Chambersburg Skilled Nursing and Rehabilitation Ce

In the surveyor’s words

From the most serious findings on record at Chambersburg Skilled Nursing and Rehabilitation Ce, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 18, 2026

  Based 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.Findings include: Facility policy, titled Abuse Prohibition, revised November 15, 2025, read in part, 5. […]

• Actual harm, isolatedF600Dec 28, 2022

  Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that residents were free from neglect, in regards to following the plan of care, which resulted in actual harm as evidenced by a non-operable nondisplaced fracture of the atlas (first bone in neck) and closed odontoid fracture (second bone in neck), for one of three residents reviewed (Resident 1). […]

• Actual harm, isolatedF689Dec 28, 2022

  Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a non-operable nondisplaced fracture of the atlas (first bone in neck) and closed odontoid fracture (second bone in neck), for one of three residents reviewed (Resident 1). Findings include: A review of the facility's policy, titled Bed Positioning, obtained from 2022 Lippincott nursing procedures manual, the policy states to verify transfer assist needed per Kardex. […]

• No harm, potential for more than minimal, patternF658May 7, 2026

  Based 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).Findings include: Review of the facility policy, titled Medication Administration - General Guidelines last reviewed March 2026, stated, The client (resident) is always observed after administration to ensure that the dose was completely ingested. Review of facility policy, titled Procedure: Wound Dressings: Aseptic, last reviewed March 2026, read, in part, Document: Treatment on Treatment Administration Record (TAR). […]

• No harm, potential for more than minimal, patternF802May 7, 2026

  Based 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). Findings include: Review of the Facility Assessment (a comprehensive evaluation that determines the resources and capabilities needed to provide quality care to residents, ensuring compliance with regulatory standards), read, in part, Nutrition/Hydration: Dining: Discuss dining to ensure systems are in place to provide an enjoyable, dignified, and sanitary dining experience.Review of Resident 7's clinical record revealed diagnoses that included osteoarthritis (a condition where… […]