Transitions Healthcare Gettysburg

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was revealed that the facility failed to ensure that one of 3 residents reviewed received a therapeutic diet per physician order (Resident 1).

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident's right to file a grievance anonymously was honored on three of three resident living areas.

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of two residents reviewed (Resident 5).

Inspectors wroteBased on observations, review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for four of 24 residents reviewed (Residents 5, 75, 99, and 118).

Inspectors wroteBased on facility policy review, observation, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 24 residents reviewed (Residents 5 and 116).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for one of 24 residents reviewed (Resident 5).

Inspectors wroteBased on observation, food committee meeting minutes, grievance review, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature.

Inspectors wroteBased on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of five residents reviewed (Resident 108). Findings Include: Review of facility policy, titled Pressure Ulcer Prevention and Management, revised September 13, 2019, revealed in a section Pressure relief: Elevate/float heels or obtain a device to provide pressure relief. Review of Resident 108's clinical record revealed diagnoses of muscle weakness (weakness in the muscles that makes movement difficult) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). [...]

Inspectors wroteBased on observations, product label review, facility policy review, and staff interview, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for two of three medication carts observed (Annex 1 North medication cart and Annex 1 South medication cart). Findings Include: Review of facility provided policy, Storage of Medications, effective September 2018, revealed, Medication and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Observation of the Annex 1 North medication cart on August 15, 2024, at 9:40 AM, revealed one Ozembic (a prescription injectable medication used to treat type 2 diabetes) that was currently in use and was not labeled with a date that it was opened. [...]

Inspectors wroteBased on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 24 residents reviewed (Resident 59).

Inspectors wroteBased on resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to follow the facility policy for reporting an allegation of neglect to the Nursing Home Administrator (NHA) immediately for one of 24 residents reviewed (Resident 5).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 27 residents reviewed (Residents 14, 20, and 51). Findings Include: Review of Resident 14's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and history of traumatic brain injury (injury to the brain caused by an external force). Review of Resident 14's physician orders revealed an order for Insulin Glargine, inject 6 units at bedtime for type 2 diabetes, hold for blood sugar level less than 150, starting May 10, 2024. Further review indicated an administration time of 9:30 PM. [...]

Inspectors wroteBased on observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed for respiratory care (Resident 9).

Inspectors wroteBased on observation, review of clinical record, facility documentation review, facility policy review, hospital records review, and staff and resident interviews, it was determined that the facility failed to ensure that residents were protected from neglect during provision of care for one of four residents reviewed (Resident 1). The facility staff member failed to verify the resident and transfer status, which resulted in actual harm to Resident 1 who sustained a laceration to the right lower leg, transfer to the hospital, and received 13 sutures to the right lower leg. Findings Include: [...]

Inspectors wroteBased on review of clinical records, facility policy review, review of facility investigation reports, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide the assistance required for a safe transfer for one of four residents reviewed (Resident 1), resulting in actual harm as evidenced by a laceration that required transfer to the hospital and 13 sutures. Findings Include: A review of the facility policy, titled Transfer/Lift Policy, stated, all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. [...]

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 27 residents reviewed (Residents 3, 34, 61, and 117). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included nicotine dependence and diabetes mellitus Type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 3's physician orders revealed no orders for insulin; [...]

Inspectors wroteBased on clinical record review and staff and resident interviews, it was determined that the facility failed to develop and/or implement a comprehensive person-centered care plan for three of 24 residents reviewed (Residents 28, 36, and 106).

Inspectors wroteBased on observations, clinical record review, review of facility provided documents, and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for two of 27 Residents reviewed (Residents 47 and 61).

Inspectors wroteBased on observations, staff interviews, and policy review, it was determined that the facility failed to ensure appropriate labeling (opened date) of medication for three of six medication carts (Annex 1 cart, South Wing cart, and East Wing cart) that effected eight residents (Residents 7, 34, 35, 36, 37, 73, 80, and 95); failed to have refrigerated one unopened vial that effected one resident (Resident 80); and failed to have an open date or resident name on one medication that was stored with medications in use.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in three of three nourishment rooms.

Inspectors wroteBased on facility policy review, clinical record 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.

Inspectors wroteBased on personnel file review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, and/or that this training included dementia management and resident abuse prevention, for seven of seven nurse aide employee records reviewed (Employees 3, 4, 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 3 was hired on November 18, 2019; Employee 4 was hired on October 4, 2011; Employee 5 was hired on August 9, 2011; Employee 6 was hired on July 19, 2019; and Employee 7 was hired on November 29, 2021. Review of training records provided by the facility failed to reveal evidence that Employees 3, 4, 5, 6, and 7 received at least 12 hours of annual in-service training. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for three of 27 residents reviewed (Residents 36, 41, and 70)

Inspectors wroteBased on clinical record review, observations, and staff and resident interviews, it was determined that the facility failed to ensure that care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of 27 residents reviewed (Residents 36, 95, and 117).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of one residents reviewed (Resident 7).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to complete a timely assessment for trauma, and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one out of 24 residents reviewed (Resident 107).