Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Transitions Healthcare Gettysburg during CMS and state inspections, most recent first.
The facility did not have a process in place to allow residents to submit grievances anonymously, despite policy requirements. Several residents were unaware of how to file grievances or do so anonymously, and posted instructions only directed residents to submit forms to staff or management, with no anonymous option available.
A resident with obstructive sleep apnea and other neurological conditions did not have a complete physician order for CPAP therapy, as required settings were missing. The resident's care plan lacked documentation of respiratory care or CPAP use, and repeated observations showed the CPAP mask was stored hanging on a wall hook, directly touching the wall. Facility policy did not address proper mask storage, and staff confirmed these deficiencies during interviews.
Surveyors identified that several residents' MDS assessments did not accurately reflect their clinical status, including conflicting documentation of pressure ulcers, incorrect reporting of tobacco use, and misrepresentation of speech clarity for residents with expressive aphasia. These inaccuracies were confirmed through interviews, record reviews, and direct observation.
The facility did not ensure that two residents had comprehensive care plans addressing all of their needs. One resident using a CPAP machine for sleep apnea did not have respiratory care or CPAP use documented in the care plan, despite physician orders and ongoing use. Another resident receiving antipsychotic medication for dementia and delusional disorder had no care plan interventions addressing this medication, even though assessments indicated it should be care planned. Staff confirmed these omissions were not in line with facility expectations.
A resident with hemiplegia, hemiparesis, and malnutrition developed a Stage 3 pressure ulcer, which later resolved. Despite a quarterly MDS showing no pressure ulcers, the care plan was not updated to reflect the healed condition, contrary to facility policy requiring timely care plan revisions.
Multiple residents reported that food, coffee, and tea were not consistently served at appropriate temperatures, with some meals and beverages being cold or not hot enough. Direct observation and a test tray confirmed that hot foods and drinks were below the required temperature, and cold beverages were above the acceptable range, with both types being served in the same style of mug. Staff interviews revealed a lack of clarity regarding proper service ware and temperature standards.
A resident with muscle weakness and diabetes did not receive care consistent with professional standards to prevent pressure ulcers. Despite a physician's order for blue off-loading boots to elevate the resident's heels, observations showed the resident was not wearing the boots on multiple occasions.
The facility failed to properly label and store medications in two medication carts, with several insulin products exceeding their recommended discard periods. The Nursing Home Administrator acknowledged the expectation for compliance with manufacturer's guidelines.
A resident with dysphagia and hemiplegia did not receive the ordered Dycem, a non-slip mat, during meals over three consecutive days. Despite facility policy and physician's orders requiring the use of adaptive equipment to prevent decline, observations showed the absence of the Dycem, which was confirmed by the Nursing Home Administrator's expectations.
A facility failed to follow its policy for reporting an allegation of neglect when a resident reported that a nurse did not change her soiled brief. The LPN informed the day shift supervisor, but the supervisor did not notify the NHA immediately. The NHA learned of the allegation the next day, and an investigation was conducted, ultimately finding the neglect unsubstantiated.
The facility failed to adhere to professional standards in medication administration for three residents. A resident with diabetes received insulin despite low blood sugar levels, another resident did not receive insulin as per a sliding scale order, and a third resident had medication left in their room despite not being authorized to self-administer. These deficiencies were confirmed by facility staff.
A facility failed to adhere to professional standards of practice by not ensuring weekly cleaning of a CPAP machine for a resident with chronic kidney disease and pulmonary fibrosis. Despite daily use of the CPAP, there was no documentation of cleaning or maintenance until new orders were established, highlighting a lapse in care.
A resident in an LTC facility sustained a leg laceration requiring 13 sutures due to neglect during a transfer. Despite needing two-person assistance, a staff member transferred the resident alone, leading to the injury. The facility confirmed the neglect and barred the staff member from returning.
A resident with a history of anorexia nervosa and failure to thrive required a two-person assist for transfers. However, a nursing assistant attempted a transfer alone, resulting in the resident sustaining a laceration on the right shin that required hospitalization and 13 sutures. The facility failed to provide adequate supervision and assistance, leading to actual harm.
Failure to Provide Anonymous Grievance Submission Process
Penalty
Summary
The facility failed to ensure that residents' rights to file grievances anonymously were honored, as required by their own grievance policy. The policy stated that grievances could be reported anonymously and that the facility could not require a signature on a grievance. However, during a resident group meeting, several residents indicated they did not know how to file a grievance or how to do so anonymously. Most residents reported that they simply told the Social Worker, nurses, or management if they had a concern, rather than using a formal or anonymous process. Observations of the posted grievance process information on all three living areas revealed instructions to return completed grievance forms to the RN Supervisor or Nurse Manager, or to contact the Nursing Home Administrator or Grievance Coordinator directly. There was no drop box or other method available for residents to submit grievances anonymously. During staff interviews, the Nursing Home Administrator confirmed that there was no process in place for anonymous grievance submission at the time of the survey.
Failure to Provide Appropriate Respiratory Care and Documentation for CPAP Therapy
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards of practice for a resident requiring CPAP therapy. The facility's policy required physician orders for CPAP to include pressure settings and hours of use, but did not specify how the CPAP mask should be stored when not in use. For a resident with diagnoses including obstructive sleep apnea, hemiplegia, hemiparesis following a stroke, and legal blindness, the physician's order for CPAP therapy lacked the required machine settings. Additionally, the resident's care plan did not include a respiratory care plan or documentation of CPAP use. Observations over several days revealed that the resident's CPAP mask was consistently stored hanging on a hook on the wall above the bed, with the mask directly touching the wall. Staff interviews confirmed the absence of required CPAP settings in the physician's order and the lack of a respiratory care plan in the resident's documentation. The facility's policy also did not provide guidance on proper storage of CPAP masks when not in use.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents, as required by policy and regulatory guidelines. For one resident with hemiplegia and moderate protein-calorie malnutrition, the Minimum Data Set (MDS) assessment contained conflicting information regarding the presence of a pressure ulcer. Specifically, the assessment indicated both the absence and presence of a pressure ulcer, with further details showing a Stage 3 pressure ulcer documented. The Director of Nursing (DON) confirmed the inaccuracy in the MDS coding for this resident. Another resident with nicotine dependence and hypertension was care planned for regular evaluation of safe smoking practices. However, the annual MDS assessment incorrectly indicated that the resident was not a current tobacco user, despite the resident's own statement and care plan documentation confirming daily supervised smoking. Similarly, a different resident with nicotine dependence and diabetes mellitus was also care planned for safe smoking but had their MDS assessment marked as not using tobacco and did not have nicotine dependence listed in the active diagnoses section, contrary to the clinical record and care plan. A further deficiency was identified for a resident with expressive aphasia and a history of stroke. The quarterly MDS assessment coded the resident's speech as clear, while observations, care plan documentation, and staff interviews indicated that the resident's speech was slurred and communication was primarily conducted through writing on a whiteboard. The DON acknowledged that the MDS should have reflected unclear speech based on the resident's documented status and care plan notes.
Failure to Develop Comprehensive Care Plans for Residents Using CPAP and Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by policy. For one resident with diagnoses including obstructive sleep apnea, hemiplegia, hemiparesis following a stroke, and legal blindness, clinical records and observations confirmed the use of a CPAP machine at bedtime per physician order. However, review of the resident's care plan revealed no documentation or respiratory care plan addressing the use of the CPAP, despite its ongoing use being documented in both annual and quarterly MDS assessments. Staff interviews confirmed the expectation that CPAP use should be included in the care plan. For another resident with dementia, behavioral disturbances, and delusional disorders, physician orders indicated the use of Seroquel for management of these conditions. Both annual and quarterly MDS assessments documented the use of antipsychotic medication, and the care area assessment summary indicated that antipsychotic medication use had triggered for care planning. Despite this, the resident's comprehensive care plan did not address the use of antipsychotic medication. Staff interviews confirmed that comprehensive care plans were expected to be developed accurately for all residents.
Failure to Revise Care Plan After Resolution of Pressure Ulcer
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of hemiplegia, hemiparesis, muscle weakness, and moderate protein-calorie malnutrition following a stroke. The resident developed a Stage 3 pressure ulcer, which was present from early July to mid-August. Despite the resolution of the pressure ulcer, the care plan continued to list an active focus on altered skin integrity related to limited mobility and an open area to the coccyx, with no updates or revisions made after the ulcer healed. A quarterly MDS assessment completed at the end of August indicated that the resident no longer had any pressure ulcers. However, the care plan was not updated to reflect this change, as confirmed by the DON during an interview. Facility policy requires care plans to be reviewed and updated at least quarterly or when there is a significant change in the resident's condition, but this was not done in this case.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and beverages at appetizing and safe temperatures, as evidenced by multiple sources including food committee meeting minutes, grievance logs, resident and staff interviews, and direct observation. Residents reported that vegetables were served cold, tea and coffee were not hot enough, and food temperatures were inconsistent, sometimes requiring staff to reheat meals. One resident specifically filed a grievance about the temperature of her tea, and several others confirmed during a group meeting that both food and coffee were often not served hot. During an interview, a resident also stated that his food was not always served hot. Observation of meal tray line service revealed that both hot and cold beverages were served in the same type of mug, and a test tray showed that creamed corn and coffee were served at 115°F, below the expected standard of above 135°F for hot foods and beverages. Iced tea was served in a hot beverage mug, was only half full, and measured 57°F, above the expected standard of below 50°F for cold beverages. The Dietary Manager acknowledged uncertainty about the use of mugs for both hot and cold drinks and confirmed that the process had not changed since her employment. The Nursing Home Administrator was made aware of the concerns regarding food and beverage temperatures and the inappropriate service ware for cold beverages.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident diagnosed with muscle weakness and diabetes. The facility's policy on Pressure Ulcer Prevention and Management required pressure relief measures such as elevating or floating heels. A physician's order dated July 22, 2024, specified the use of blue off-loading boots for the resident's bilateral heels. However, observations on three separate occasions revealed that the resident was not wearing the prescribed off-loading boots to elevate her heels off the bed.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store drugs in accordance with accepted professional principles, as observed in two medication carts. The Annex 1 North medication cart contained an Ozembic pen that was in use but not labeled with the date it was opened, a Levemir pen that was not refrigerated and lacked a date indicating when it was removed from refrigeration, and a Basaglar pen that was open without a date of opening. These observations indicate a failure to adhere to the facility's policy on medication storage, which requires medications to be stored safely and properly following the manufacturer's recommendations. The Annex 1 South medication cart contained a vial of Lantus insulin labeled with an open date of 51 days prior and another vial labeled 31 days prior, both exceeding the manufacturer's recommended discard period of 28 days. Additionally, two insulin Aspart pens were labeled with open dates of 31 days prior, also exceeding the recommended discard period. The Nursing Home Administrator acknowledged the expectation that medications should be labeled, stored, and disposed of according to the manufacturer's guidelines, highlighting a lapse in compliance with these standards.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident with specific medical conditions, including dysphagia and hemiplegia. The facility's policy on restorative adaptive equipment, revised in 2016, mandates the use of such devices to promote individual resident functional levels and prevent decline. Despite this, observations over three consecutive days revealed that the resident did not have the ordered Dycem, a non-slip rubber mat, present during meals in his room. The resident's care plan and physician's orders specified the use of Dycem during meals, but it was not provided, as confirmed by the Nursing Home Administrator's expectation that the adaptive equipment should have been available at all meals.
Failure to Report Allegation of Neglect Immediately
Penalty
Summary
The facility failed to adhere to its policy for reporting an allegation of neglect involving a resident. The policy, last revised in June 2024, mandates that any report or suspicion of an incident be immediately reported to the charge nurse or supervisor, who must then notify the Nursing Home Administrator (NHA) or Director of Nursing. In this case, a resident, who is cognitively intact with a BIMS score of 13, reported to a Licensed Practical Nurse (LPN) that a nurse on the night shift did not change her soiled brief. The LPN reported this allegation to the day shift supervisor the following morning. However, the Registered Nurse Supervisor, who was informed of the allegation, did not report it to the NHA immediately as required by the facility's policy. The NHA only became aware of the allegation the day after it was reported to the supervisor. An investigation was initiated, and statements were collected from the staff and the resident. The resident's statement indicated that she was changed, but the staff was slow to respond. The facility ultimately found the allegation of neglect to be unsubstantiated.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for three residents. Resident 14, diagnosed with type 2 diabetes mellitus and a history of traumatic brain injury, had a physician's order for Insulin Glargine to be administered at bedtime, with instructions to hold the insulin if blood sugar levels were below 150. However, the facility did not adhere to this order, as insulin was administered on multiple occasions despite blood sugar levels being below the threshold. Additionally, there was a lack of documentation for blood sugar levels corresponding with the insulin administration time. Resident 20, who has major depressive disorder and hypertension, had a physician's order for insulin administration based on a sliding scale for blood sugar levels. Despite having blood sugar levels that required insulin administration, the facility failed to administer insulin on several occasions as per the physician's order. This oversight was acknowledged by the Nursing Home Administrator, who expected the insulin to be administered as ordered. Resident 51, diagnosed with cerebral infarction and hemiplegia, had a physician's order for Trolamine Salicylate cream to be applied topically as needed for muscle pain. During an observation, it was found that the cream was left in the resident's room, despite the resident not being authorized to self-administer the medication. This was confirmed by the Regional Nurse, who stated that the cream should not have been left in the room.
Failure to Provide Proper CPAP Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who required the use of a CPAP machine. The facility's policy required the CPAP system to be cleaned weekly. However, upon review of the resident's clinical record, there was no documentation indicating that the CPAP mask, tubing, filter, and water supply had been cleaned or changed. The resident had a physician's order for CPAP use at bedtime and during naps, and the Medication Administration Record confirmed daily use of the CPAP machine. The resident had diagnoses including stage 3 chronic kidney disease and pulmonary fibrosis, necessitating the use of a CPAP machine. Despite the resident's condition and the facility's policy, there were no cleaning orders in place for the CPAP equipment until new orders were established with an active date set for a future date. The Nursing Home Administrator acknowledged that cleaning orders should have been in place earlier and expected the CPAP to be cleaned weekly, indicating a lapse in adherence to the facility's policy and professional standards of care.
Neglect During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to protect a resident from neglect during the provision of care, resulting in actual harm. A staff member, Employee 1, did not verify the resident's transfer status and proceeded to transfer the resident independently, despite the care plan indicating that the resident required assistance from two persons and a rolling walker. This oversight led to the resident sustaining a laceration on the right lower leg, necessitating hospital transfer and 13 sutures. The resident, who had been admitted with diagnoses including anorexia nervosa and failure to thrive, was supposed to be transferred with two-person assistance. However, Employee 1, who was instructed to wash and dress the resident only, mistakenly attempted to weigh the resident and transferred her alone. During the transfer, the resident's leg was injured when it was caught on the wheelchair, causing a significant laceration. Interviews and statements from staff confirmed that Employee 1 was aware of the transfer requirements but failed to adhere to them. The facility's policy on abuse and neglect was not followed, as the staff member did not provide the necessary care to prevent harm. The incident was reported, and the facility substantiated the neglect, resulting in the decision that Employee 1 should not return to the facility.
Failure to Provide Adequate Assistance During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide the necessary assistance required for a safe transfer of a resident, resulting in actual harm. The resident, who had a history of anorexia nervosa and failure to thrive, required a two-person assist with a rolling walker for transfers as per their care plan. However, during a transfer from bed to wheelchair, only one staff member assisted the resident, leading to a laceration on the resident's right shin. This injury required hospitalization and 13 sutures. The incident occurred when the nursing assistant attempted to transfer the resident alone, contrary to the care plan that specified a two-person assist. The resident's leg was caught on a metal piece of the wheelchair during the transfer, causing the laceration. The Director of Nursing confirmed that the facility did not provide adequate supervision and assistance during the transfer, which resulted in harm to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 207 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gettysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia At Spiritrust Gettysburg | 0.9 mi | ★★★★★ | 7 | 0 |
| Gettysburg Center | 1 mi | ★★★★★ | 13 | 0 |
| Gardens At Gettysburg, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Cross Keys Village-brethren Home Community, The | 8.8 mi | ★★★★★ | 0 | 0 |
| Paramount Nursing And Rehab At Fayetteville, Llc | 11.9 mi | ★★★★★ | 2 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Transitions Healthcare Gettysburg.
100% money-back within 48 hours.
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.