Chambersburg Skilled Nursing and Rehabilitation Ce

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to ensure residents were free from resident to resident abuse by a resident with a history of abuse (Resident 1). This resulted in actual physical harm by Resident 1, as evidenced by multiple skin tears and bruising of a resident (Resident 2). Effective interventions were not put into place to protect residents from physical and psychosocial abuse. This failure resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice for three of 38 residents reviewed (Residents 2, 23, and 163).

Inspectors wroteBased on review of the facility assessment, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a member of the Food and Nutrition Services staff participates on the interdisciplinary team as required for two of 38 residents reviewed (Residents 7 and 105).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to monitor freezer temperatures in four of four (Station 1, Station 2, Station 3, and Arcadia) nourishment pantries; failed to maintain clean refrigerators in four nourishment pantries (Station 1, Station 2, Station 3, and Arcadia); and failed to discard food items brought in for residents in one of four nourishment areas (Station 3).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for three of 38 residents reviewed (Residents 7, 15, and 18).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and to promote healing and prevent infection of a pressure ulcer for two of five residents reviewed for pressure ulcers (Residents 17 and 23). Findings Include: Review of facility policy, titled Procedure: Wound Dressings: Aseptic, last reviewed March 2026, read, in part, Document: Treatment on Treatment Administration Record (TAR). [...]

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to maintain a safe and sanitary environment that supports infection prevention and control during the medication administration for one of five residents observed (Resident 186).

Inspectors wroteBased on facility policy and procedure review, clinical record reviews, facility provided documentation reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of two residents reviewed (Resident 4).

Inspectors wroteBased on staff interviews, clinical record review, and select guidelines, it was determined that the facility failed to discontinue/alter medication dosage and/or to ensure the risks were known with refusal of monitoring to prevent hyperkalemia (elevated potassium level) for one of three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, observations, product label, and staff interviews, it was determined that 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.

Inspectors wroteBased on facility policy review, observations, review of select facility documentation, and resident and staff interviews, it was determined that the facility failed to maintain a clean, comfortable and home-like environment in one of 35 resident rooms reviewed.

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 35 residents reviewed (Residents 48 and 82).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of 38 residents reviewed (Resident 84).

Inspectors wroteBased on facility policy review, record review, and staff and resident interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for two of 4 residents reviewed for nutritional status (Residents 60 and 72).

Inspectors wroteBased on clinical record review as well as resident and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 36 residents reviewed (Residents 12, 52 and 80).

Inspectors wroteBased on policy review, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for three of 6 residents reviewed for pressure ulcers (Residents 11, 72 and 110). Findings Include: Review of policy, Wound Dressings: Aseptic, revised December 1, 2021, revealed that following application of a wound treatment, staff should document the treatment on the Treatment Administration Record (TAR- form used to document physician orders as well as when and how treatments are administered to a resident). [...]

Inspectors wroteBased on policy review, observation, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 32 residents reviewed (Resident 36).

Inspectors wroteBased on review of the review of clinical records, and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 32 residents reviewed (Resident 107).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior for three of four nursing units observed (Stations 1, 2, and 3).

Inspectors wroteBased on facility policy and interview, it was determined the facility failed to ensure individuality and respect of resident personal property for one of three residents reviewed (Resident R2).