Cycle 1
Health 2025-04-03 · Fire 2025-04-03
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Chambersburg, PA
Transitions Healthcare Shook Home
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
55 South Second Street, Chambersburg, PA
(717) 264-6815
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Transitions Healthcare
Operator or chain grouping
Approved since
1993-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 3 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
0.85
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.67
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
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,143
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.38% · Performance 21.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.94
Baseline 6.79% · Performance 6.06% · Measure score 5.94 · Achievement 5.94 · Improvement 3.56
Total nurse turnover
2.72
Baseline 59.61% · Performance 52.54% · Measure score 2.72 · Achievement 2.72 · Improvement 1.53
Adjusted total nurse staffing
2.41
Baseline 5.62 hours · Performance 3.76 hours · Measure score 2.41 · Achievement 2.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.74% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 151 · Observed rate 11.26% · Lower 95% interval 7.8% |
| Discharge to community | 44.37% |
50.57%
6.2 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 37.31% · Lower 95% interval 37.63% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 142 · Denominator 142 |
| Falls with major injury | 0.7% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 142 |
| Discharge self-care score | 38% |
53.69%
15.7 pts worse
|
Numerator 38 · Denominator 100 |
| Discharge mobility score | 47% |
50.94%
3.9 pts worse
|
Numerator 47 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 4.93% |
2.29%
2.6 pts worse
|
Numerator 7 · Denominator 142 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 4.31% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 139 |
| Staff flu vaccination coverage | 51.32% |
42%
9.3 pts better
|
Numerator 97 · Denominator 189 |
| Discharge function score | 49% |
56.45%
7.5 pts worse
|
Numerator 49 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 75 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 17.81% |
25.2%
7.4 pts worse
|
Numerator 13 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.1 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.2
0.6 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.3 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.6% |
86.9%
1.3 pts worse
|
93.4%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 82.2% · Q3 80.4% · Q4 84.4% · 4Q avg 85.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
93.5%
4.5 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.2%
2.3 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.2% · Q3 6.5% · Q4 6.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 13.0% |
6.5%
6.5 pts worse
|
5.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 17.9% · Q3 18.6% · Q4 4.9% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
19.9%
2.1 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.0% · Q3 22.2% · Q4 28.6% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.0% |
18.7%
12.3 pts worse
|
16.7%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 31.4% · Q3 27.5% · Q4 33.3% · 4Q avg 31.0% · 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 | 24.4% |
19.6%
4.8 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.4% |
18.3%
10.1 pts worse
|
14.9%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 33.3% · Q3 31.8% · Q4 31.0% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
26.4%
4.5 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 26.7% · Q3 26.0% · Q4 38.4% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
5.3%
1.9 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 7.1% · Q3 5.0% · Q4 4.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
68.9%
16.8 pts better
|
81.7%
4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 88.3% · Q3 79.8% · Q4 84.4% · 4Q avg 85.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.8%
2.2 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
68.7%
18.6 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
23.1%
1.8 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 25.7% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-04-03
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 2025-06-14
E · Potential for more than minimal harm
2025-04-03
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-06-14
E · Potential for more than minimal harm
2024-05-30
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 2024-05-16
E · Potential for more than minimal harm
2024-05-30
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-16
C · Minimal harm
2024-05-30
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-05-16
Inspection history
Recent health citations
G · Actual harm
2025-07-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-04-03
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-04-03
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 2025-05-13
E · Potential for more than minimal harm
2025-04-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-04-03
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 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
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 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
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 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-09
K · Immediate jeopardy
2024-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-09
J · Immediate jeopardy
2024-06-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-05-30
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 2024-07-09
D · Potential for more than minimal harm
2024-05-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-30
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 2024-07-09
E · Potential for more than minimal harm
2023-06-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-06-22
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 2023-08-20
D · Potential for more than minimal harm
2023-06-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-22
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 2023-08-20
D · Potential for more than minimal harm
2023-06-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-22
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 2023-08-20
B · Minimal harm
2023-06-22
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 2023-08-20
B · Minimal harm
2023-06-22
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 2023-08-20
Penalties and ownership
What sits behind the stars
$205,694
2024-05-30
Fine
Fine · fine $205,694
Fine
Ownership
Feldman, Marc
5% Or Greater Direct Ownership Interest · Individual
Maurano, Matthew
5% Or Greater Direct Ownership Interest · Individual
Williams, Kevin
5% Or Greater Direct Ownership Interest · Individual
Decort, Ryan
Operational/Managerial Control · Individual
Feldman, Marc
Operational/Managerial Control · Individual
Flasher, Douglas
Operational/Managerial Control · Individual
Maurano, Matthew
Operational/Managerial Control · Individual
Members First Federal Credit Unions
5% Or Greater Mortgage Interest · Organization
Transitions Healthcare LLC
Operational/Managerial Control · Organization
Williams, Kevin
Operational/Managerial Control · Individual
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#2
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Chambersburg, PA
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Laurel Lakes Rehabilitation And Wellness Center
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1-star overall rating with 1-star inspections with $224,602 in total fines with 16 recent health deficiencies
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