Pennsylvania Department of Health
SHIPPENVILLE NURSING AND REHAB
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHIPPENVILLE NURSING AND REHAB
Inspection Results For:

There are 128 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SHIPPENVILLE NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on June 12, 2026, it was determined that Shippenville Nursing and Rehab was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement an intervention in a comprehensive person-centered care plan for a resident requiring suctioning (a procedure to remove unwanted fluid from a person) for one of 19 residents reviewed. (Residents R12).

Findings include:

Review of facility policy entitled, "Comprehensive Care Plan" dated 1/22/26, indicated "It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident ..." and "Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions ..."

Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and dysphagia (difficulty swallowing).

Review of Resident R12's physician's orders revealed an order for suction every four hours if cannot clear secretions.

Review of Resident R12's plan of care revealed a plan of care for respiratory impairment dated 2/6/23, with an intervention of, "may suction as directed for increased secretions. Change canister post suction."

Observations on 6/9/26, at 1:45 p.m. and again at 2:13 p.m. revealed a suction machine (a medical device designed to remove unwanted fluids from a patient's body) sitting on Resident R12's bedside stand. The collection container (a container where the unwanted fluids are collected) was three quarters of the way full of cloudy liquid which appeared to be secretions.

During an interview on 6/11/26, at 1:36 p.m. the Director of Nursing (DON) confirmed that Resident R12's respiratory impairment plan of care intervention to change canister post suction was not implemented. The DON also confirmed that care plan interventions should be implemented.

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 201.18 (b)(1) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/22/2026

F 0656
The suction canister for the suction machine in R12's room was replaced immediately with a new collection container (a container where unwanted fluids are collected) after identification.
All suction machines in the facility were inspected to ensure collection containers were present and clean.
Director of Nursing or designee will educate Licensed Nursing staff to follow the resident care plan for suctioning. Residents with respiratory care needs, including suctioning and changing the suction canister post suction per policy.
Audits will be completed by the Director of Nursing/or Designee on current residents that are currently being suctioned for secretions have a careplan and they are following the careplan including that suction canisters are changed post suctioning. Audits to be completed five days per week for two weeks, then weekly for two weeks, then monthly for two months.
All findings will be reviewed and tracked for patterns or trends at monthly quality assurance meetings.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of 19 residents reviewed (Resident R12).

Findings include:

Review of facility policy entitled "Suctioning the Upper Airway" dated 1/22/26, indicated "Empty and rinse collection container if necessary or as indicated by facility protocol."

Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that include multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and dysphagia (difficulty swallowing).

Review of Resident R12's physician's orders revealed an order for suction every four hours if cannot clear secretions.

Review of Resident R12's plan of care revealed a plan of care for respiratory impairment dated 2/6/23, with an intervention of, "may suction as directed for increased secretions. Change canister post suction."

Review of Resident R12's treatment record revealed the last time that Resident R12's suction machine (a medical device designed to remove unwanted fluids from a patient's body) was documented as used was 4/1/26.

Review of Resident R12's progress notes revealed the last note indicating that Resident R12's suction machine was used was dated 4/2/26.

Observations on 6/9/26, at 1:45 p.m. and again at 2:13 p.m. revealed a suction machine sitting on Resident R12's bedside stand. The collection container (a container where the unwanted fluids are collected) was three quarters of the way full of cloudy liquid which appeared to be secretions.

During an interview on 6/9/26, at 2:56 p.m. the Director of Nursing (DON) confirmed that Resident R12's suction machine collection container needed emptied. The DON also confirmed that the collection container should be emptied after every use.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/22/2026

F 0695
The suction canister for the suction machine in R12's room was replaced immediately with a new collection container (a container where unwanted fluids are collected) after discovery.
All suction machines in the facility were inspected to ensure collection containers were present and clean.
Director of Nursing or designee will educate Licensed Nursing staff that a resident who needs respiratory care, including tracheostomy care, and tracheal suctioning that the canister will be emptied per policy.
Audits will be completed by the Director of Nursing/or Designee on current residents with suctioning canisters and suctioning equipment in their rooms. Audits to be completed five days per week for two weeks, then weekly for two weeks, then monthly for two months.
All findings will be reviewed and tracked for patterns or trends at monthly quality assurance meetings.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R27).

Findings include:

Review of the facility policy "Hemodialysis," dated 1/22/26, indicated that the licensed nurse will communicate to the dialysis facility and attending physician medication administration or withholding of certain medications prior to the dialysis treatment and document such orders.

Review of Resident R27's clinical record revealed an admission date of 4/09/26, with diagnoses that included heart disease, heart failure, acquired absence of right &; left leg below the knee, type II diabetes ( the body does not make enough insulin to control blood sugar), and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, and Friday each week for dialysis treatments.

Review of physician's orders dated 4/09/26, indicated that Resident R27 was to have Calcium Carbonate Antacid (a medication used to treat indigestion and heartburn), 500 milligrams (mg) three times daily with meals and Novolog insulin per sliding scale blood sugar monitoring (a medication used to treat high blood sugar levels with blood sugar checks), before meals and at bedtime.

Review of May and June 2026, Medication Administration Records (MARs) revealed that Resident R27 did not receive the following medications as ordered with reason given as: "Not in Facility or Absent from Home"

Calcium Carbonate noon and Novolog insulin 11:30 a.m. doses on 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/18/26, 5/20/26, 5/25/26, 5/27/26, 6/1/26, 6/3/26, 6/5/26, 6/8/26, and 6/10/26.

There was no documentation until 6/11/26, that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R27 on dialysis days.

During an interview on 6/11/26, at 1:30 p.m. the Assistant Director of Nursing confirmed that the above medications for Resident R27 were not administered on dialysis days as ordered by the physician.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/22/2026

F 0698
The attending Physician was notified of a need to hold or alter the time of administration for medications for resident R27.
A medication review was conducted on other resident(s) on dialysis to ensure medication compliance and physician notification if necessary. Medications will be timed around dialysis times to ensure medications are not missed.
Director of Nursing or designee will educate Licensed Registered Nursing staff on the policy of communication with the dialysis facility and attending physician medication administration. Medications will be given around dialysis times to ensure mediations given per physician orders.
Audits will be completed by the Director of Nursing/or Designee on current residents on dialysis to ensure that medication orders are timed around dialysis times. Audits to be completed five days per week for two weeks, then weekly for two weeks, then monthly for two months.
All findings will be reviewed and tracked for patterns or trends at monthly quality assurance meetings.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (B wing medication cart) and one of two medication rooms reviewed (200/300 medication room) and failed to prevent the opportunity for potential unauthorized access of medications on one of three medication carts observed (C wing medication cart).

Findings include:

Review of facility policy entitled "Labeling of Medications and Biologicals" dated 1/22/26, indicated "Labels for multi-use vials must include:
The date the vial was initially opened or accessed ...All opened or accessed vials should be discarded within 28 days ..."

Review of facility policy entitled "Medication Storage" date 1/22/26, indicated "During a medication pass, medications must be under the direct observation of the person administering medications, or locked in the medication storage area/cart."

Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin.

Review of manufacturer's guidelines revealed that an open vial of Tubersol (an injectable solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening.

Observation of drug storage on 6/9/26, at 12:51 p.m. of the B-wing medication cart revealed an open pen of Lantus insulinlacking an open date. Observations in the 200/300 wing medication room revealed in the refrigerator an open vial of Tubersol with an open date of 4/1/26.

During an interview on 6/9/26, at the time of observations LPN Employee E2 confirmed that the open Lantus insulin pen lacked an open date, and staff were unable to determine the discard date and the vial of Tubersol had an open date of 4/1/26. He/she also confirmed that the Lantus insulin pen and vial of Tubersol should have been discarded.

Observations on 6/9/26, between 1:00 p.m. and 1:05 p.m. revealed LPN Employee E3 unlocked C wing medication cart parked in the hall against the wall with the drawers facing into the hallway. He/she then proceeded to walk down the hall and around the corner without securely locking C wing medication cart and was unable to view the medication cart.

During an interview on 6/9/26, at 1:06 p.m. LPN Employee E3 confirmed that he/she left the C wing medication cart unlocked which was out of their view. He/she also confirmed that the medication cart should be locked when out of view.

28. Pa. Code 201.18(b)(1) Management

28. Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 07/22/2026

F 0761
The medication cart was immediately secured by the Licensed Practical Nurse E3 upon identification of the cart was unlocked.
The vial of Tubersol and Lantus pen were discarded upon identification they were not properly labeled. New medications were issued and labeled according to facility policy.
All medication carts and medication rooms were inspected to ensure all medications were labeled properly.
Director of Nursing or designee will educated Licensed Nursing staff on the facility policy and procedures for Labeling of Medications and Biologicals and Medication Storage policy. Nursing staff will be educated to keep the medication cart and medication rooms always locked or under direct supervision of the nurse.
An audit of 1 medication cart and med room will be completed by the Director of Nursing/or Designee to ensure Insulin and Tubersol are labeled and dated. The medication cart and medication rooms will be monitored to ensure they are locked if not under direct supervision of the staff. Audits to be completed five days per week for two weeks, then weekly for two weeks, then monthly for two months. Audits to be completed on various shifts.
All findings will be reviewed and tracked for patterns or trends at monthly quality assurance meetings.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination during completion of a wound dressing change for one of 19 residents reviewed (Resident R29).

Findings include:

Review of facility policy entitled "Wound Care" dated 1/22/26, indicated "Steps in the procedure ... Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves ..."

Observations on 6/11/26, at 11:01 a.m. revealed Registered Nurse (RN) Employee E1 completing a wound dressing change in Resident R29's room. During the dressing change RN Employee E1 removed a soiled dressing from Resident R29's coccyx. He/she then proceeded to clean the wound without washing his/her hands and changing his/her gloves after removing the soiled dressing.

During an interview on 6/11/26, at 11:15 RN Employee E1 confirmed that he/she did not wash their hands or change gloves after removing the soiled dressing. RN Employee E1 also confirmed that he/she should have washed their hands and applied clean gloves before cleaning the wound.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/22/2026

F 0880
Registered Nurse (E1) was re-educated on facility policy for "Wound Care" and "Hand Hygiene." R29 did not suffer any ill effects due to nurse not changing her gloves during dressing change. Current residents with wounds were reviewed to ensure that no one has had any ill effects related to infection control.
Director of Nursing or designee will educate Licensed Nursing Staff on the facility policy for Wound Care proper procedures to prevent the possible spread of infection.
Audits will be completed by the Director of Nursing/or Designee on wound care treatments to ensure compliance. Dressing change audits on 1 resident will be completed five days per week for two weeks, then weekly for two weeks, then monthly for two months. Audits to be completed on various shifts.
All findings will be reviewed and tracked for patterns or trends at monthly quality assurance meetings.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement