 0 |
| Brookview Health Care Center | 3.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.