Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on clinical record review and staff interviews, it was determined that the facility failed to provide a
transfer notice to the resident or their representative upon transfer out of the facility, which included the
following information: the reason for the transfer or discharge, date of transfer, location of transfer,
statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of
the Office of the State Long-Term Care Ombudsman for three of three residents reviewed for
hospitalizations (Residents 63, 77, and 84).
Findings include:
Review of the clinical record for Resident 63 on February 19, 2025, revealed clinical diagnoses that
included depression disorder (major loss of interest in pleasurable activities, characterized by change in
sleep patterns, appetite and or daily routine) and dementia (irreversible, progressive degenerative disease
of the brain, resulting in loss of reality contact and functioning ability).
Further review of Resident 63's clinical record revealed transfers to the hospital on March 28, 2024, to April
1, 2024; July 30, 2024, to August 9, 2024; and January 6, 2025, to January 21, 2025.
The surveyor requested copies of the transfer, bed hold, and Ombudsman notification. The Ombudsman
notification and bed hold notices were provided, however, the transfer notices provided failed to include a
statement of the Resident's appeal rights and the name, address (mailing and email), and telephone
number of the Office of the State Long-Term Care Ombudsman.
During an interview with the Nursing Home Administrator (NHA) on February 20, 2025, at 10:50 AM, the
NHA confirmed that the written transfer notice should include information that is required.
Review of Resident 77's clinical record revealed diagnoses that included congestive heart failure
(decreased ability of heart to pump blood through out the body) and atrial fibrillation (irregular heartbeat).
Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute
medical change in condition on June 23, 2024. Review of Resident 77's clinical record revealed no
evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's Representative.
Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute
medical change in condition on January 22, 2025. Review of Resident 77's clinical record revealed no
evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's
(continued on next page)
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 8
Event ID:
395733
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0623
representative.
Level of Harm - Minimal harm
or potential for actual harm
During a staff interview on February 20, 2025, at approximately 1:00 PM, the NHA confirmed that the
facility did not provide Resident 77 or Resident 77's Representative with a notice of transfer letter for the
transfers to the hospital on June 23, 2024, and January 22, 2025.
Residents Affected - Some
Review of Resident 84's clinical record revealed diagnoses that included dementia with agitation (loss of
memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with
daily life) and history of falling.
Further review of Resident 84's clinical record revealed that she was transferred to the hospital on January
13, 2025, following a fall with fracture, and was subsequently admitted .
Review of Resident 84's clinical record failed to reveal that written notification was provided to her or her
representative regarding her transfer to the hospital, which included the following required contents: reason
for transfer, effective date of the transfer, location to which the Resident was transferred, a statement of the
Resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman.
During an interview with the NHA on February 20, 2025, at 12:52 PM, she confirmed that the
aforementioned transfer notice was not provided to Resident 84 or her Representative.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 2 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to
ensure the care plan was reviewed and revised for one of 24 residents reviewed (Resident 4).
Residents Affected - Few
Findings Include:
Review of Resident 4's clinical record revealed diagnoses that included congestive heart failure (a serious
condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs) and
anxiety (a group of mental health conditions characterized by excessive worry, fear, and nervousness that
can interfere with daily life).
Observation of Resident 4 on February 17, 2025, at 11:22 AM, revealed Resident 4 lying in bed and
Resident 4 had facial hair.
Review of Resident 4's care plan revealed a focus area of, Resident/Patient requires assistance/is
dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer,
locomotion, toileting, with a revision date of August 31, 2024. Review of the interventions of this care plan
failed to mention any expectation that Resident 4 refuses care or that Resident 4 would complete their own
facial shaving.
Interview with the Director of Nursing on February 19, 2025, at 11:56 AM, revealed that Resident 4 often
refuses care and completes her own facial shaving when she feels it is necessary, and that it should have
and would be added to the care plan.
28 Pa. Code 211.12(d)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 3 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interviews, clinical record review, and facility's policy review, it was determined
that the facility failed to ensure that a resident with a pressure ulcer received care consistent with
professional standards of practice for one of three residents reviewed (Resident 54).
Residents Affected - Few
Findings include:
A review of the facility policy, titled Wound Dressings: Aseptic, last reviewed January 2025, directed staff to
do the following: after applying and securing the clean dressing, to apply a label with date and initials.
A review of the clinical record for Resident 54 on February 19, 2025, revealed clinical diagnoses that
included stage IV sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone of the
large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) and
bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to
manic highs).
A review of Resident 54's physician orders dated February 2025, included an order for wound care to the
sacrum every evening shift. The physician order stated, cleanse with normal saline solution (salt solution),
lightly pack with calcium alginate (absorbs excess wound exudate, creating a moist environment that
promotes wound healing), cover with bordered gauze island dressing.
Observation of wound care on February 19, 2025, at 2:23 PM, revealed there was no dressing in place to
indicate when the last dressing change was completed. Employee 6 (Registered Nurse) had no explanation
for the missing dressing and agreed that there should have been a dressing in place from the previous day.
During an interview with the Nursing Home Administrator (NHA) on February 20, 2025, at 10:50 AM, the
NHA agreed that Resident 54's dressing should have been in place from the previous treatment and dated
and initialed as the facility policy stated.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 4 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, facility policy review, and staff interview, it was determined that the facility failed to
ensure protection from contamination of a urinary catheter for one of three residents reviewed with
indwelling catheters (Resident 17).
Findings include:
Review of facility policy, Catheter:Indwelling Urinary - Care of, revised February 1, 2023, revealed, Secure
catheter tubing to keep the drainage bag below the level of the patient's bladder and off of the floor.
Review of Resident 17's clinical record revealed diagnoses that included obstructive uropathy (condition in
which urine cannot drain through the urinary tract and causes kidney damage) and hydronephrosis
(swelling of the kidneys when urine flow is obstructed in any part of the urinary tract).
Review of Resident 17's care plan revealed that he utilized an indwelling foley catheter (small, flexible tube
that can be inserted through the urethra and into the bladder, allowing urine to drain) for obstructive
uropathy. Further review of Resident 17's care plan revealed Keep catheter off floor.
Observation of Resident 17 on February 18, 2025, at 11:43 AM, revealed him being transported by staff in
his wheelchair, and his catheter tubing was dragging on the ground underneath his chair.
During an interview with the Nursing Home Administrator on February 20, 2025, at 10:45 AM, she revealed
the expectation that Resident 17's catheter tubing should not have been touching the ground.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 5 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observations and staff interview, it was determined that the facility failed to post required nurse
staffing information on a daily basis.
Residents Affected - Many
Findings Include:
Observations on February 19, 2025, at 9:02 AM, and February 20, 2025, at 9:20 AM, revealed the posted
facility's nursing staff information was dated for February 18, 2025.
During an interview with the Nursing Home Administrator on February 20, 2025, at approximately 10:30
AM, it was revealed that it was the facility's expectation that posted staffing be updated daily.
28 Pa. Code 201.14(a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 6 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observations and staff interviews, it was determined that the facility failed to ensure medications
were stored in a manner that met professional standards for three of three medication carts observed
(North Hall B, North Hall C, and South Hall A medication carts).
Findings include:
Observations of North B Hall medication cart on February 19, 2025 revealed multiple loose pills (whole and
fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the
medication cart drawers and in the bottom of the cart under the drawers. It was also observed that a
blister-pack of medications was lodged behind the lowest drawer, which had been filled by the pharmacy in
April 2024, for a Resident that had been discharged from the facility in April 2024.
During a staff interview directly after the aforementioned observation, Employee 3 (Licensed Practical
Nurse) revealed that she was unaware of the facility's procedure for cleaning the medication carts.
Observations of North C Hall medication cart on February 19, 2025, revealed multiple loose pills (whole
and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the
medication cart drawers and in the bottom of the cart under the drawers.
Observations of the South A Hall medication cart on February 19, 2025, revealed multiple loose pills (whole
and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the
medication cart drawers and in the bottom of the cart under the drawers.
During a staff interview on February 19, 2025, directly after the aforementioned observation of South A Hall
medication cart, Employee 4 (Licensed Practical Nurse) revealed she was familiar with the facility's
procedure regarding cleaning of the medication carts as she was recently hired by the facility.
During a staff interview on February 20, 2025, at approximately 1:00 PM, Nursing Home Administrator
(NHA) revealed that the facility did not have policy or procedure in place that addressed how often
medication carts should be inspected and cleaned. During the interview, the NHA revealed that it was the
facility's expectation that medication carts are clean
211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 7 of 8
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
395733
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gettysburg Center
867 York Road
Gettysburg, PA 17325
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observations, facility document review, and staff interviews, it was determined that the facility
failed to serve all items on the posted menu, and failed to serve items in the appropriate quantity for one of
12 residents observed (Resident 8).
Findings include:
Review of Resident 8's clinical record revealed diagnoses that included dysphagia (difficulty swallowing)
and need for assistance with personal care.
Review of Resident 8's physician orders revealed an order for a regular/liberalized diet, dysphagia puree
texture (type of diet for those with swallowing difficulties consisting of pureed, homogenous and cohesive
foods that are pudding-like), effective September 26, 2024.
Review of Resident 8's lunch meal ticket for February 18, 2025, (paper slip provided with tray that indicates
diet, items to be received, as well as resident allergies and preferences) revealed she was to receive the
following: #8 scoop (1/2 cup/4 oz) pureed dysphagia sweet and sour meatballs, pureed boiled potatoes,
pureed white rice, pureed warm bread, pudding, and brown gravy.
Observation of meal service on February 18, 2025, at 12:39 PM, revealed Employee 1 (Dietary Aide)
plating Resident 8's meal, then nursing staff delivering the meal tray. Employee 1 served the pureed
meatballs using a #16 scoop (1/4 cup/2 oz). Additionally, it was observed that Resident 8 did not receive
pureed rice.
During an interview with Employee 1 on February 18, 2025, at 12:47 PM, he confirmed that he missed
serving Resident 8's rice. He also confirmed that he used a #16 scoop to serve the pureed meatballs.
Review of Resident 8's lunch meal ticket for February 19, 2025, revealed that she was supposed to receive
2 ounces of brown gravy with her meal.
Observation on February 19, 2025, at 12:50 PM, revealed Resident 8 was served her lunch meal in her
room. No gravy was present on her tray.
During an immediate interview with Employee 2 (Dietary Aide), she confirmed that she had not given
Resident 8 her gravy.
During an interview with the Nursing Home Administrator on February 20, 2025, at 12:34 PM, she revealed
the expectation that Resident 8 should have received all of her food and in the correct portion sizes.
28 Pa. Code 201.14(a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395733
If continuation sheet
Page 8 of 8
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Back to topCitations
7 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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the February 20, 2025 survey of GETTYSBURG CENTER?
This was a inspection survey of GETTYSBURG CENTER on February 20, 2025. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GETTYSBURG CENTER on February 20, 2025?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.