Gardens at Gettysburg, the

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to complete criminal background checks prior to hire for one of five personnel records reviewed (Employee 7); failed to verify licensure status for one of two nurses reviewed (Employee 8); and failed to verify nurse aide registry status for one of two nurse aides reviewed (Employee 9).

Inspectors wroteBased on policy review, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of one Residents receiving intravenous medications reviewed (Resident 98).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 18 residents reviewed (Resident 48).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 28 residents reviewed (Residents 48, 83, 85, and 90). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Observation of Resident 48 on May 12, 2025, at 12:41 PM, revealed Resident 48 lying in bed. Beside Resident 48 on his bedside stand was a CPAP (continuous positive airway pressure) machine with the mask lying on top of it. The mask was not in a bag or put away. Observation of Resident 48 on May 13, 2025, at 12:04 PM, revealed Resident 48 lying in bed. [...]

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming for resident's dependent on staff for assistance with activities of daily living for one of 28 residents reviewed (Residents 91).

Inspectors wroteBased on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 55). Findings Include: Review of the facility's policy, titled Oxygen Therapy, with no review date, revealed in the section, Oxygen Concentrators, staff are to connect one end of the cannula tubing to the concentrator and place the other end into the resident's nostrils. The policy does not address the addition of a humidification bottle. Review of Resident 55's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause persistent and progressive airflow obstruction and breathing problems) and difficulty in walking. [...]

Inspectors wroteBased on review of clinical records, hospital records review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident's total program of care, including medications, was reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 23 residents reviewed (Residents 14, 52, 56, and 69).

Inspectors wroteBased on clinical record review, facility policy review, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 20 residents reviewed (Resident 56).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of five residents reviewed for use of a catheter (Resident 92). Findings Include: Review of Resident 92's clinical record revealed diagnoses that included obstructive and reflux uropathy (structural or functional hindrance of normal urine flow) and hemiplegia and hemiparesis following cerebral infarction (one-sided weakness or inability to move following stroke). Further review of Resident 92's clinical record revealed he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure timely practitioner services following discovery of a skin integrity concern for two of three residents reviewed for pressure injuries (Residents 26 and 92).

Inspectors wroteBased on observations, facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure clinical records were complete and accurately documented for one of three residents reviewed for oxygen use (Resident 30).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 12 residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain). [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 12 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs) and congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain). Review of Resident 2's February and May 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Miacalcin Nasal Solution (medication that contains calcitonin, a hormone that helps prevent bone loss in postmenopausal women) daily for osteoporosis effective February 17, 2023. [...]

Inspectors wroteBased on staff interviews, record review, policy review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration for one of three residents reviewed (Resident 1).

Inspectors wroteBased on review of select facility documentation, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need on two of four nursing units (200 and 400 hallways).