Shippensburg Rehabilitation And Health Care Center

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents reviewed (Residents 3 and 35).Findings Include: Facility policy, titled Trauma Informed Care, reviewed February 2026, read, in part, Policy: .Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing.Procedure: . 7. When a resident has experienced a traumatic event, the SW (social worder) will interview resident/resident representative regarding: Potential/actual triggers that may cause re-traumatization of the resident. Review of Resident 3's clinical record revealed diagnoses that included Post-Traumatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review 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 24 residents reviewed (Residents 6 and 35).Findings Include: Review of Resident 6's clinical record revealed diagnoses that included gastro esophageal reflux disease ([GERD] when stomach acid flows back up into the esophagus) and major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life). Review of Resident 6's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated March 25, 2026, indicated in Section N0415 High-Risk Drug Classes: Use and Indication, section E, indicated that Resident 6 had taken an anticoagulant during the look-back period. Review of Resident 6's clinical record failed to reveal any evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 24 residents reviewed (Residents 3, 11, and 28).Findings include: Review of facility policy, titled Care Plans-Comprehensive, with a last review date of February 2026, revealed, in part, The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition changes. Review of Resident 3's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of two residents reviewed (Residents 1 and 2). Findings include:Review of facility policy, titled Administering Medications, read, in part, Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame.8. The following information must be checked/verified for each resident prior to administering medications.b. Vital signs, if necessary.Review of Resident 1's clinical record revealed diagnoses that included Parkinson's disease (neurodegenerative disorder causing motor issues) and hypertension (high blood pressure).Review of Resident 1's physician orders revealed the following orders:Lisinopril (antihypertension medication) 2.5 milligrams (mg) one tablet in the morning for hypertension. Give if systolic blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, each resident received written notice, including the reason for the change, before the resident's room was changed for one of three residents reviewed (Residents 1). Findings include: Review of facility policy, titled Change of Room or Roommate, stated, 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as resident and their representatives, will be given advance notice of such a change as in possible. Parties can be notified either in person, via telephone or in writing.Review of Resident 1's clinical revealed diagnoses that included Parkinson's disease (neurodegenerative disorder causing motor issues) and dementia (progressive decline in memory, thinking, and behavior).Review of Resident 1's clinical record progress notes revealed a note dated January 6, 2026, at 11:01 AM, that indicated Employee 1 (Social Services Coordinator) informed Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observations, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas. Findings include: Review of facility policy, titled Food Storage last reviewed April 4, 2025, read, in part, Food will be purchased in quantities that can be stored properly and arranged in food groups for organized storage and inventory. All stock must be rotated with each new order received. Food should be dated as it is placed on the shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. Scoops should be kept covered in a protected area near the containers rather than in the containers. Thermometers should be checked at least two times each day. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. All foods should be covered, labeled and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for one of 21 residents reviewed (Resident 76). Findings include: Review of Resident 76's clinical record revealed diagnoses that included congestive heart failure (CHF- a condition characterized by a gradual loss of kidney function), atrial fibrillation (irregular heart rhythm), and hyperlipidemia (high blood cholesterol). Review of Resident 76's physician orders revealed an order for Daily weights. Notify doctor and give PRN (as needed) Lasix (diuretic- a medication that increases urine production and excretion of water) if weight gain > or = 2 lbs (pounds) in 1 day or 5lbs in a week, in the morning related to CHF, with a start date of September 22, 2023. Further review of Resident 76's physician orders revealed an order for Lasix Oral Tablet 40 MG, Give 0.5 tablet by mouth every 24 hours as needed for Weight gain, give for weight gain of 2 pounds in 1 day or 5 pounds in 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility document review and staff interview, it was determined that the facility's Quality Assurance Committee failed to meet on a quarterly basis for one quarter of four reviewed (first quarter of 2025). Findings include: Review of the facility's Quality Assurance Committee meeting signatory pages revealed that the facility's Quality Assurance Committee did not meet during the first quarter of year 2025 (January, February, and March). During a staff interview on May 15, 2025, at approximately 10:20 AM, Nursing Home Administrator confirmed that it was the facility's expectation that the Quality Assurance Committee meets at least once every quarter. 28 Pa code 201.18(b)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident 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 26 residents reviewed (Resident 9 and 26). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included obstructive sleep apnea (characterized by episodes of a complete [apnea] or partial collapse [hypopnea] of the upper airway with an associated decrease in oxygen saturation or arousal from sleep) and seizures (a burst of uncontrolled electrical activity between brain cells). Review of Resident 9's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated April 4, 2024, revealed in Section O0110. Special Treatments, Procedures, and Programs, G1. Non-invasive Mechanical Ventilator, that Resident 9 did not use a non-invasive mechanical ventilator during the previous 14 days. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 8). Findings include: Based on facility policy, titled Care Plan Policy, not dated, read, in part, Changes in the resident's condition must be reported to the MDS Assessment Coordinator (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) so that a review of the resident assessment and care plan should be made. Review of Resident 8's clinical record revealed diagnoses that included difficulty in walking and muscle weakness. Review of Resident 8's clinical record on June 11, 2024, at 9:28 AM, revealed she was discharged to the hospital on May 1, 2024, and returned to the facility on May 2, 2024. Observation of Resident 8 on June 11, 2024, at 09:49 AM, revealed her face was heavily bruised. Interview with Resident 8 on June 11, 2024, at 09:52 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 23 residents reviewed (Resident 100). Findings include: Review of Resident 100's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and presence of cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). Observation of Resident 100 on June 10, 2024, at 10:19 AM, revealed a pacemaker monitoring device (a device used by a cardiologist [heart specialist] to perform an electronic periodic pacemaker function test) that was noted to be plugged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and Resident Responsible Party and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents reviewed (Resident 91). Findings include: Review of facility policy, titled Policy and Procedure Trauma Informed Care, last revised April 15, 2024, read, in part: Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD [Post Traumatic Stress Disorder] will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Procedure . 7. When a Resident has experienced a traumatic event, The Social worker will interview the resident/resident representative regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel file review, facility policy review, job descriptions, and staff interviews, it was determined that the facility failed to implement written policies and procedures by not completing criminal background checks prior to hire for five of five personnel records reviewed (Employees 4, 5, 6, 7, and 8); and verifying professional licensure for three of three personnel records reviewed. Findings include: Review of the facility's current policy, titled Abuse Prevention & Reporting Policy revealed in the section, titled Policy Statement that the facility will comply with all Federal, State, and local regulations regarding the prevention, recognition, and reporting of abuse, neglect, and/or misappropriation of property. Review of section of the policy, titled Procedure indicated 1) Individuals functioning in an 'employee' status .will have a State Criminal Background Check completed at the time of employment; and 2) [in part] Persons hired as part of the professional staff .are required to have and maintain a valid current license or certification .and must submit a copy of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.