Inspection·May 1, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure the physician was contacted regarding an incomplete order prior to medication administration for one of eight residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of the facility's job description for RNs revealed The purpose of the RN is to deliver care to residents utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation under the direction of the residents' attending physician. The RN will effectively interact with residents, family and other health team members while maintaining all standards of professional nursing. Review of Resident R1's clinical record revealed an admission date of 4/8/25, with diagnoses that included osteomyelitis (an infection in the bone), weakness, and type II diabetes (condition where the body does not use insulin properly). Resident R1's order summary revealed a physician's order for Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams (an antibiotic used to treat many different infections caused by bacteria), use 1 dose intravenously every 6 hours for 5 days. The physician's order lacked the amount the medication was to be reconstituted with and/or the rate the medication was to be administered. Resident R1's clinical record progress notes dated 4/8/25, documented that Resident R1 received his/her Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams at 8:08 p.m. and 11:36 p.m. and that the medication was reconstituted per instructions and on 4/9/25, that the Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams was administered at the wrong rate and route. Review of facility documents dated 4/10/25 and 4/15/25, revealed that the RN failed to ensure 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 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 05/01/2025 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)