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Citation history
Health deficiencies cited at Shippensburg Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Two residents with PTSD and major depressive disorder did not receive adequate trauma-informed care when the facility failed to identify and document their specific trauma-related triggers and did not ensure follow-up mental health services. In both cases, trauma-informed care assessments showed that the residents had experienced trauma and reported distressing memories, dreams, and other PTSD-related symptoms, and their care plans broadly referenced potential behaviors related to past trauma with an intervention to identify triggers. However, the plans did not include resident-specific traumas or triggers, and one resident did not receive a psychiatry consult despite a physician order and consent, while the other had no documented follow-up related to PTSD, as confirmed by the NHA and DON.
The facility failed to ensure accurate MDS assessments for two residents. For one resident with GERD and major depressive disorder, the quarterly MDS incorrectly indicated anticoagulant use despite no documentation of anticoagulant medications in the clinical record. For another resident with documented PTSD and major depressive disorder, both the admission and quarterly MDS omitted the PTSD diagnosis, even though it was present in the clinical record. Staff interviews confirmed that these MDS assessments were coded in error and did not accurately reflect the residents’ clinical status.
Surveyors found that the facility did not consistently review and revise comprehensive, person-centered care plans as residents’ conditions and information changed. One resident with PTSD, anxiety, and depression had a known trigger of being scared by noises reported by a representative, but this trigger was never added to the behavior care plan. Another resident with dementia lacked a dedicated care plan addressing dementia, with the diagnosis only noted in the nutrition section. A third resident with atrial fibrillation and heart failure was receiving apixaban, but anticoagulant therapy was omitted from the care plan after being removed in error. The DON acknowledged that these elements should have been included or maintained in the residents’ care plans.
Surveyors found that staff did not follow physician-ordered parameters for antihypertensive medications for two residents. One resident with Parkinson’s disease and hypertension received Lisinopril doses when SBP readings were below the ordered thresholds, and PRN Lisinopril was not given when SBP readings met or exceeded the ordered level. Another resident with hypertension and heart failure received scheduled hydralazine even when BP readings were below the ordered hold parameters. The DON confirmed that the expectation was for medications to be administered according to physician orders and parameters.
A resident with Parkinson's disease and dementia was moved from a private room to a semiprivate room after a B bed became available, but neither the resident nor the representative received the required written notice explaining the room change. Facility policy required advance notice to involved parties, which could include written notification, yet documentation showed only verbal communication from the social services coordinator to the resident's spouse and a prior verbal discussion months earlier. The DON and social services coordinator confirmed that no written notice was given and that they typically relied on conversations to obtain consent for room moves, leading to the representative becoming upset when the move occurred while they were out of the building.
Surveyors found that food items in the kitchen and nourishment areas were not consistently labeled, dated, or properly stored, with some packaging left open and some items appearing freezer burned. Temperature logs for refrigerators and freezers were incomplete or missing, and kitchen equipment logs could not be provided. Staff interviews confirmed that these practices did not meet facility policy or professional standards.
A resident with CHF and other cardiac conditions experienced significant weight gains on two occasions, but staff did not notify the physician or administer PRN Lasix as ordered. The DON confirmed that these required actions were not completed according to the resident's care plan and physician orders.
The Quality Assurance Committee did not hold a required quarterly meeting during one quarter, as confirmed by review of meeting records and staff interview. The Nursing Home Administrator acknowledged the expectation for quarterly meetings, which was not met for the specified period.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their clinical records. One resident's use of a CPAP machine was not reflected in the MDS, while another resident was incorrectly documented as having cancer despite no supporting medical records. The DON acknowledged these errors during interviews.
A resident with difficulty walking and muscle weakness was discharged to the hospital after a fall and returned to the facility. Despite an MDS assessment being completed, the care plan was not updated to reflect the fall and injury. The DON acknowledged that the care plan should have been revised according to facility policy.
A facility failed to ensure proper pacemaker monitoring and follow-up for a resident with a cardiac pacemaker. The resident's care plan lacked necessary safety interventions and follow-up details, and no physician orders were in place for pacemaker checks. The issue was identified when the resident returned from a clinic appointment, revealing missed cardiac appointments.
A resident with PTSD and severe depression did not receive culturally competent, trauma-informed care as required by facility policy. The resident's care plan lacked identification of PTSD triggers and interventions, despite a social services assessment indicating the need for such measures. Staff interviews confirmed the absence of evidence for trauma-informed care.
Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care to residents with PTSD and related mental health diagnoses by not identifying resident-specific trauma triggers and not ensuring timely psychiatric services. For one resident with PTSD, anxiety disorder, and major depressive disorder, the trauma-informed care assessment documented that the resident had experienced trauma and reported feeling very upset when reminded of the stressful experience, feeling jumpy or easily startled, and having trouble falling or staying asleep. The comprehensive care plan included a focus on potential behaviors related to past trauma due to childhood abuse and an intervention to identify potential triggers, but the record did not contain any documentation of the resident’s specific triggers. Additionally, although there was a physician’s order for a psychiatry consult and consent from the resident’s representative, the clinical record contained no documentation that the consult had occurred, and the DON confirmed that the resident had not received psychiatric services. For a second resident with PTSD and major depressive disorder, the trauma-informed care assessment showed that the resident had experienced trauma and reported repeated, disturbing and unwanted memories of the stressful event and disturbing dreams of the stressful experience. The comprehensive care plan included a focus on potential behaviors related to past trauma with an intervention to identify potential triggers, but the plan did not specify the resident’s particular trauma or any identified triggers. The clinical record also lacked any follow-up related to the resident’s PTSD, and during interviews, the NHA and DON stated that the facility had no additional information regarding this resident’s PTSD. The DON acknowledged that the facility’s expectation was that trauma and triggers be identified and that residents receive trauma-informed care, but this had not occurred for these two residents.
Inaccurate MDS Coding for Diagnoses and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected two residents' clinical status. For one resident with diagnoses including GERD and major depressive disorder, review of the quarterly MDS dated March 25, 2026, showed that Section N0415E (High-Risk Drug Classes: Use and Indication – anticoagulant) was coded to indicate the resident had taken an anticoagulant during the look-back period. However, review of the resident’s clinical record did not reveal any evidence that the resident had been receiving any anticoagulant medications, indicating inaccurate MDS coding in relation to the resident’s actual medication regimen. For another resident with documented diagnoses of PTSD and major depressive disorder, review of the admission and quarterly MDS assessments showed that PTSD was not coded as a diagnosis on either assessment. This omission occurred despite the diagnosis being present in the clinical record. Staff interviews confirmed that these MDS reports were coded incorrectly, demonstrating that the resident’s documented mental health condition was not accurately reflected on the MDS assessments for that resident.
Failure to Review and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop, review, and revise comprehensive, person-centered care plans in accordance with its policy and regulatory requirements. Facility policy required that comprehensive care plans be developed within seven days of the MDS and revised as resident information and conditions changed. For one resident with PTSD, anxiety disorder, and depression, the care plan included a focus on potential behaviors related to past trauma and an intervention to identify potential triggers. However, after the resident’s representative informed staff that the resident was timid and became scared by noises, this specific trigger was not added to the care plan, despite documentation of the concern in a social services progress note. The DON confirmed that the resident’s fear of noise should have been added to the care plan when the facility became aware of it. Another resident, admitted with a primary diagnosis of dementia and also diagnosed with anxiety disorder, did not have a comprehensive, person-centered care plan addressing dementia; the only reference to dementia appeared in the nutrition section of the care plan. Additionally, a third resident with atrial fibrillation and heart failure had a current physician order for apixaban (Eliquis) but the care plan did not include the resident’s use of anticoagulant medication. The DON stated that anticoagulant therapy had been removed from this resident’s care plan by accident and acknowledged that it was expected to remain on the care plan. These findings demonstrate that the facility did not ensure care plans were consistently reviewed and revised to reflect residents’ diagnoses, treatments, and identified triggers, as required by policy and 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Failure to Follow Antihypertensive Medication Parameters for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer antihypertensive medications in accordance with physician orders and facility policy for two residents. Facility policy required medications to be administered according to orders, including time frames and verification of vital signs when necessary. For a resident with Parkinson’s disease and hypertension, multiple physician orders for Lisinopril 2.5 mg included specific systolic blood pressure (SBP) parameters for administration and PRN use. Review of the August and September 2025 and January 2026 MARs showed that Lisinopril was administered when SBP values were below or outside the ordered parameters on numerous dates, including SBPs such as 118, 119, 122, 123, 131, 132, 137, 138, 139, and 140 when the order required higher SBP thresholds. Additionally, the PRN Lisinopril ordered for SBP greater than 140 was not administered on multiple dates when SBP readings met or exceeded that threshold, including readings of 140, 141, 143, 144, 149, 151, 153, 154, 156, 161, and 170. For a second resident with hypertension and heart failure, physician orders specified hydralazine HCL 20 mg twice daily with instructions to hold the medication for blood pressure less than 100/60. Review of the January 2026 MAR revealed that hydralazine was administered despite blood pressure readings below the ordered hold parameters, including 98/50, 96/57, and 84/51. During an interview, the DON stated that the facility’s expectation was that medications be administered in accordance with physician orders and ordered parameters. The survey findings concluded that the facility did not ensure care and services were provided in accordance with professional standards of practice and physician-ordered parameters for these two residents.
Failure to Provide Required Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, before changing a resident's room. Facility policy titled "Change of Room or Roommate" stated that, prior to making a room change or roommate assignment, all persons involved, such as the resident and their representative, would be given advance notice of the change, and that parties could be notified in person, via telephone, or in writing. For one resident with Parkinson's disease and dementia, clinical record review showed a progress note indicating that on January 6, 2026, the Social Services Coordinator informed the resident's wife that the resident would be moved from a private room to a semiprivate room because a B bed was available. Further review of the resident's clinical record did not reveal any documentation that the resident or the resident's representative received written notice of the room change or the reason for the change. During an interview, the DON and the Social Services Coordinator stated that the representative had been notified approximately six months earlier that the resident would be moved to a semiprivate room once a B bed became available, and that the Social Services Coordinator had spoken with the representative the morning of the move and obtained agreement. They reported that the representative later became upset that the move occurred while they were out of the building and felt it would negatively affect the resident due to his cognitive level. The Social Services Coordinator acknowledged that no written notice had been provided and that she typically relied on verbal conversations to obtain consent for room moves.
Failure to Store and Monitor Food and Equipment per Professional Standards
Penalty
Summary
The facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two nourishment areas. Observations revealed multiple instances of food items not being labeled or dated, such as bins of brown and white sugar, packs of succotash vegetables, boxes of green beans, packages of hot dog buns, and various cookies and cake mixes. Some food items were found with packaging left open or appeared freezer burned. Additionally, open containers of food, such as vanilla puddings labeled for medication pass, were left in refrigerators, and thickening powder was found with two different open dates and a scoop stored inside the container. These findings were confirmed through staff interviews, which acknowledged that food items should be labeled, dated, and stored properly per facility policy. Temperature logs for refrigerators and freezers in the kitchen and nourishment areas were incomplete or missing for several dates, and the facility was unable to provide certain kitchen equipment temperature logs when requested. Observations also noted that scoops were stored inside containers rather than in a protected area nearby, contrary to policy. The facility's policy required food to be properly labeled, dated, and stored, with temperatures monitored and recorded at least twice daily, but these procedures were not consistently followed. The Nursing Home Administrator confirmed that the facility's expectation was for expired items to be discarded and for food items and equipment to be managed according to professional standards.
Failure to Follow Physician Orders for Weight Monitoring and PRN Medication
Penalty
Summary
The facility failed to follow physician orders and the resident's care plan for a resident with diagnoses including congestive heart failure, atrial fibrillation, and hyperlipidemia. The resident had specific physician orders for daily weights, with instructions to notify the physician and administer PRN Lasix if the resident experienced a weight gain of 2 pounds in one day or 5 pounds in one week. The care plan also included interventions to obtain weights as indicated and report significant changes. On two separate occasions, the resident experienced weight gains that met the criteria for physician notification and PRN Lasix administration: a 2.8-pound gain in one day and a 4.6-pound gain in one day. However, there was no documentation that the physician was notified or that the PRN Lasix was administered as ordered. The DON confirmed during interview that these actions were not taken, despite expectations that staff would follow the physician's orders and care plan.
Failure of Quality Assurance Committee to Meet Quarterly
Penalty
Summary
The facility's Quality Assurance Committee failed to meet at least once during the first quarter of 2025, as required. Review of the committee's meeting signatory pages showed that no meeting was held in January, February, or March of that year. During a staff interview, the Nursing Home Administrator confirmed that it was the facility's expectation for the committee to meet quarterly, but this did not occur for the specified period.
Inaccurate Resident Assessments in Clinical Records
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their clinical records. Resident 9, diagnosed with obstructive sleep apnea and seizures, was found to have used a CPAP machine from April 1-4, 2024, as documented in the Treatment Administration Record. However, the Minimum Data Set (MDS) completed on April 4, 2024, did not reflect this usage, as it was incorrectly coded to indicate that the resident did not use a non-invasive mechanical ventilator during the previous 14 days. This error was acknowledged by the Director of Nursing during an interview. For Resident 26, who was admitted with diagnoses including anxiety disorder, major depression, and fibromyalgia, the clinical record inaccurately indicated an active cancer diagnosis. Despite the resident's belief of having colon cancer, there was no documentation in the routine physician notes or clinical record to support this. The Quarterly MDS assessment incorrectly marked the resident as having cancer, which was not corroborated by any medical records. The Director of Nursing confirmed that the resident was being followed for fibroids contributing to abdominal pain, but there was no record of an active cancer diagnosis.
Failure to Revise Care Plan After Resident's Fall
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as Resident 8, was reviewed and revised following a significant change in her condition. Resident 8, who had diagnoses including difficulty in walking and muscle weakness, was discharged to the hospital after a fall on May 1, 2024, and returned to the facility. Despite the completion of an MDS assessment on May 15, 2024, after her return, the care plan, which focused on minimizing the risk of falls, had not been updated since April 24, 2024, to reflect the recent fall and injury. The deficiency was identified through a combination of facility policy review, clinical record review, and interviews with the resident and staff. An observation on June 11, 2024, revealed that Resident 8 had a heavily bruised face, indicating the severity of the fall. The Director of Nursing acknowledged that the care plan should have been revised to address the fall with injury, as per the facility's policy that requires changes in a resident's condition to be reported and the care plan reviewed accordingly.
Failure to Ensure Pacemaker Monitoring and Follow-Up for Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for Resident 100, who was admitted with diagnoses including hypertension, dementia, and a cardiac pacemaker. Upon review, it was found that there were no physician orders regarding pacemaker monitoring or follow-up cardiology appointments for the resident. The care plan included an intervention for pacemaker checks but lacked safety interventions and follow-up visit details. The hospital discharge paperwork indicated a scheduled cardiology follow-up, which was not reflected in the facility's records. The Director of Nursing (DON) confirmed that the facility was aware of the resident's pacemaker upon admission but failed to obtain necessary information from the cardiologist. It was revealed that a remote pacemaker check scheduled shortly after admission was canceled because the monitoring device was at the resident's previous assisted living facility. The deficiency was identified when the resident returned from a wound clinic appointment, and the after-visit summary listed all cardiac appointments, prompting the nursing staff to update the resident's orders.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care to a resident diagnosed with PTSD and severe recurrent major depressive disorder with psychotic symptoms. The facility's policy required that residents with mental disorders or PTSD receive appropriate treatment and services to achieve the highest practicable level of mental and psychosocial well-being. However, the facility did not identify or attempt to identify the resident's PTSD triggers, nor did it develop an individualized care plan that included the source of the resident's PTSD or any known triggers or interventions. The resident, a Vietnam War veteran, suffered from PTSD due to experiences such as fighting in the war, witnessing violence, being a prisoner of war, and exposure to harmful chemicals. Despite a social services assessment indicating active signs of trauma and the need for interventions, the resident's comprehensive care plan only addressed the risk for changes in mood related to dementia, depression, and PTSD, without detailing specific triggers or interventions. Interviews with facility staff revealed a lack of further information or evidence that trauma-informed care was provided, as required by professional standards of practice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shippensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Swaim Health Center | 8.5 mi | — | 1 | 1 |
| Spiritrust Lutheran The Village At Luther Ridge | 8.5 mi | — | 0 | 0 |
| Brookview Health Care Center | 9.9 mi | — | 1 | 0 |
| Menno Haven Rehabilitation Center | 10.2 mi | — | 0 | 0 |
| Chambers Pointe Health Care Center | 11 mi | — | 4 | 0 |
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