Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0559
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice
before a change is made.
Based on review of facility policy, clinical record review, and staff interviews, it was determined that the
facility failed to ensure that in preparation for a room change, each resident received written notice,
including the reason for the change, before the resident's room was changed for one of three residents
reviewed (Residents 1). Findings include: Review of facility policy, titled Change of Room or Roommate,
stated, 4. Prior to making a room change or roommate assignment, all persons involved in the
change/assignment, such as resident and their representatives, will be given advance notice of such a
change as in possible. Parties can be notified either in person, via telephone or in writing.Review of
Resident 1's clinical revealed diagnoses that included Parkinson's disease (neurodegenerative disorder
causing motor issues) and dementia (progressive decline in memory, thinking, and behavior).Review of
Resident 1's clinical record progress notes revealed a note dated January 6, 2026, at 11:01 AM, that
indicated Employee 1 (Social Services Coordinator) informed Resident 1's wife that Resident 1 would be
moving out of his private room due to a B bed being available.Further review of Resident 1's clinical record
failed to reveal documentation that Resident 1 or his Representative had received written notice of the room
change or the reason for the room change.During an interview with the Director of Nursing (DON) and
Employee 1 on February 2, 2026, at approximately 11:00 AM, it was revealed that Resident 1's
Representative had been notified six months prior to the move that Resident 1 would be moved to a
semiprivate room once a B bed became available. Employee 1 stated that she had spoken with Resident
1's Representative the morning of the move prior to Resident 1 leaving for an appointment, and Resident
1's Representative was in agreement with the move. Upon returning from the appointment, Resident 1's
Representative was upset that the move occurred while they were out of the building and felt that it would
have negative effects on Resident 1 due to his cognitive level. Employee 1 stated that no written notice had
been given to Resident 1 or Resident 1's Representative and that she typically just has a conversation with
the resident or representative to obtain consent for room moves. 28 Pa. Code 201.14(a) Responsibility of
licensee.28 Pa. Code 201.29(j) Resident rights.
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:
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
02/02/2026
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)
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 facility policy review, clinical record review, and staff interviews, it was determined that the facility
failed to ensure care and services are provided in accordance with professional standards of practice that
will meet each resident's physical, mental, and psychosocial needs for two of two residents reviewed
(Residents 1 and 2). Findings include:Review of facility policy, titled Administering Medications, read, in
part, Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with
the orders, including any required time frame.8. The following information must be checked/verified for each
resident prior to administering medications.b. Vital signs, if necessary.Review of Resident 1's clinical record
revealed diagnoses that included Parkinson's disease (neurodegenerative disorder causing motor issues)
and hypertension (high blood pressure).Review of Resident 1's physician orders revealed the following
orders:Lisinopril (antihypertension medication) 2.5 milligrams (mg) one tablet in the morning for
hypertension. Give if systolic blood pressure (SBP) 150s - 160s only. Start date of August 2, 2025; end date
September 9, 2025.Lisinopril 2.5 mg one tablet in the morning for hypertension. Give if SBP is greater than
160. Start date of September 10, 2025; end date September 18, 2025.Lisinopril 2.5 mg one tablet in the
morning related to hypertension. If SBP is greater than 140 give extra dose of Lisinopril 2.5 mg. Start date
of September 19, 2025; end date October 31, 2025.Lisinopril 2.5 mg one tablet every 24 hours as needed
for SBP greater than 140. Start date of September 19, 2025; end date of October 31, 2025.Lisinopril 2.5 mg
one tablet in the morning related to hypertension. If SBP is greater than 140 give extra dose of Lisinopril 2.5
mg. Start date of November 1, 2025; end date January 6, 2026.Lisinopril 2.5 mg one tablet every 24 hours
as needed for SBP greater than 140. Start date of October 31, 2025; end date of January 6, 2026.Lisinopril
2.5 mg one tablet in the morning related to hypertension. If SBP is greater than 140 give extra dose of
Lisinopril 2.5 mg. Hold if SBP is less than 120. Start date of January 7, 2026.Lisinopril 2.5 mg one tablet
every 24 hours as needed for SBP greater than 140. Start date of January 7, 2026.Review of Resident 1's
August 2025 Medication Administration Record (MAR) revealed Resident 1's Lisinopril had been
administered outside of the physician ordered parameters as follows: August 4, SBP 138August 5, SBP
123August 6, SBP 132August 7, SBP 140August 8, SBP 141August 12, SBP 142August 13, SBP
148August 16, SBP 122August 17, SBP 139August 18, SBP 119August 19, SBP 143August 20, SBP
137August 21, SBP 138August 26, SBP 143August 28, SBP 144August 29, SBP 131Review of Resident
1's September 2025 MAR revealed Resident 1's Lisinopril had been administered outside of the physician
ordered parameters as follows: September 2, SBP 118September 4, SBP 129September 8, SBP
144September 10, SBP 156September 11, SBP 130September 15, SBP 130Review of Resident 1's
January 2026 MAR revealed Resident 1's Lisinopril had been administered outside of the physician ordered
parameters as follows: January 9, SBP 118January 18, SBP 118Further review of Resident 1's MARs for
August 2025 - February 2026 revealed Resident 1's PRN [as needed] dose of Lisinopril was not
administered per physician orders for a SBP greater than 140 on the following dates:September 22, SBP
140September 24, SBP 153September 25, SBP 161September 30, SBP 141October 1, SBP 170October
13, SBP 149October 20, SBP 154November 11, SBP 143November 12, SBP 151November 26, SBP
143December 1, SBP 153December 10, SBP 144December 14, SBP 151December 24, SBP 141January
2, SBP 156January 12, SBP 142Review of Resident 2's clinical record revealed diagnoses that included
hypertension and heart failure (condition that develops when your heart doesn't pump enough blood for
your body's needs).Review of Resident 2's physician orders revealed an order for hydralazine HCL
(antihypertensive medication) 20 mg two times a day related to hypertension, hold for blood pressure (BP)
less than 100/60.Review of Resident 2's January 2026 MAR revealed Resident 2's hydralazine HCL had
been administered outside of the
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395964
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
395964
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/02/2026
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
physician ordered parameters as follows: January 8, BP 98/50January 9, BP 96/57January 19, BP
84/51During an interview with the Director of Nursing on February 2, 2026, at approximately 1:15 PM, it
was revealed that it was the facility's expectation that medications be administered following physician
orders and physician ordered parameters for medication administration be followed.28 Pa. Code 201.14(a)
Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(c)(d)(1)(2)(5)
Nursing Services.
Event ID:
Facility ID:
395964
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F559 - The right to share a room with his or her spouse when married residents live
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 2, 2026 survey of SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER?
This was a inspection survey of SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER on February 2, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER on February 2, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.