Cycle 1
Health 2025-04-30 · Fire 2025-04-30
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Chambersburg, PA
Chambersburg Skilled Nursing And Rehabilitation Ce
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1070 Stouffer Avenue, Chambersburg, PA
(717) 263-0436
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
175
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,598
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.62
Baseline 16.67% · Performance 19.29% · Measure score 4.62 · Achievement 4.62 · Improvement 0
Healthcare-associated infections
0
Baseline 5.94% · Performance 10.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.33
Baseline 61.88% · Performance 54.17% · Measure score 2.33 · Achievement 2.33 · Improvement 1.58
Adjusted total nurse staffing
0.98
Baseline 3.20 hours · Performance 3.36 hours · Measure score 0.98 · Achievement 0.98 · Improvement 0.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 194 · Observed rate 14.95% · Lower 95% interval 9.84% |
| Discharge to community | 47.39% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 198 · Observed rate 36.36% · Lower 95% interval 40.57% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 228 · Denominator 230 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 230 |
| Discharge self-care score | 18.31% |
53.69%
35.4 pts worse
|
Numerator 26 · Denominator 142 |
| Discharge mobility score | 19.72% |
50.94%
31.2 pts worse
|
Numerator 28 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 3.48% |
2.29%
1.2 pts worse
|
Numerator 8 · Denominator 230 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 10.4% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 15.87% · Lower 95% interval 6.87% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 4 · Denominator 180 |
| Staff flu vaccination coverage | 32.37% |
42%
9.6 pts worse
|
Numerator 78 · Denominator 241 |
| Discharge function score | 24.65% |
56.45%
31.8 pts worse
|
Numerator 35 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 126 · Denominator 126 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.55% |
25.2%
8.6 pts worse
|
Numerator 23 · Denominator 139 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
86.9%
5.5 pts better
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 90.7% · Q3 93.0% · Q4 92.5% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
93.5%
1.2 pts better
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.7% · Q3 3.8% · Q4 3.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.3% |
6.5%
53.8 pts worse
|
11.4%
48.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 67.3% · Q3 65.4% · Q4 65.2% · 4Q avg 60.3% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
6.5%
2.9 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 10.6% · Q3 12.2% · Q4 6.7% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
19.9%
6.2 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 13.8% · Q3 13.7% · Q4 13.8% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.7% |
18.7%
7 pts worse
|
16.7%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 25.2% · Q3 26.9% · Q4 24.8% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.9% |
19.6%
14.3 pts worse
|
16.3%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 38.8% · Q3 34.5% · Q4 35.7% · 4Q avg 33.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.2% |
18.3%
14.9 pts worse
|
14.9%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 32.2% · Q3 33.8% · Q4 36.1% · 4Q avg 33.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.1% · Q3 3.3% · Q4 3.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
26.4%
3.5 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 29.4% · Q3 32.0% · Q4 25.9% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.3%
2.6 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.2% · Q3 2.3% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.8% |
68.9%
1.1 pts worse
|
81.7%
13.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 54.3% · Q3 64.1% · Q4 80.4% · 4Q avg 67.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
9.8%
0.1 pts worse
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.1% · Q3 1.2% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.2% |
68.7%
15.5 pts worse
|
79.7%
26.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
23.1%
6.3 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 34.2% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
19 health deficiencies
Top issue: Resident Rights (9 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-04-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-04-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-06
C · Minimal harm
2025-04-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-06
C · Minimal harm
2025-04-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
C · Minimal harm
2025-04-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-06
C · Minimal harm
2025-04-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-06
E · Potential for more than minimal harm
2024-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-28
E · Potential for more than minimal harm
2023-06-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-27
C · Minimal harm
2023-06-15
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
E · Potential for more than minimal harm
2024-05-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-02-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-22
D · Potential for more than minimal harm
2023-09-27
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-06-15
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-04-18
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-04-11
Penalties and ownership
What sits behind the stars
Ownership
Genesis Pm Pa Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Anjum, Rashid
Operational/Managerial Control · Individual
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Munday, Breanne
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Transitions Healthcare Shook Home
Chambersburg, PA
1-star overall rating with 2-star inspections with $205,694 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Laurel Lakes Rehabilitation And Wellness Center
Chambersburg, PA
1-star overall rating with 1-star inspections with $224,602 in total fines with 16 recent health deficiencies
#3
Chambers Pointe Health Care Center
Chambersburg, PA
3-star overall rating with 2-star inspections with abuse icon flag with $30,863 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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