Gardens at Gettysburg, The

In the surveyor’s words

From the most serious findings on record at Gardens at Gettysburg, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657May 15, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF641Jun 27, 2024

  Based 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). Findings include: Review of Resident 14's clinical record revealed diagnoses that included chronic embolism and thrombosis of deep veins of left lower extremity (blockage in blood vessel, usually by a blood clot) and peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs). […]

• No harm, potential for more than minimal, patternF584Jul 27, 2023

  Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three dining rooms (both 300 unit dining areas), and four of 46 resident rooms (Resident 7, 8, 35, and 51's rooms). Findings include: Observations in the 300 unit main and auxiliary dining areas on July 24, 2023, at 10:40 AM, and on July 26, 2023, at 10:50 AM and at 1:40 PM, revealed that an accumulation of dried food debris was present on the surface of several dining chairs. […]

• No harm, potential for more than minimal, patternF641Jul 27, 2023

  Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 26 residents reviewed (Resident 22, 35, 44, 61, 75, and 84). Findings Include: Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). […]

• No harm, potential for more than minimal, patternF684Jul 27, 2023

  Based on facility policy, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 30 residents reviewed (Residents 22, 23, 61, and 86). Findings include: Review of facility policy, titled Catheter care, urinary last reviewed June 29, 2023, revealed, Review the resident's care plan to assess for any special needs of the resident .Maintain an accurate record of the resident's daily output, per facility policy and procedure. […]