Inspection·May 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for one of 21 residents reviewed (Resident 76). Residents Affected - Few Findings include: Review of Resident 76's clinical record revealed diagnoses that included congestive heart failure (CHF- a condition characterized by a gradual loss of kidney function), atrial fibrillation (irregular heart rhythm), and hyperlipidemia (high blood cholesterol). Review of Resident 76's physician orders revealed an order for Daily weights. Notify doctor and give PRN (as needed) Lasix (diuretic- a medication that increases urine production and excretion of water) if weight gain > or = 2 lbs (pounds) in 1 day or 5lbs in a week, in the morning related to CHF, with a start date of September 22, 2023. Further review of Resident 76's physician orders revealed an order for Lasix Oral Tablet 40 MG, Give 0.5 tablet by mouth every 24 hours as needed for Weight gain, give for weight gain of 2 pounds in 1 day or 5 pounds in 1 week. Give half a tab to equal 20 mg, with a start date of May 16, 2024. Review of Resident 76's care plan revealed a focus area [Resident 76] has cardiac disease, with an intervention for obtain weights as indicated and report significant changes, initiated May 1, 2023. Review of Resident 76's clinical record revealed she had a weight gain of 2.8 lbs from August 28 to 29, 2024. Further review of her clinical record failed to reveal doctor notification, and review of her August MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) failed to reveal the PRN Lasix order was administered. Review of Resident 76's clinical record revealed she had a weight gain of 4.6 lbs from November 2 to 3, 2024; further review of her clinical record failed to reveal doctor notification, and review of her November MAR failed to reveal the PRN Lasix order was administered. Interview with the Director of Nursing on May 15, 2025, at 10:37 AM, revealed the doctor was not notified of the weight gain on the aforementioned dates and the PRN Lasix was not given. She further revealed her expectation of doctor notification and PRN Lasix administration per physician order. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 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 4 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 05/16/2025 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)