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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER
Inspection Results For:

There are  40 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.
SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 21, 2025, at Shippensburg Rehabilitation and Health Care Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #035002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Shippensburg Rehabilitation and Health Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE 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 State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation, observation and interview on May 21, 2025, between 9:00 AM and 10:15 AM, revealed the facility's portable life safety drawings lacked room capacities, room labeling, smoke walls, fire walls and hazardous areas.

Interview with the Administrator and Environmental Service Director on May 21, 2025, at 1:30 PM, confirmed the portable life safety drawings of the facility lacked the information required for the survey.




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

The Environmental Services Director has labeled new life safety drawings to include room labeling, room capacity, hazardous area smoke walls and fire walls, based on original life safety drawings. These drawings will be reviewed semiannually or whenever a floor plan is changed by a governing body. This semi-annual audit was added to the Maintenance TELS task list and the results of these audits will be presented in the Quality Assurance Performance Improvement Meeting.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on one of three stairtowers within the component

Findings include:

1. Observation on May 21, 2025, at 11:20 AM, revealed 3rd floor Stairtower Door, North Hall, gap margins were 3/16 inch at the top and latch side of the door.

Interview with the Administrator and Environmental Service Director on May 21, 2025, at 1:30 PM, confirmed the door exceeded the allowed gap margin.



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

The Environmental Services Director has requested a quote from a contractor to install new metal door. Due to lead time involved in the door production, the facility has requested a time limited waiver from the Division of Safety Inspection until November 21, 2025. The Environmental Services Director has purchased GAP 90 to be installed until such time, replacement door can be installed. Environmental Service Director will audit stair tower doors for gap margin on a weekly basis; the results of these audits will be presented in the Quality Assurance Performance Improvement Meeting for three months until compliance is maintained.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of extraneous weight, affecting two of three floors within the component.

Findings include:

1. Observation on May 21, 2025, between 11:00 AM and 11:50 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 11:00 AM, 3rd floor, above ceiling, by resident room 333, various wires;
b. 11:05 AM, 3rd floor, above ceiling, Common Area, above elevator doors, multiple wires;
c. 11:30 AM, 2nd floor, West Hall, above ceiling, by Resident Room 233, multiple wires;
d. 11:35 AM, 2nd floor, East Hall, above ceiling, by East Stairtower, various wires;
e. 11:40 AM, 2nd floor, above ceiling, Common Area, above smoke doors, multiple wires and flex conduit;
f. 11:50 AM, 2nd floor, above ceiling, Common Area, above elevator doors, multiple wires.

Interview with the Administrator and Environmental Service Director on May 21, 2025, at 1:30 PM, confirmed various items laying across sprinkler pipes.


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

The Environmental Services Director inspected above the ceiling on 3rd floor and 2nd floor and removed any items being supported by the sprinkler piping system. The Environmental Service Director will educate all maintenance staff and any outside contractors to ensure items are not to be supported by sprinkler piping system. The Environmental Service Director or designee will QA above ceilings monthly for three months as well as after any contractual work is completed, then quarterly thereafter. All findings will be reported the Quality Assurance Performance Improvement Meeting for three months until compliance is maintained.

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