Shippensburg Health Care Center and Falling Spring Nursing Home & Rehabilitation in Chambersburg are among the nation’s worst nursing care facilities, according to a list released this week by the federal government. The two area facilities appear on the list of 400 homes in the country that have “a documented pattern of poor care.”

Following an inquiry by U.S. Sens. Bob Casey (D-PA) and Pat Toomey (R-PA) into under-performing nursing homes, the Centers for Medicare and Medicaid Services (CMS) recently handed over the unreleased list of facilities.

CMS oversees a program for nursing homes that consistently underperform, called the Special Focus Facility program. The names of the facilities chosen to participate in the program are made public, however, the approximately 400 nursing homes that are not selected to participate are kept hidden from the public. In order to provide greater transparency to individuals and families, Casey and Toomey requested the names of these additional facilities be made publicly available by CMS. After CMS chose not to release this list, Casey and Toomey are releasing this information alongside a report with additional background and context.

“Across Pennsylvania, and the nation, most nursing homes serve their residents well and treat them with dignity and kindness. It is outrageous that we continue to hear stories of abuse and neglect in nursing homes that do not live up to these high standards,” said Casey. “Choosing a nursing home is a difficult, and often painful, decision to make. Individuals and families deserve to have all the information available to choose the facility that is right for them. I will continue to press the Administration to ensure every person has ready access to the information they need to make a fully informed choice.”

“When a family makes the hard decision to seek nursing home services for a loved one, they deserve to know if a facility under consideration suffers from systemic shortcomings. While the vast majority of nursing homes provide high-quality care, there are some that are consistently failing to meet objective standards of adequacy. To date, CMS has arbitrarily excluded from public disclosure a subset of these underperforming nursing homes. Moving forward, I hope CMS will give the public this particular list, as well as all relevant information about nursing home quality,” Toomey said.

In March, Sens. Casey and Toomey wrote to CMS requesting information on its oversight of nursing homes in the Special Focus Facility program, including those identified by news reports that alleged reports of abuse and neglect. Shippensburg Health Care Center is listed as a candidate to be in the Special Focus Facility Program, while Falling Spring is already listed in the program.

Shippensburg Health Care

According to a 20-page inspection report released on Shippensburg Health Care Center, 121 Walnut Bottom Road, a number of deficiencies were recorded on April 2, 2019, the latest report filed for the center. Complete reports dating as far back as 2006 can be found online at:

In the April 2, 2019, inspection report, a revisit survey and complaint survey completed on April 2 determined the center failed to correct deficiencies identified between Feb. 8 and Feb. 19, 2019, and continued to be out of compliance regarding requirements for long-term care facilities and licensure regulations.

The report indicates Shippensburg Health Care Center failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 16 residents reviewed. The patient was prescribed Oxycodone and doses were signed out for administration on several dates in March. However, the clinical records showed no documented evidence that the medication was actually administered to the patient on those dates and times. A plan of correction to be completed by April 19 included proper documentation and re-education of licensed staff on keeping proper records.

Another investigated complaint surrounded the respect and dignity of residents, such as one who required assistance with eating at meal time. The resident had highly impaired vision and suffered from confusion, and required assistance. On April 2, the resident was observed sitting in the dining area for an hour wearing a clothing protector rolled up on her lap, with food debris on her lap and on her wheelchair. The nurse aide told inspectors she was not aware the resident had food debris on her, and told the staff member who fed her supper they should have cleaned her up.

In the corrective action plan, nurses are to complete audits of residents after meals to confirm there has been no food left on a patient after they have eaten.

The report also showed Shippensburg Health Care staff failed to notify a patient’s physician of the patient’s change in blood pressure and medication, and licensed staff was to be re-educated on updating the physicians with changes of blood pressure outside of the resident’s baseline.

Patients who had issued grievances against the staff also reported they had not received a report that the grievance had been resolved. One patient indicated that she was prescribed Oxycodone for chronic pain, and even though her pain was severe, it still took 20 minutes to receive her medication.

The director of nursing told inspectors there is a one-hour window before and after a medication is due but it is only for routinely ordered medications, and not “as needed” pain medication.

Two other residents complained of not receiving required assistance with their oral care every day, and the report showed the oral care was not documented in the patients’ charts.

Falling Spring

The latest report for Falling Spring was filed on April 4, 2019. The 24-page report, along with previous reports filed as far back as 2006, can be found online at:

The report indicates the nursing home was in violation of the following policies on April 2:

-Patients on dialysis were prescribed a medication, but the change in medication was not reported to their physicians

-A nurse’s aide was witnessed by a surveyor loudly protesting a call bell with an obscenity that could be heard by nearby residents. The aide said she was having a bad day, and knew it was wrong to use the foul language.

-Improper wound care

-Labeling and storage of medication.

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