Pennsylvania Department of Health
 GETTYSBURG CENTER
Patient Care Inspection Results

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GETTYSBURG CENTER
Inspection Results For:

There are  141 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GETTYSBURG CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on findings of an abbreviated complaint survey completed on June 6, 2024, it was determined that Gettysburg Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.


 Plan of Correction:


483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observations, facility document review, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for the lunch meal on June 5, 2024, for three of three residents on a renal diet (Resident 1, 3, and 12) and two of two residents reviewed for a consistent carbohydrate diet (Residents 2 and 4).

Findings include:

Review of the facility meal extension sheets for June 5, 2024, revealed that residents on a renal diet (a diet to control potassium, phosphorus, sodium, protein for kidney health) were to be served a half a cup of seasoned beets instead of a half a cup of stewed tomatoes; and a half a cup of fruit sherbet instead of a half a cup of chocolate ice cream.

Further review of the facility meal extension sheets for June 5, 2024, revealed that residents on a consistent carbohydrate diet (a diet designed to keep blood sugar levels stable by eating the same amount of carbohydrates every day) were to receive a dinner roll.

Review of Resident 1's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

Review of Resident 1's physician orders revealed an order for a renal diet, dated May 10, 2024.

Observation of Resident 1's meal tray and tray ticket on June 5, 2024, at 12:24 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets. Resident 1 had stewed tomatoes in place of the seasoned beets.

Interview with Employee 1 (Dietary Aide) who was serving the food on the unit where Resident 1 resides on June 5, 2024, at 12:28 PM, revealed that they did not have seasoned beets on the tray line to serve.

Review of Resident 2's clinical record revealed diagnoses that included diabetes mellitus type II and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure).

Review of Resident 2's physician orders revealed an order for a consistent carbohydrate diet, dated May 30, 2024.

Observation of Resident 2's meal tray and tray ticket on June 5, 2024, at 12:30 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive a dinner roll. Resident 2 did not have a dinner roll present on their tray at time of delivery.

Review of Resident 3's clinical record revealed diagnoses that included CKD and diabetes mellitus type II.

Review of Resident 3's physician orders revealed an order for a renal diet, dated January 17, 2024.

Review of Resident Council Meeting minutes for February 27, 2024, revealed that Resident 3 questioned why their renal diet was not always being followed. The minutes also indicated that the Dietary Manager said she would educate dietary staff on making sure that the Resident receives what they are supposed to be receiving on their meal trays.

Observation of Resident 3's meal tray and tray ticket on June 5, 2024, at 12:35 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets and a half cup of fruit sherbet. Resident 3 had stewed tomatoes in place of the seasoned beets and chocolate ice cream instead of the fruit sherbet. During observation, Resident 3 stated, "they never follow my renal diet."

Review of Resident 4's clinical record revealed diagnoses that included diabetes mellitus type II and CKD.

Review of Resident 4's physician orders revealed an order for a consistent carbohydrate diet, dated March 12, 2018.

Observation of Resident 4's plate and tray ticket on June 5, 2024, at 12:36 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive wheat bread only. Resident 4's plate had a dinner roll in place of the wheat bread. Resident 4 stated, "I don't always get wheat bread."

Review of Resident 12's clinical record revealed diagnoses that included diabetes mellitus type II and CKD.

Review of Resident 12's physician orders revealed an order for a renal diet, dated May 22, 2024.

Review of facility grievance log for June 2024, revealed that a grievance had been received on June 3, 2024, from Resident 12 and their significant other, which indicated that their renal diet was not being followed as they felt Resident 12 was receiving too many potatoes.

Interview with Employee 2 (Dietary Manager in Training) on June 5, 2024, at 12:45 PM, she indicated that no beets were prepared for the lunch meal and confirmed that Residents 1, 3, and 12 were not provided the seasoned beets as their ordered diet indicated. She further indicated that they were available in the kitchen, but offered no information as to why they were not prepared for the lunch meal. She also indicated that fruit sherbet was available and could not answer why Resident 3 did not receive it.

During an interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 2:45 PM, the aforementioned observations and interviews were shared. The NHA confirmed that she would expect residents to receive their ordered therapeutic diets.

Pa code 211.6(a) Dietary Services
Pa code 211.10(c) Resident Care Policies
Pa code 211. 12(d)(5) Nursing Services



 Plan of Correction - To be completed: 06/18/2024

Residents 1, 2, 3, 4 and 12 will receive food based on their specifically ordered diet.
Residents that are ordered a renal or CCD diet will have their meal audited for accuracy.
The kitchen staff will receive re-education on serving food based on the residents' specific diet order.
Residents having a renal or CCD diet will have their meals audited 3 times per week for 2 weeks. Audit results will be reviewed at the next QAPI meeting.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on document review and staff interviews, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on both day and evening shifts and one nurse aide per 20 residents on the overnight shift for seven of seven days reviewed (May 26, 2024, through June 1, 2024).

Findings include:

Review of facility provided staffing ratio information for May 26, 2024, through June 1, 2024, on day shift, revealed a resident census of 105 residents. The information also revealed a Nurse Aide ratio of 7.59 to 8.70 worked during the day shift on the following dates: May 26 and 30, 2024, and June 1, 2024. Therefore, the facility did not meet the minimum nurse aide ratio of 8.75 required for the facility census of residents on those shifts.

Review of facility provided staffing ratio information for May 26, 2024, through June 1, 2024, on evening shift, revealed a resident census of 105 residents. The information also revealed a Nurse Aide ratio of 4.93 to 8.43 worked during the evening shift on the following dates: May 27, 28, 29, 30, and 31, 2024. Therefore, the facility did not meet the minimum nurse aide ratio of 8.75 required for the facility census of residents on those shifts.

Review of facility provided staffing ratio information for May 26, 2024, through June 1, 2024, on the overnight shift, revealed a resident census of 105 residents. The information also revealed a Nurse Aide ratio of 2.09 to 5.20 worked during the overnight shift on the following dates: May 26, 27, 28, 29, 30, and 31, 2024, and June 1, 2024. Therefore, the facility did not meet the minimum nurse aide ratio of 5.25 required for the facility census of residents on those shifts.

During an interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 2:52 PM, she confirmed that the nurse aide ratios were not met. She indicated that the facility did not schedule it that way, but that she had no other information to offer.

During a final interview with the NHA and Director of Nursing on June 6, 2024, at 4:06 PM, both confirmed that they would expect the facility to be staffed according to state mandated ratios.


 Plan of Correction - To be completed: 06/18/2024

The facility will meet the minimum staffing ratio for CNA's going forward. The facility will staff for 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents on evenings and 1 nurse aide per 20 residents overnight. The facility will audit the CNA ratio daily and take the results of the audits to the next QAPI meeting. The scheduler or designee will monitor staffing ratios each shift to ensure compliance. If staff have to leave early or arrive late for their scheduled shift a replacement staff will be contacted. Staffing grid will be completed daily to ensure compliance. Staffing grid results will be taken to QAPI.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on document review and staff interviews, it was determined that the facility failed to ensure a required minimum of one licensed practical nurse per 25 residents on the day shifts and one licensed practical nurse to 30 residents on the evening shifts for five of seven days reviewed (May 27, 28, 29, and 30, 2024; and June 1, 2024).

Findings include:

Review of facility provided staffing ratio information for May 26, 2024, through June 1, 2024, on day shift, revealed a resident census of 105 residents. The information also revealed a licensed practical nurse ratio of 3.21 to 3.87 worked during the day shift on the following dates: May 28 and 30, 2024, and June 1, 2024. Therefore, the facility did not meet the minimum licensed practical nurse ratio of 4.20 required for the facility census of residents on those shifts.

Review of facility provided staffing ratio information for May 26, 2024, through June 1, 2024, on evening shift, revealed a resident census of 105 residents. The information also revealed a licensed practical nurse ratio of 2.65 to 3.08 worked during the evening shift on the following dates: May 27 and 29, 2024. Therefore, the facility did not meet the minimum licensed practical nurse ratio of 3.50 required for the facility census of residents on those shifts.

During an interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 2:52 PM, she confirmed that the licensed practical nurse ratios were not met. She indicated that the facility did not schedule it that way, but that she had no other information to offer.

During a final interview with the NHA and Director of Nursing, on June 6, 2024, at 4:06 PM, both confirmed that they would expect the facility to be staffed according to state mandated ratios.


 Plan of Correction - To be completed: 06/18/2024

The facility will meet the minimum staffing ratios for LPN's going forward. The facility will staff 1 LPN per 25 residents during the day, 1 LPN per 30 residents on evening shift and 1 LPN per 40 residents overnight. The facility will audit the LPN ratio daily and take the results of the audits to the next QAPI meeting.Scheduler or designee will monitor staffing ratios each shift to ensure compliance. If staff have to leave early or arrive late for their scheduled shift a replacement staff will be contacted. A staffing grid will be completed daily to ensure compliance and results will be taken to QAPI.

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