Gettysburg Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

following commands when I went closer to him he then lunged forward pinning me on to the bed. Fellow CNA called for help [Resident 4] still wasn't following commands and still was very aggressive .no way to console him or de-escalate. Employee 7 was helping to hold his knees down until Employee 2 [Registered Nurse] came in.Review of Employee 9's (Nurse Aide) witness statement dated August 11, 2025, revealed,

in part, [Resident 4] was getting up from his bed. I assisted him by bringing his wheelchair, but he wouldn't sit down. The nurse was walking past and I asked her for help but one of the aides came in to help assist as

we told [Resident 4] to have a seat in his chair cause we didn't want him to fall. He pushed the other aide down to this bed and held her down. We tried to tell him we were there to help but he kept holding her down to the bed .Nurse and aides came to assist but he became aggressive.Review of Employee 10's (Registered Nurse) witness statement dated August 11, 2025, revealed, in part, I was alerted by CNA screaming down the A hall that they needed help with [Resident 4]. I go in the room and see [Resident 4] pinning one of the CNAs on the bed. As another aide attempts to take him off her, but as she tries to get him off her he tries to throw punches at them. We attempted to get him to sit on the chair, but he continued to throw punches and kick with both legs at all staff members. As he continues his aggression I call [practitioner] and get order to send to ER [Emergency Room]. When Employee 10 entered room [Employee 8 (Nurse Aide)] had Resident's left wrist. [Employee 13 (Licensed Practical Nurse)] had right wrist. They sat him down on chair. He began kicking staff so Employee 2 was holding his right thigh down to keep him from kicking.Review of Employee 11's (Licensed Practical Nurse) witness statement dated August 11, 2025, revealed, in part, I was down C Hall when [Employee 9] came down the hall stating they need help with [Resident 4]. She said he was trying to punch staff. When I entered the room [Employee 8] was holding [Resident 4's] left arm, [Employee 2] was assisting trying to hold his legs down as he was trying to kick staff and [Employee 13] was holding his right arm. He continued to try to kick, bite, and punch staff. I assisted holding his right forearm as he continued to try to punch staff, kick and turn his head to bite Ambulance crew arrived then [State Police] who after [Resident 4] was administered IM [Intramuscular] medication in his left thigh by the ambulance crew directed us one by one out of the room.Review of Resident 4's physician orders failed to reveal an order allowing use of physical restraint either before or immediately following the aforementioned incident.During an interview with the Director of Nursing on August 13, 2025, at 1:33 PM, she confirmed that no order for application of a physical restraint was obtained for Resident 4.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.8 (d) Use of restraints.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gettysburg Center

867 York Road Gettysburg, PA 17325

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

because no one approached her about the event. Resident 1 said she wasn't sure if it was reported by the male nurse. Resident said staff took her blood pressure on July 31, 2025, at 10:30 AM, and it was 100/60, (confirmed in clinical record) which was low per Resident 1. Resident 1 added that she didn't urinate for about 6-8 hours, which she said was unusual for her, but denied any pelvic pressure. (Note: a side effect of morphine is urinary retention and reduced arterial blood pressure). Resident 1 said was able to attend activities and had no complaints of discomfort.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at 11:45 AM, she confirmed that Employee 1 never reported the medication error with Resident 1. A statement written August 1, 2025, by Employee 1 failed to admit syringe entered Resident 1's mouth, but did admit to approaching Resident 1 and that Resident 1 stopped him. The NHA stated that Employee 1 no longer works at the facility. There was no record of the physician being notified of the event.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gettysburg Center

867 York Road Gettysburg, PA 17325

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, as well as resident, resident family member, and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of four residents reviewed (Resident 1).Findings include: A review of the facility policy, titled Infection Control Policies and Procedures, last revised February 24, 2025, stated, Centers will record incidents identified under the Infection Prevention and Control Program (IPCP) and the corrective actions taken. Breaches in Practice are failures in infection control practices, such as non-compliance.Reports from staff, patients, or families on any healthcare associated infection or spread of disease due to possible errors

in infection prevention or control Centers for Disease Control states all single-dose syringes should never be used for more than one patient and is a breach in practice.Review of the admission record indicated Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses that included hypertension (elevated blood pressure) and dysphagia (difficulty swallowing).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) completed May 5, 2025, revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition.Review of select documents revealed Resident 1 reported to her daughter that Employee 1 (Registered Nurse) on July 31, 2025, at 2:00 AM, entered her room, where

she resides with her spouse who is hospice status. Resident 1 said she was asleep, and Employee 1 placed a syringe in the corner of her mouth. Resident 1 immediately woke up and said no, no, no that is my husband's medication. Resident 1 reported that she was able to taste some of the medication before the syringe was removed. Resident 1 reported that Employee 1 pulled the syringe out of her mouth, turned around, and inserted the same syringe into her husband's mouth and administered the Morphine (opioid).Resident 1 reported the event to nursing on July 31, 2025, at 7:00 AM. Resident 1 notified her daughter in the evening of the event on July 31, 2025.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025. Resident 1's daughter was also concerned about the syringe being placed in her dad's mouth due to a current infection Resident 1 was receiving antibiotics to treat.A review of Resident 1's clinical record revealed the Resident was diagnosed with bacterial sinusitis and was currently receiving Cefuroxime Axetil (antibiotic that treats bacterial infections) 500 milligrams twice a day for 7 days, effective July 29, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at approximately 1:00 PM, the NHA agreed that

the syringe should have been discarded after being inserted into Resident 1's mouth and the event should have been reported by Employee 1. The NHA added that Employee 1 no longer works at the facility.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet