Transitions Healthcare Gettysburg

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 6, 2026

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident. Resident 1 was found by security staff at a nearby college campus as she was attempting to enter a locked building. This failure placed an additional 14 residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15).Findings include: Review of facility policy, titled Elopement/Wandering Resident, revised August 27, 2025, revealed, Managing elopement risk is crucial for ensuring… […]

• Actual harm, isolatedF600Jun 11, 2024

  Based 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. […]

• Actual harm, isolatedF689Jun 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF641Aug 20, 2026

  Based on clinical record review 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 24 residents reviewed (Resident 2, 7, 14, and 55).Findings include: Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills) and bipolar disorder (unusual shifts in mood, ranging from extreme highs to lows). […]

• No harm, potential for more than minimal, patternF656Aug 20, 2026

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for four of 24 residents reviewed (Residents 6, 7, 12, and 55).Findings include: Review of facility policy, titled OPS 351a Care Plan-Comprehensive, with a last review date of July 20, 2026, revealed, in part, Each resident will have a comprehensive care plan developed that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. […]