F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records and facility documentation, and staff interview, it was determined that the facility
failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately
reflect the resident's status at the time of the assessment for one of 19 residents reviewed (Resident R50).
Residents Affected - Few
Findings include:
Review of Resident R50's clinical record revealed an admission date of 8/02/22, with diagnoses that
included Alzheimer's disease (a disease that affects short term memory and the ability to think logically),
anxiety, depression, diabetes and high blood pressure.
Review of Resident R50's clinical record revealed that the resident sustained a fall on 4/16/24, without
injury. Nurses notes dated 4/20/24, revealed that a large bruise was noted to Resident R50's right ribs and
that resident had a recent fall on 4/16/24. Nurses note dated 4/21/24, revealed x-ray results of the right rib
received showing a right 8th anterior rib fracture and possibly the 7th rib also.
Review of the Annual MDS dated [DATE], under the Health Conditions Section J1900 Number of Falls
Since Admission indicated that Resident R50 had no falls with major injury.
During an interview on 7/10/24, at 1:15 p.m. the Registered Nurse Assessment Coordinator confirmed that
Section J1900 of the Annual MDS dated [DATE], was incorrectly coded for Resident R50 regarding falls
with major injury.
28 Pa. Code 211.5(f)(ix) Medical records
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 3
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
07/11/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility
failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic
(affecting the mind) medication beyond 14 days for one of 19 residents reviewed (Resident R57).
Findings include:
A facility policy entitled Antipsychotic Medication Use dated 1/19/2024, indicated that PRN orders for
antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has
evaluated the resident for the appropriateness of that medication and documented the rational for continued
use. The duration of the PRN order will be indicated in the order.
Resident R57's clinical record revealed an admission date of 11/11/20, with diagnoses that included
dementia (a disease that affects short term memory and the ability to think logically), arthritis (a condition
when there is swelling and tenderness of one or more joints in the body), and cerebral atherosclerosis (a
disease where blood vessels become blocked and decrease blood flow in the brain and can lead to stroke).
Review of Resident R57's medication orders revealed a physician order dated 6/17/24, to administer
Lorazepam (anti-anxiety medication) 2 milligrams (mg) per milliliter (ml) give 0.25 ml by mouth every four
hours as needed for anxiety, restlessness, and agitation. The medication order lacked the required stop
date within 14 days or a clinical rationale for continuing beyond 14 days.
During an interview on 7/10/24, at 12:57 p.m. the Assistant Director of Nursing confirmed that Resident
R57's Lorazepam order lacked the required stop date within 14 days and a clinical rationale for continued
use beyond 14 days. He/she also confirmed that the medication should have a clinical rationale and
duration to continue beyond 14 days.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395607
If continuation sheet
Page 2 of 3
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
07/11/2024
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policies, observations and staff interviews, it was determined that the facility
failed to appropriately discard outdated medications for two of three medication carts reviewed (B wing
skilled and A wing medication carts).
Findings include:
Review of facility policy entitled Medication Storage in the Facility dated 1/19/24, indicated Outdated,
contaminated or deteriorated medications . are immediately removed from stock, disposed of according to
procedures for medication disposal .
Review of manufacturer's guidelines revealed that an open vial of Humalog 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 Lantus Insulin must be used within 28
days after opening or be discarded, even if the vial still contains insulin.
Observation of drug storage on 7/8/24, at 3:55 p.m. of A wing medication cart revealed an open vial of
Lantus with an open date of 6/9/24, which was beyond the 28 days after opening.
Observation of drug storage on 7/8/24, at 4:00 p.m. of B wing skilled medication cart revealed an open vial
of Lantus with no date indicating when it was opened. Further review of B wing skilled medication cart
revealed an open vial of Humalog Insulin with an open date of 4/24/24, which was beyond the 28 days after
opening.
During an interview at the time of observation, LPN Employee E1 confirmed that the open date on the
Lantus Insulin was beyond the 28 days and should have been discarded.
During an interview at the time of observation with LPN Employee E2 confirmed that there was no open
date on the Lantus Insulin and the open date on the Humalog Insulin was beyond the 28 days and should
have been discarded.
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395607
If continuation sheet
Page 3 of 3
