Pennsylvania Department of Health
SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER
Inspection Results For:

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SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER - 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 a complaint survey completed on May 16, 2025, it was determined that Shippensburg Rehabilitation and Health Care Center did not meet the 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Plan of Correction - To be completed: 06/25/2025

Facility cannot retroactivity correct areas identified regarding food storage and facility temperatures.

Facility immediately disposed of and replaced the brown sugar and white sugar and ensured these were dated according to policy. All non-dated/unwrapped vegetables were immediately disposed of. All items in the freezer were checked to ensure appropriate labels/dates were in place as well as items covered/wrapped/sealed appropriately. Hot dog buns in dry storage were disposed of. All items in dry storage were immediately checked to ensure dating is occurring in accordance with facility policy.

2nd and 3rd floor nourishment rooms have been inspected to ensure all items are labeled and dated in accordance with facility policy.

Facility food storage/labeling/dating policies have been reviewed to ensure they meet the regulation. New temperature logs have been implemented in the main kitchen as well as 2nd and 3rd floor nourishment rooms.

All dietary staff will be in serviced on the facility storage/temperature policies and the new logs to ensure compliance. Nursing staff and managers will be in serviced on dating/labeling & equipment temperatures for 2nd and 3rd floor nourishment rooms.

Food Service Manager or designee will audit temperature logs/labeling/dating weekly for the next 3 months and monthly thereafter.

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

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 week. Give half a tab to equal 20 mg," with a start date of May 16, 2024.

Review of Resident 76's care plan revealed a focus area "[Resident 76] has cardiac disease," with an intervention for "obtain weights as indicated and report significant changes," initiated May 1, 2023.

Review of Resident 76's clinical record revealed she had a weight gain of 2.8 lbs from August 28 to 29, 2024. Further review of her clinical record failed to reveal doctor notification, and review of her August MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) failed to reveal the PRN Lasix order was administered.

Review of Resident 76's clinical record revealed she had a weight gain of 4.6 lbs from November 2 to 3, 2024; further review of her clinical record failed to reveal doctor notification, and review of her November MAR failed to reveal the PRN Lasix order was administered.

Interview with the Director of Nursing on May 15, 2025, at 10:37 AM, revealed the doctor was not notified of the weight gain on the aforementioned dates and the PRN Lasix was not given. She further revealed her expectation of doctor notification and PRN Lasix administration per physician order.

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

Plan of Correction - To be completed: 06/25/2025

Facility cannot retroactively correct clinical records to accurately reflect resident 76 status as it relates to the daily weight and MD notification order.

Primary care physician was notified about the incident on August 28-29, 2024 and November 2-3, 2024 where there was a documented weight gain but no notification has been made nor a PRN Lasix has been administered per order. There was no adverse effect on the resident. Physician has no further orders; current protocol reviewed and will still be in effect.

Facility reviewed all residents with daily weight orders and a tracking system was created to ensure that timely notification and order implementation is being done.

Facility conducted an in-service with license staff to follow the tracking system.

RN Supervisor or designee will monitor all daily weights, ensure that physician notification is done with weights that are outside parameter and orders obtained. This will be discussed daily during clinicals. Audit will be done weekly x 4 weeks; monthly x 3 months to ensure compliance is achieved. Findings will be discussed with DON or designee and reported to the Quality Assurance Performance Improvement Committee.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

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

Plan of Correction - To be completed: 06/25/2025

1.Facility is unable to correct the fact that a Quality Assurance Performance Improvement committee did not meet at least quarterly to coordinate and evaluate activities under the QAPI program.
2. Quality Assurance Performance Improvement meeting was held on 5/23/2025 where the Quality Assurance Performance Improvement team was educated on the need to have said meetings quarterly. The Quality Assurance Performance Improvement team decided to set meetings every month to achieve compliance.

3. Assistant Director of Nursing or designee will review the Quality Assurance Performance Improvement meetings to ensure quarterly meetings are held in accordance with the regulations for the next 4 quarters.

4. Findings of the audit will be presented to the Quality Assurance Performance Improvement meeting to ensure continued compliance.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that three of nine required multidisciplinary members were present at the Infection Control Committee meetings (physical plant personnel, laboratory personnel, and pharmacy staff).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members includes Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility provided attendee signature page for their quarterly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting held on August 30, 2024, revealed physical plant personnel, laboratory personnel, and pharmacy staff had not attended.

Review of the facility provided attendee signature page for their quarterly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting held on December 6, 2024, revealed physical plant personnel, laboratory personnel, and pharmacy staff had not attended.

Review of the facility provided attendee signature page for their quarterly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting held on April 4, 2025, revealed physical plant personnel, laboratory personnel, and pharmacy staff had not attended.

During a staff interview with the Nursing Home Administrator on May 14, 2025, at 10:32 AM, he confirmed that not all required members had attended the facility's Infection Control Meetings and that he would expect all required members be in attendance.

Plan of Correction - To be completed: 06/25/2025

1.Facility is unable to correct the fact that 3 of the 9 required multidisciplinary members were not present at the Infection Control Committee Meeting. (Physical Plant personal, Laboratory personal, Pharmacy staff.

2. Infection Control meeting was held on 5/23/2025 where the Infection control team was educated on the need to have said required members present at the meetings. Team decided to set meetings every month to achieve compliance.

3. Assistant Director of Nursing or designee will review the attendance of the Infection Control meeting for the next 4 quarters to ensure required attendees are present.

4. Findings of the audit will be presented to the Quality Assurance Performance Improvement meeting to ensure continued compliance.

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