Cycle 1
Health 2025-05-16 · Fire 2025-05-16
3 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Shippensburg, PA
Shippensburg Rehabilitation And Health Care Center
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
121 Walnut Bottom Road, Shippensburg, PA
(717) 530-8300
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,774
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9957
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.90
Baseline 23.73% · Performance 18.10% · Measure score 7.90 · Achievement 7.18 · Improvement 7.90
Healthcare-associated infections
3.09
Baseline 8.05% · Performance 6.96% · Measure score 3.09 · Achievement 2.94 · Improvement 3.09
Total nurse turnover
4.05
Performance 47.12% · Measure score 4.05 · Achievement 4.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.06
Baseline 3.27 hours · Performance 3.66 hours · Measure score 2.06 · Achievement 2.06 · Improvement 1.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 7.81% · Lower 95% interval 6.63% |
| Discharge to community | 58.74% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 54.24% · Lower 95% interval 47.04% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 48 · Denominator 50 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 20 · Denominator 33 |
| Discharge mobility score | 78.79% |
50.94%
27.9 pts better
|
Numerator 26 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 2.34% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 21 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.23% |
25.2%
22 pts worse
|
Numerator 1 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
86.9%
5.3 pts better
|
93.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 92.8% · Q3 94.6% · Q4 87.4% · 4Q avg 92.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
93.5%
1.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.1% · Q3 2.2% · Q4 1.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.5%
3.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.5% · Q3 1.2% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
19.9%
6.3 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.9% · Q3 14.6% · Q4 17.3% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
18.7%
2.5 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 15.9% · Q3 16.7% · Q4 14.8% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.6% |
19.6%
7 pts worse
|
16.3%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 31.5% · Q3 23.8% · Q4 14.1% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.3%
1.2 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 21.5% · Q3 15.6% · Q4 19.7% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
26.4%
About the same
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 26.5% · Q3 27.2% · Q4 24.9% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.3%
1.6 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 2.6% · Q3 2.4% · Q4 2.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
68.9%
13.8 pts better
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.6% · Q2 81.5% · Q3 79.7% · Q4 91.4% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
9.8%
0.9 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.3% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.5% |
68.7%
12.8 pts better
|
79.7%
1.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
23.1%
7 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 30.2% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-25
C · Minimal harm
2025-05-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-25
E · Potential for more than minimal harm
2024-06-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-08-02
E · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-16
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-06-25
D · Potential for more than minimal harm
2024-06-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-31
E · Potential for more than minimal harm
2023-08-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
Shippensburg Opco Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Bl Panho Trust
5% Or Greater Indirect Ownership Interest · Organization
Cottle, Larry
W-2 Managing Employee · Individual
Gottesman, Daniel
5% Or Greater Indirect Ownership Interest · Individual
Kolman, Robert
5% Or Greater Indirect Ownership Interest · Individual
Kolman, Robert
Corporate Officer · Individual
Mlspa LLC
5% Or Greater Indirect Ownership Interest · Organization
Mlspa Trust
5% Or Greater Indirect Ownership Interest · Organization
Mvrk I LLC
5% Or Greater Indirect Ownership Interest · Organization
Panho Capital Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Premier Management Support LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Swaim Health Center
Newville, PA
4-star overall rating with 4-star inspections with $12,735 in total fines with 4 recent health deficiencies
#2
Spiritrust Lutheran The Village At Luther Ridge
Chambersburg, PA
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Brookview Health Care Center
Chambersburg, PA
4-star overall rating with 3-star inspections with $16,801 in total fines with 6 recent health deficiencies
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