Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens At Gettysburg, The during CMS and state inspections, most recent first.
Surveyors found that care plans were not updated to reflect the current needs and preferences of four residents, including the use of a CPAP mask, pressure offloading boots, an anticoagulant medication, and an arm sling. Staff confirmed these omissions, indicating that care plans did not accurately represent the residents' care requirements.
A resident with severe cognitive impairment, dependent on staff for ADL assistance, was observed with unclean fingernails and facial stubble, and reported not receiving regular showers or nail care. Documentation and interviews confirmed inconsistent provision of personal hygiene and grooming, resulting in a deficiency for failure to maintain adequate care.
A resident with COPD was found with oxygen concentrator tubing disconnected from the humidification bottle, resulting in no oxygen flow despite the nasal cannula being in place. The LPN immediately reattached the tubing upon discovery, and interviews revealed conflicting explanations for the disconnection. The facility's policy did not address humidification bottle use, and staff failed to ensure the resident received appropriate respiratory care.
A resident with epilepsy and bipolar disorder did not receive prescribed anti-seizure medications after returning from the hospital, due to a failure in reviewing and continuing the medication orders. The facility's policy required timely medical assessments, but the medication regimen review and physician's note did not address the continuation of Lamictal and Gabapentin. The resident was later found unresponsive, highlighting the lapse in medication administration.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documentation. A resident with chronic embolism was inaccurately recorded as not receiving anticoagulant medication, while another with dementia was noted for wandering behaviors not reflected in the MDS. A third resident's MDS incorrectly stated no antipsychotic medication was given and reported a fall with major injury that did not occur. Lastly, a resident receiving enteral feeding was inaccurately documented as not receiving nutrition via a feeding tube. These errors were confirmed by the NHA.
A resident with severe dementia and muscle weakness experienced a fall with major injury. Despite placing the resident's mattress on the floor as a safety measure, the facility failed to update the care plan to include this intervention. The Nursing Home Administrator acknowledged the oversight, which was contrary to the facility's policy requiring timely care plan revisions.
A resident with a Foley catheter did not have documented orders for its use or care for six days after admission, leading to a deficiency in preventing urinary tract infections. The Nursing Home Administrator confirmed the delay was due to pending confirmation of orders in the electronic record.
The facility failed to provide timely practitioner services for two residents with pressure injuries. One resident with Alzheimer's and peripheral vascular disease had a pressure injury identified but not evaluated or treated for nine days. Another resident with a sacral skin alteration was not evaluated by a wound consultant until eight days after admission due to a scheduling oversight, resulting in delayed treatment orders.
A facility failed to accurately document oxygen administration for a resident with COPD and anoxic brain damage. Observations showed the resident receiving oxygen, but records indicated otherwise, and the Treatment Administration Record showed discontinued oxygen. An error in entering the order led to its absence from the TAR, resulting in incomplete clinical records.
A resident with osteoporosis and osteoarthritis did not receive their prescribed Miacalcin Nasal Solution on multiple occasions due to pharmacy issues. The facility failed to notify the physician about the missed doses, as confirmed by the Nursing Home Administrator.
A resident with peripheral vascular disease and congestive heart failure developed a stage II pressure ulcer on the left foot. Despite recommendations for daily treatment by a wound consultant, there was a gap in treatment orders from the time of discovery until several days later. The Nursing Home Administrator acknowledged that treatment orders should have been implemented immediately.
A resident with osteoporosis and osteoarthritis did not receive their prescribed Miacalcin Nasal Solution on multiple occasions due to the facility's failure to ensure the medication was available. The medication was not administered from February 22 to 26 and on May 16, as the pharmacy required facility approval to fill the non-covered medication, causing delays.
An LPN administered the wrong medication to a resident, who ingested a pill not prescribed to her. The error was identified and reported immediately, and the resident was monitored for side effects. The DON and NHA confirmed the LPN did not follow the facility's medication administration policy.
Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current needs and preferences of four residents. For one resident with diabetes and muscle weakness, observations showed a CPAP mask left out on the bedside stand according to the resident's preference, but the care plan did not document this preference. Another resident with diabetes and protein-calorie malnutrition was observed wearing bilateral pressure offloading boots, yet the care plan addressing pressure ulcer risk did not include the use of these boots. A third resident with dementia, depression, and atrial fibrillation was prescribed Apixaban, an anticoagulant, but the care plan did not reflect the use of this medication. Additionally, a resident with a history of cerebral infarction and hypertension was observed using a left arm sling, but the care plan did not mention the use of the sling. In each case, staff interviews confirmed that these interventions or preferences should have been included in the respective care plans.
Failure to Maintain Adequate Personal Hygiene and Grooming for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia, who was dependent on staff for assistance with activities of daily living (ADLs), did not consistently receive adequate personal hygiene and grooming. The resident's clinical record indicated severe cognitive impairment, requiring supervision or touch assistance for bathing and partial to moderate assistance with personal hygiene, including shaving and hand/face washing. Despite these needs, observations revealed the resident had a brown substance under his fingernails and was not shaved, with facial stubble present. The resident expressed that his nails needed cleaning and requested a shower, although he did not mind some facial hair. Documentation showed that showers and bed baths were provided intermittently over the previous 30 days, but there were gaps in the provision of these services. Further observations confirmed that, while the resident's fingernails were trimmed, two fingernails still had a brown substance underneath, and the resident remained unshaved. Interviews with the resident and the Nursing Home Administrator (NHA) corroborated these findings, with the NHA acknowledging the need for nail cleaning and stating that the resident was educated on hand hygiene. The resident later confirmed that his fingernails were cleaned, but minimal residue remained. The deficiency was cited under 28 Pa code 211.12.(d)(1)(5) for nursing services, as the facility failed to maintain adequate personal hygiene and grooming for a resident dependent on staff assistance.
Failure to Ensure Proper Oxygen Therapy Setup
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and difficulty walking was not provided with safe and appropriate respiratory care as required. During an observation, the resident's oxygen concentrator tubing was found disconnected from the humidification bottle, which is necessary to add moisture to the oxygen. The resident had the nasal cannula in place but was not receiving any oxygen flow at the time of the observation. The facility's policy on oxygen therapy did not address the use of a humidification bottle, and the tubing was immediately reattached by a Licensed Practical Nurse upon discovery. Interviews revealed conflicting accounts regarding how the tubing became disconnected. The resident stated she does not remove the tubing from the concentrator to the humidification bottle, while the Nursing Home Administrator indicated that the resident sometimes disconnects the tubing while using the restroom. Regardless, the deficiency was identified as staff failed to ensure the oxygen equipment was properly set up and functioning, resulting in the resident not receiving prescribed oxygen therapy.
Failure to Review and Administer Anti-Seizure Medications
Penalty
Summary
The facility failed to ensure that a resident's total program of care, including medications, was accurately reviewed at each physician visit. The resident, who had a history of symptomatic epilepsy, bipolar disorder, and migraines, was admitted with orders for Lamictal and Gabapentin to manage seizures. After a hospital visit for acute enterocolitis, the resident returned with discharge orders for these medications to be continued for only seven days. The facility's documentation showed that the medications were discontinued after this period, and they were not administered from October 15 to October 30, 2024. The facility's policy required timely medical assessments and appropriate medical regimens, but the October 8, 2024, medication regimen review and the physician's note from October 9, 2024, did not address the continuation of the anti-seizure medications. The resident was later found unresponsive and sent to the hospital, where it was determined that the medications had been discontinued without proper documentation or a gradual reduction, as recommended by the FDA. The Nursing Home Administrator confirmed the lapse in medication administration and the lack of documentation supporting the discontinuation.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. Resident 14, diagnosed with chronic embolism and thrombosis, was documented as receiving Xarelto, an anticoagulant, daily in May 2024. However, the MDS assessment inaccurately indicated that the resident did not receive anticoagulant medication during the look-back period. Similarly, Resident 52, with frontotemporal neurocognitive disorder and dementia, was noted in progress notes to exhibit wandering behaviors, yet the MDS assessment failed to reflect these behaviors. Resident 56, diagnosed with severe unspecified dementia and muscle weakness, was documented as receiving Aripiprazole daily, but the MDS assessment incorrectly stated that no antipsychotic medication was administered. Additionally, the MDS inaccurately reported a fall with major injury, which was not supported by the clinical record. Resident 69, with dysphagia and gastrostomy status, was documented as receiving daily enteral feeding, but the MDS assessment incorrectly indicated no nutrition via a feeding tube. These errors were confirmed by the Nursing Home Administrator during interviews.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised in a timely manner following a significant change in the resident's condition. Resident 56, who has severe unspecified dementia with agitation and muscle weakness, experienced a fall with a major injury. Despite the fall and the subsequent placement of the resident's mattress on the floor as a safety intervention, the care plan was not updated to reflect this new intervention. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in the case of Resident 56. During interviews, the Nursing Home Administrator acknowledged that the care plan should have been updated to include the mattress intervention, as it was implemented due to the ineffectiveness of previous fall interventions. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own care planning policies.
Failure to Document and Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections and complications related to the use of a Foley catheter for a resident. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia following a cerebral infarction, was admitted with a Foley catheter. However, there were no documented orders related to the presence, indication for use, or care of the catheter until six days after admission. During this period, the clinical record lacked documentation of daily care or maintenance of the Foley catheter. The Nursing Home Administrator confirmed that the orders and documentation for catheter use and care were not timely. The orders were entered into the electronic record at admission but were pending confirmation, which delayed their appearance on the Medication/Treatment Administration Records until the issue was discovered and corrected.
Delayed Practitioner Services for Pressure Injuries
Penalty
Summary
The facility failed to ensure timely practitioner services for two residents with skin integrity concerns. Resident 26, diagnosed with Alzheimer's disease and peripheral vascular disease, was noted to have a dark area of discoloration on the left outer ankle on May 7, 2024. Despite the need for a wound team assessment, there was no evidence that a physician or practitioner was notified or evaluated the wound until May 16, 2024, when a nurse practitioner determined it to be a pressure injury. During this period, no treatment was prescribed, and the Nursing Home Administrator confirmed the lack of practitioner notification and evaluation. Resident 92, admitted with a sacral skin alteration and a history of pressure ulcers, was expected to be seen by a wound consultant the day after admission. However, due to a scheduling oversight, the wound consultant was not informed, and the resident's wound was not evaluated until eight days later, on May 16, 2024. The physician's initial assessment on May 9, 2024, noted a stage III pressure injury but did not include a treatment plan. Consequently, no treatment orders were documented until May 20, 2024. The Nursing Home Administrator acknowledged the delay in evaluation and treatment.
Failure to Document Oxygen Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident who was receiving oxygen therapy. The facility's policy on oxygen administration, last revised in October 2010, requires detailed documentation of oxygen setup or adjustment, including the date and time of the procedure, the name and title of the individual performing it, the rate of oxygen flow, route, rationale, frequency, duration, and assessment data. However, the clinical record for a resident with chronic obstructive pulmonary disease (COPD) and anoxic brain damage did not reflect accurate documentation of oxygen administration. Observations revealed that the resident was receiving oxygen at 2 liters per minute via nasal cannula, but the clinical record progress notes indicated that the last entry was dated several days prior, stating the resident was not receiving oxygen. Further review of the resident's Treatment Administration Record (TAR) showed that oxygen administration was discontinued earlier in the month, despite the resident being observed with oxygen. Interviews with the Nursing Home Administrator confirmed that the oxygen administration should have been documented, and an error in entering the oxygen order led to its absence from the TAR. This lack of documentation and failure to update the resident's medical records as per the facility's policy resulted in a deficiency in maintaining accurate and complete clinical records.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with osteoporosis and osteoarthritis. The resident had a physician's order for Miacalcin Nasal Solution, a medication to prevent bone loss, to be administered daily. However, the Medication Administration Records (MARs) indicated that the medication was not administered on several occasions in February and May 2024. Specifically, the medication was not given from February 22 to 26, 2024, and on May 16, 2024. The nursing progress notes revealed that the medication was unavailable due to issues with the pharmacy, including needing approval from the Director of Nursing and awaiting delivery. Despite these missed doses, there was no documentation indicating that the physician was notified of the missed medication. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the physician was informed about the missed doses, which constitutes a failure to meet the resident's physical needs as per professional standards.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection of a pressure ulcer for one resident. The resident, who had diagnoses including peripheral vascular disease and congestive heart failure, was evaluated by a wound consultant on May 16, 2024, for a new stage II pressure injury on her left medial distal foot. The wound consultant recommended daily treatment, including cleansing the area with wound cleanser, applying calcium alginate, and securing it with bordered gauze. However, the clinical record of the resident did not show any treatment orders for the wound between May 16, 2024, and May 21, 2024. The active physician orders for treatment were only effective starting May 21, 2024, indicating a gap in care. During an interview, the Nursing Home Administrator acknowledged that treatment orders should have been in place immediately following the discovery of the new skin concern.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with osteoporosis and osteoarthritis. The resident had a physician's order for Miacalcin Nasal Solution, a medication to help prevent bone loss, to be administered daily. However, the Medication Administration Records (MARs) indicated that the medication was not administered on several occasions, specifically from February 22 to 26, 2024, and on May 16, 2024. The nursing progress notes revealed that the medication was unavailable due to issues with the pharmacy, which required approval from the facility to fill the prescription as it was a non-covered medication. This process caused delays in obtaining the medication. During an interview, the Nursing Home Administrator confirmed that the medication was not administered because the staff could not locate it, and the pharmacy needed facility approval to provide a replacement. The administrator did not have additional information regarding the missed dose on May 16, 2024.
Medication Administration Error
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for one resident. An LPN administered medication intended for another resident to Resident 1, who had diagnoses including tibia and fibula fractures and chronic obstructive pulmonary disease (COPD). The error occurred when Resident 1 was handed Resident 2's medications and ingested one pill before realizing the mistake. The ingested pill was identified as Tamsulosin, a medication not prescribed to Resident 1 during her stay at the facility. The Director of Nursing (DON) confirmed that the LPN did not adhere to the facility's medication administration policy, which mandates that medications be administered according to the written orders of the attending physician. The incident was reported immediately, and the physician was notified to monitor Resident 1 for any side effects. The Nursing Home Administrator (NHA) also confirmed the policy breach by the LPN, leading to the medication error.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gettysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare Gettysburg | 1.4 mi | ★★★★★ | 6 | 0 |
| Concordia At Spiritrust Gettysburg | 2.2 mi | ★★★★★ | 7 | 0 |
| Gettysburg Center | 2.4 mi | ★★★★★ | 13 | 0 |
| Cross Keys Village-brethren Home Community, The | 10.1 mi | ★★★★★ | 0 | 0 |
| Paramount Nursing And Rehab At Fayetteville, Llc | 10.6 mi | ★★★★★ | 2 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.