A list of the most recent deficiencies for The Gardens at Gettysburg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-28 | 2023-10-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-27 | 2023-08-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-07-27 | 2023-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-27 | 2023-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-27 | 2023-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-08-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-07-27 | 2023-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-27 | 2023-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-27 | 2023-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-06 | 2023-07-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-06 | 2023-07-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-06 | 2023-07-19 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-18 | 2023-02-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-14 | 2023-01-05 | Y |
| Meet other general requirements. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-17 | 2022-09-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-04 | 2022-09-13 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-08-04 | 2022-09-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-04 | 2022-09-13 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-04 | 2022-09-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-04 | 2022-09-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-04 | 2022-09-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-09-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-08-04 | 2022-09-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-04 | 2022-09-13 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-08-04 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-09-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-04 | 2022-09-13 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-03 | 2022-02-17 | Y |
| Post nurse staffing information every day. | Health | 2022-02-03 | 2022-02-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-21 | 2022-01-11 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-27 | 2021-09-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-22 | 2021-09-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-22 | 2021-09-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-22 | 2021-09-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-22 | 2021-09-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-22 | 2021-09-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-22 | 2021-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-22 | 2021-09-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-22 | 2021-09-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-07-22 | 2021-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-22 | 2021-09-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-03 | 2021-06-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-05 | 2021-03-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-05 | 2021-03-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-05 | 2021-03-30 | Y |
| 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. | Health | 2021-03-05 | 2021-03-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-03-05 | 2021-03-30 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-03-05 | 2021-03-30 | Y |
