Inspection·June 23, 2023

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 resident and staff interviews, state regulations, record review, scope of practice, and facility policy, it was determined that the facility failed to follow professional standards of practice when providing medication administration to one of three residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. A review of the facility policy, titled Administering Medications no date, states, Medications must be administered in accordance with the orders, including any required time-frame. The policy also states, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident, or suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the Resident's Attending Physician or the facility's Medical director to discuss the concerns. A review of the clinical record for Resident 1 on June 22, 2023, at 5:00 PM, revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) . During an interview with Resident 1 on June 22, 2022, at approximately 4:15 PM, Resident 1 stated that she was not administered her Lasix (medication for edema) or the clonazepam (medication to treat her anxiety) on June 16, 2023, as ordered by the physician. Resident 1 also stated that she reminded the medication nurse at 3:30 PM that she hadn't received the clonazepam, but the nurse stated that it was too close to the next dose. Resident 1 stated that she requested the nurse to call the physician because he could approve administering the missed dose, but the nurse never administered the missed dose and Resident 1 stated the nurse would not call the physician. A review of Resident 1's Medication Administration Record (MAR) revealed orders for clonazepam 0.5 milligrams daily at 2:00 PM, and Lasix 20 milligrams daily at 1:00 PM. (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 2 Event ID: 395964 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 395964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 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)