Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Menno Haven Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain hot food at required temperatures during meal service, resulting in several residents receiving lukewarm and unappetizing meals. Food items that were initially at safe temperatures in the kitchen were observed to be below the facility's standard by the time they reached residents, and multiple residents reported dissatisfaction with the temperature of their meals.
A resident who required non-invasive ventilation for sleep apnea was using a CPAP device at bedtime without a documented physician's order, despite facility policy requiring such an order. This was confirmed through record review and staff interview.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
The facility failed to create comprehensive care plans for two residents, one requiring a CPAP machine for sleep apnea and another self-administering cough drops. The care plans were not updated to reflect changes in their care needs, as confirmed by the Nursing Home Administrator.
The facility was found to be in violation of its food handling policies, with hot dogs thawing at room temperature and several food items in the kitchen not being labeled, dated, or secured. The Director of Dietary and the Executive Director of Culinary confirmed these practices were against policy.
The facility failed to maintain complete and accurate clinical records for three residents, as staff marked required exercises as Not Applicable or left documentation blank, contrary to care plans. This issue was confirmed by the Nursing Home Administrator.
A facility failed to notify a physician about a significant weight gain in a resident with end-stage kidney disease and on diuretics. The resident's weight increased by 12.8 pounds in one day, but there was no documented evidence of physician notification, as confirmed by an RN Clinical Manager.
A facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions, did not have these needs documented in their care plan. Observations confirmed the presence of the catheter and precautions, but the necessary documentation was missing, as confirmed by the Nursing Home Administrator.
A facility failed to administer a diuretic to a resident as prescribed, despite significant weight gain indicating the need for the medication. The resident, who was cognitively intact and dependent on staff, had a care plan requiring Bumex for edema if there was a 2-pound weight increase. The resident's weight increased significantly over two days, but the medication was not given, as confirmed by the RN Clinical Manager.
The facility's QAPI committee failed to address recurring deficiencies in quality of care and sanitary food preparation and storage. Despite having plans of correction, the facility was cited again for these issues, indicating ineffective implementation of corrective measures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing and safe temperatures, as required by its own dietary policy. The policy specified that hot foods should be held at 155-170 degrees Fahrenheit at the tray line and served at 135-155 degrees Fahrenheit, while cold foods should be held at 31-41 degrees Fahrenheit and served at 33-50 degrees Fahrenheit. However, observations and temperature logs revealed that while the macaroni and cheese and stewed tomatoes were at appropriate temperatures in the kitchen (184°F and 168°F, respectively), by the time they were served to residents, their temperatures had dropped to 126.3°F and 130.8°F, which is below the facility's standard for hot food service. Multiple residents reported that their food was consistently cold and unappetizing, with one stating that the food would taste better if it was not always cold. Staff interviews confirmed that the food should have been hotter at the time of service. The deficiency was identified through review of facility policies, food production logs, direct observation of food service, and interviews with residents and staff.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP device for one resident who required non-invasive ventilation for sleep apnea. According to facility policy, an order specifying the use and settings of the CPAP device must be obtained from a practitioner. Documentation reviewed included an admission MDS assessment indicating the resident was cognitively intact and used non-invasive ventilation, a care plan referencing CPAP use per physician's order, and a nursing note confirming CPAP use at bedtime. However, there was no documented evidence of a physician's order for the CPAP, a fact confirmed by the Director of Nursing during an interview.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific care needs. For one resident, who had a diagnosis of dementia and required the use of a CPAP machine for obstructive sleep apnea, the care plan was initially resolved because the resident was not using the CPAP. However, after the resident's wife convinced him to use the CPAP again, the facility did not develop a new individualized care plan to address this change in the resident's care needs. This oversight was confirmed during an interview with the Nursing Home Administrator. Another resident, who was capable of understanding and self-administering medication, was found with cough drops in his room. Although a new physician's order was obtained to allow the resident to have cough drops at his bedside and self-administer them as needed, the facility did not develop an individualized care plan to document and support this ability. This lack of documentation was also confirmed by the Nursing Home Administrator during an interview. These deficiencies indicate a failure to adhere to the facility's policy on comprehensive care plans, which requires the development of person-centered plans with measurable objectives and timeframes.
Improper Food Thawing and Storage Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the proper thawing and storage of food, as observed during a survey. Specifically, 38 hot dogs were found thawing at room temperature on a counter, contrary to the policy that prohibits thawing food at room temperature. Additionally, several food items in the kitchen were not labeled, dated, or secured as required. These included a cup of sage in a plastic bag, a piping bag full of whipped cream, and three pounds of dry spaghetti, all of which were undated and, in some cases, unsecured. The Director of Dietary and the Executive Director of Culinary confirmed these practices were against the facility's policies.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for three residents. For Resident 11, the admission Minimum Data Set (MDS) assessment indicated the resident was understood, could understand others, and had a hip fracture diagnosis. The care plan required the resident to perform specific exercises twice daily. However, nurse aide documentation for July and August 2024 showed these exercises were marked as Not Applicable (NA) on several occasions. Similarly, Resident 26, who had a cerebral vascular accident diagnosis, was also on a Restorative Nurse Program for active range of motion. The documentation for June, July, and August 2024 showed numerous instances where the exercises were marked as NA or left blank. Resident 29, with a hip fracture diagnosis, had similar documentation issues in July and August 2024. An interview with the Nursing Home Administrator confirmed that staff should document whether the resident received, did not receive, or refused the exercises, rather than marking them as NA or leaving blanks.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a significant change in a resident's condition. The facility's policy, dated June 12, 2024, required that any changes in a resident's condition be communicated to the physician. Resident 11, who was cognitively intact and required substantial assistance for care, was on a diuretic medication for high blood pressure and had end-stage kidney disease. The resident's care plan required daily monitoring for the effectiveness of the diuretic, including daily weight checks. On July 31, 2024, the resident's weight was recorded at 204 pounds, and on August 1, 2024, the weight increased to 216.8 pounds, a gain of 12.8 pounds in one day. There was no documented evidence that the physician was notified of this significant weight gain. An interview with RN Clinical Manager 1 confirmed the lack of notification and acknowledged that it should have been addressed.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The policy, dated June 12, 2024, mandates that a baseline care plan should include essential healthcare information such as initial goals based on admission orders, physician's orders, dietary orders, therapy orders, and social services. This plan should be developed by the admitting or supervising nurse using information from the admission physical assessment, hospital transfer information, physician's orders, and discussions with the resident and their representative. However, for one resident, admitted on August 2, 2024, there was no documented evidence of a baseline care plan addressing the resident's needs related to an indwelling urinary catheter and Enhanced Barrier Precautions. The resident had specific physician's orders for the management of an indwelling urinary catheter, including daily care, periodic changes, and irrigation as needed for blockage. Additionally, the resident was placed on Enhanced Barrier Precautions to prevent the transmission of resistant organisms. Observations on August 5 and August 6, 2024, confirmed the presence of the catheter and the precautionary measures, but the baseline care plan did not reflect these critical care needs. The Nursing Home Administrator confirmed the absence of the necessary documentation for the baseline care plan, indicating a lapse in meeting the facility's policy requirements.
Failure to Administer Diuretic as Prescribed
Penalty
Summary
The facility failed to follow physician orders for a resident who was cognitively intact and dependent on staff for daily care needs. The resident was prescribed a diuretic, Bumex, to be administered as needed for edema if there was a 2-pound weight increase in one day. Despite a documented weight increase from 202 pounds to 204 pounds on one day, and a further increase to 216.8 pounds the following day, the resident did not receive the prescribed medication on either occasion. This oversight was confirmed by the RN Clinical Manager during an interview, indicating a failure to adhere to the physician's orders as documented in the resident's care plan and medication records.
Repeated Deficiencies in Quality of Care and Food Safety
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies in quality of care and sanitary food preparation and storage. During a survey ending in September 2023, the facility was cited for deficiencies in these areas and developed plans of correction that included conducting audits and reporting the results to the QAPI committee. However, the subsequent survey ending in August 2024 revealed that these deficiencies persisted, indicating that the QAPI committee did not effectively implement or maintain compliance with the corrective measures. Specifically, the facility was cited under F684 for failing to maintain compliance with quality of care regulations and under F812 for failing to ensure proper food preparation and storage. Despite having plans of correction in place, the facility's QAPI committee did not successfully address these issues, leading to repeated citations. The report highlights the facility's inability to correct these deficiencies, as evidenced by the repeated findings in the current survey.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Brookview Health Care Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Chambers Pointe Health Care Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Laurel Lakes Rehabilitation And Wellness Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Transitions Healthcare Shook Home | 2.1 mi | ★★★★★ | 8 | 0 |
| Chambersburg Skilled Nursing And Rehabilitation Ce | 3 mi | ★★★★★ | 15 | 0 |
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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.