Gettysburg Center
GETTYSBURG CENTER in GETTYSBURG, PA — inspection on March 19, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
professional standards of practice that will meet each resident's physical, mental, and psychosocial
Medication Administration, General Guidelines; dated January 2025, failed to reveal any expectation of employees giving medications to remain with the resident and observe the resident take the medication.
Review of the Pennsylvania Nursing Practice Act, Chapter 21.145.
Functions of the LPN (Licensed Practical Nurse).
The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures.Review of Resident 92's clinical record revealed diagnoses of gastro esophageal reflux disease without esophagitis (disease (GERD) characterized by typical acid reflux symptoms-heartburn and regurgitation) and peripheral vascular disease (a slow, progressive circulation disorder involving blood vessel damage, narrowing, or blockages outside the heart and brain).Observation of Resident 92 on March 17, 2026, at 10:20 AM, revealed the resident sitting in bed. On her overbed table there were eight pills {identified as aspirin 81 mg (nonsteroidal anti-inflammatory drug) , bupropion ER 150 mg (antidepressant), bupropion ER 300 mg, Calcitriol 0.5 mcg (vitamin D3), Vitamin B12 500 mcg- 2 tablets, Metoprolol 50 mg (blood pressure medication), and Senna 8.5 mg (laxative)}.
Interview with Resident 92 at that time revealed that Employee 2 (Licensed Practical Nurse) had left them there with her to take after she was finished with her breakfast.Review of Resident 92's physician orders failed to reveal a physician's order for self-administration of medication.Review of Resident 92's Care Plan failed to reveal a care plan for self-administration of medication.Review of Resident 92's clinical record failed to reveal an evaluation of Resident 92 for self-administration of medication.Interview with the Nursing Home Administrator on March 18, 2026, at 1:00 AM, revealed that Resident 92 should not have had her medications left at her bedside. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
395733 03/19/2026
Gettysburg Center 867 York Road Gettysburg, PA 17325
confirmed that there was no dietary fluid intake recorded with Resident 11's meal intake
period.
She confirmed that she would expect staff to follow a resident's ordered fluid restrictions and
395733 03/19/2026
Gettysburg Center 867 York Road Gettysburg, PA 17325
Based on facility policy reviews, observations, and staff interviews, it was determined that the
Hall C cart); and failed to discard expired medications in two of three medication carts observed (South Hall B and C carts).Findings include: Review of facility policy, titled Storage of Medication, dated January 2025, revealed, in part, Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration.
Note the date on the label for insulin vials and pens when first used.
Review of facility policy appendix Medications with Shortened Expiration Dates, dated 2007, revealed that Lispro insulin should be discarded 28 days after opening.
Observation of the South Wing B Hall medication cart on March 17, 2026, at 12:12 PM, with Employee 4 (Registered Nurse) revealed an opened haloperidol 1 ml single dose vial, which had no resident name or date indicated on the vial.
The vial was laying loose in the plastic bin with insulin pens.
During an immediate staff interview with Employee 4, Employee 4 confirmed that the vial was not labeled or dated and that it should have been discarded when used since it was a single dose vial.
Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed a lispro insulin belonging to Resident 74 which was dated as being opened on February 16, 2026; and a Lantus insulin pen belonging to Resident 5, which was opened, but not dated.
The pharmacy label indicated that the Lantus pen had been dispensed from the pharmacy on March 13, 2026.
During an immediate staff interview with Employee 5, Employee 5 confirmed that Resident 74's insulin pen was beyond the 28-day expiration date and should have been discarded.
Employee 5 also confirmed that Resident 5's Lantus insulin pen should have been dated with an open date and indicated that she may have been the nurse that opened it and failed to date it.
During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that she would expect medications to be labeled and stored properly, and that she expected discarded medications to be discarded when expired according to policy or manufacturer guidelines. 28 Pa.
Code 201.18(b)(1) Management.28 Pa.
Code 211.9(a)(1) Pharmacy services.
395733 03/19/2026
Gettysburg Center 867 York Road Gettysburg, PA 17325
Observation of the lunch meal service on March 17, 2026, at 11:51 AM, revealed residents on a regular diet being served rotini pasta salad with a 3-ounce scoop.
Review of diet extension sheets for the lunch meal to be served on March 17, 2026, revealed that residents on a regular diet are to be served 1/2 cup (4 ounces) of rotini pasta salad.
Interview with the Nursing Home Administrator on March 18, at 11:50 AM, revealed that she would expect resident meals to be prepared and served in accordance with the menus that have been approved by the dietician and physician. Pa code 211.6(a)(b) - Dietary Services
395733 03/19/2026
Gettysburg Center 867 York Road Gettysburg, PA 17325
Review of facility policy, titled IC308 Enhanced Barrier Precautions, revised November 14, 2025, revealed that Enhanced Barrier Precautions expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in the transfer of MDROs (Multi Drug Resistant Organisms) to the hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated.
Review of facility policy, titled Section 7.11 Medication Administration Eye Drops, dated January 2026, revealed that gloves are recommended to protect both patient and provider from transmission of infectious agents and staff are to perform hand hygiene and don (apply) gloves prior to administering eye drops.
Review of Resident 92's clinical record revealed diagnoses that included pressure ulcer of the right buttock, stage 4 (severe wounds that extend through the skin and underlying tissues, exposing muscle, tendon, and bone, and require immediate medical attention) and dementia (a syndrome characterized by a decline in cognitive function).
Review of Resident 92's physician orders revealed an order for, Infection precautions - enhanced barrier, starting January 31,
- Review of Resident 92's care plan revealed a care plan focus area of, Resident is at risk for
- Observation of Employee 1 (Registered Nurse) on March 18, 2026, at 9:41 AM, revealed
MDRO colonization/infection due to chronic wounds, revised November 18, 2025, with an intervention of, Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care(any skin opening requiring a dressing), created January 23,
Employee 1 completed ordered wound care on Resident 92's sacral pressure ulcer.
Employee 1 failed to wear a gown at any time during the dressing change.
Interview with the Nursing Home Administrator (NHA) on March 19, 2026, at 11:30 AM, revealed that she would expect employees to use appropriate personal protective equipment.
Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed that Employee 5 had her jacket stored in the bottom drawer of the medication cart along with medications.
During an immediate interview with Employee 5, she confirmed that her jacket should not be in the medication cart.
During a staff interview with the NHA and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that staff personal items should not be stored in medication carts.
Observation of Employee 5 administering medications to Resident 127 on March 18, 2026, at 9:15 AM, revealed that she took Resident 127's inhaler and antibiotic eye drops in their boxes into the Resident's room and sat them directly on his overbed table.
Employee 5 failed to apply gloves prior to administering Resident 127's antibiotic eye drops. In addition, Employee 5 failed to wear gloves when applying Resident 127's lidocaine patch.
After administering Resident 127's medications, Employee 5 returned the inhaler and eye drop boxes to the medication cart and placed them in the drawer of the cart.
During an immediate interview with Employee 5 after completing Resident 127's medication administration, Employee 5 confirmed that she should have placed a clean barrier on Resident 127's overbed table before setting the medication boxes down.
She also confirmed that she should have worn gloves when administering the eye drops and applying the lidocaine patch.
During a staff interview with the NHA and DON on March 18, 2026, at 12:11 PM, the DON confirmed that Employee 5 should have worn gloves when administering Resident 127's eye drops and applying his lidocaine patch.
She also confirmed that Employee 5 should have placed a clean barrier under the medication boxes. 28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services.