Health inspection·August 31, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and documents, and staff interviews it was determined that the facility failed to maintain a clean, homelike environment for two resident rooms (rooms [ROOM NUMBERS]). Findings include: Review of a facility policy entitled Cleaning and Disinfecting Residents' Rooms dated 4/28/23, indicated that floors will be cleaned on a regular basis, when spills occur, and when visibly dirty, and that window curtains will be cleaned when these surfaces are visibly contaminated or soiled. Review of three months of Resident Council Meeting notes revealed: 6/13/23, two of nine residents in attendance confirmed that their rooms were not being cleaned daily. 7/11/23, four of eight residents in attendance confirmed that their rooms were not being cleaned daily, and eight of eight residents confirmed that their curtains were dirty. Observation of room [ROOM NUMBER] on 8/28/23 at 12:40 p.m. revealed items on the floor between the beds that included two clear plastic lids with straws, a greeting card, pepper packet, tissue, a French fry, a sock and plastic tabs from an incontinence product under one of the beds. Observations of room [ROOM NUMBER] on 8/29/23, at 11:18 a.m. and 8/30/23, at 11:48 a.m. revealed one clear plastic lid with a straw on the floor in the same location between the beds, the sock and incontinence product plastic tabs remained under the bed. Observations of room [ROOM NUMBER] on 8/29/23, at 9:35 a.m. and 8/30/23, at 11:44 a.m. revealed several areas of brown substance/stain on the privacy curtain that separated the beds in the room. During an interview on 8/31/23, at 9:40 a.m. Housekeeping Director confirmed room [ROOM NUMBER] was not cleaned under the bed properly and that the above items were under resident's bed and should have been captured with cleaning; that the privacy curtain in room [ROOM NUMBER] was soiled and should have been replaced; and that when staff are performing daily cleaning, the privacy curtain should be checked for cleanliness. During an interview on 8/31/23, at 9:54 a.m. the Nursing Home Administrator confirmed that the rooms should be cleaned daily to prevent items being left under the beds and on the floors, and that the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395607 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)