Federal inspectors found the hygiene failures during a September 24 complaint investigation at the 120-bed facility on York Road.
Resident 1, who has high blood pressure and chronic lung disease, was scheduled for showers on Mondays and Thursdays according to facility records. But the resident missed showers on August 28, September 4, September 8, and September 11 — all marked "not applicable" in the shower task log.
The resident's care plan specifically noted the importance of allowing them to choose between different bathing options: tub bath, shower, bed bath, or sponge bath.
Resident 3 faced similar neglect. The resident, who has dementia and heart problems related to high blood pressure, was scheduled for showers on Mondays and Fridays. Staff marked shower days as "not applicable" on August 29, September 5, September 8, September 15, September 19, and September 22.
Like the other resident, this person's comprehensive care plan emphasized the importance of choice in bathing methods. The plan, created on August 29, stated it was important for the resident "to engage in daily routines that are meaningful relative to their preferences."
The administrator told inspectors during a September 24 interview that staff were using the wrong documentation. If residents refused showers on their scheduled days, she said, staff should mark it as a "refusal" rather than "not applicable."
The distinction matters for tracking whether residents are receiving adequate hygiene care or choosing to decline it.
Federal regulations require nursing homes to provide care and assistance with daily living activities for residents who cannot perform them independently. Personal hygiene and grooming fall under these requirements.
Inspectors reviewed 10 residents' records and found the hygiene documentation failures affected two of them. The violations received a "minimal harm" rating, indicating the problems created potential for actual harm rather than immediate jeopardy.
Both residents affected by the shower scheduling failures have serious underlying health conditions. Resident 1's chronic obstructive pulmonary disease causes ongoing lung inflammation and breathing difficulties. Resident 3's dementia affects memory, language, and problem-solving abilities severe enough to interfere with daily functioning.
The inspection report notes that Resident 1's portable care document, called a Kardex, emphasized the importance of offering bathing choices. This suggests staff were aware of the resident's preferences but failed to properly document when scheduled showers didn't occur.
For Resident 3, the care plan was created on August 29 — the same day the first missed shower was marked "not applicable." This timing indicates the facility had recently assessed the resident's bathing needs and preferences but immediately began improperly documenting missed care.
The administrator's admission that staff should mark refusals differently suggests the facility knew proper documentation procedures but wasn't following them consistently.
Pennsylvania nursing home regulations require facilities to provide adequate nursing services and protect resident rights, including the right to personal hygiene care and meaningful daily routines.
The improper documentation creates gaps in understanding whether residents are choosing to decline showers or simply not receiving scheduled hygiene care. This distinction is crucial for ensuring residents maintain dignity and health while receiving appropriate assistance with daily living activities.
Gettysburg Center must submit a correction plan to continue participating in Medicare and Medicaid programs. The facility has 120 beds and provides skilled nursing and rehabilitation services in Adams County.
The September complaint investigation that uncovered these violations suggests someone — possibly a family member, resident, or employee — raised concerns about care quality at the facility.
Both residents continue living at Gettysburg Center while the facility addresses the hygiene documentation and care provision failures identified by federal inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gettysburg Center from 2025-09-24 including all violations, facility responses, and corrective action plans.