Pennsylvania Department of Health
CHAMBERSBURG SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHAMBERSBURG SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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CHAMBERSBURG SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an abbreviated complaint survey completed on February 20, 2024, at Chambersburg Skilled Nursing and Rehabilitation identified that the facility was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based 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).

Findings include:

Observations made on February 20, 2024, at the noted times and locations revealed the following:

- 9:03 AM in the dining room outside of the main kitchen (corner of Station 1 and 2) - the air vent was noted to be covered in a black, speckled substance.
- 9:32 AM in Resident 1's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit.
- 9:37 AM in Resident 2's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit.
- 9:41 AM in the Station 3 lounge - presence of a black substance on the grates of the wall heating/cooling unit.
- 9:42 AM in Resident 3's room (Station 3) - the wall above the heating/cooling unit appeared to be crumbling with debris noted in and on the heating/cooling unit.
- 9:44 AM in Resident 4's room (Station 3) - the plastic grate was missing from the heating/cooling unit. Food and other debris were noted in the unit.
- 9:45 AM in Resident 5's room (Station 3) - dried spill/splash spots on the front grill panel of the heating/cooling unit. Food and other debris were observed inside of the unit. A black substance was present on the air vent grates.
- 9:47 AM in Resident 6's room (Station 3) - an accumulation of debris was noted in the heating/cooling unit. Additionally, the air vent grates were noted to be soiled.
- 9:57 AM in Resident 7's room (Station 2) - a black substance was present in the corner near the heating unit vent.
- 9:59 AM in the Chapel Dining Room (located at the corner of Station 1 and 2) - black film on the wall around the vent/heating unit.
- 10:01 AM in Resident 8's room (Station 1) - a black substance was present along the seam of the wallpaper in the corner near the heating unit.

During a tour with the Nursing Home Administrator and Director of Nursing (DON) on February 20, 2024, at 10:30 AM, they acknowledged the aforementioned concerns.

During a later interview with the DON on February 20, 2024, at 1:33 PM, she revealed that work orders had been submitted to have required repairs completed, and staff were in the process of going room to room to audit for cleanliness.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 03/22/2024

1. Resident rooms/dining rooms identified during the visit have all been cleaned to ensure a safe, clean, comfortable, homelike environment.

2. The NHA/designee will review 5 random resident rooms and dining rooms to ensure air vents and heat/cooling units are clean of debris and black substance.

3. To ensure the deficient practice does not re-occur, NHA will educate maintenance staff/environmental services on proper cleaning practices for heating/cooling units.

4. The NHA/designee will review 5 random rooms and dining rooms a week x4 weeks to ensure the facility is meeting the new cleaning policy.

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