Cycle 1
Health 2025-05-15 · Fire 2025-05-15
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Gettysburg, PA
Gardens At Gettysburg, The
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
741 Chambersburg Road, Gettysburg, PA
(717) 334-6764
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Healthcare Group
Operator or chain grouping
Approved since
1968-09-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,413
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.94
Baseline 21.05% · Performance 19.61% · Measure score 3.94 · Achievement 3.94 · Improvement 3.08
Healthcare-associated infections
6.39
Baseline 9.56% · Performance 6.42% · Measure score 6.39 · Achievement 4.74 · Improvement 6.39
Total nurse turnover
1.45
Baseline 65.42% · Performance 57.76% · Measure score 1.45 · Achievement 1.45 · Improvement 1.39
Adjusted total nurse staffing
1.40
Baseline 3.39 hours · Performance 3.48 hours · Measure score 1.40 · Achievement 1.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.72% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 17.28% · Lower 95% interval 9.26% |
| Discharge to community | 49.32% |
50.57%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 45.45% · Lower 95% interval 38.5% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 54 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 52.83% |
53.69%
0.9 pts worse
|
Numerator 28 · Denominator 53 |
| Discharge mobility score | 43.4% |
50.94%
7.5 pts worse
|
Numerator 23 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 3 · Denominator 57 · Adjusted rate 5.65% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 1.77% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 113 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.83% |
56.45%
3.6 pts worse
|
Numerator 28 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.82% |
25.2%
16.4 pts worse
|
Numerator 3 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
86.9%
3 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 91.2% · Q3 55.8% · Q4 94.6% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
93.5%
5.4 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.3% · Q3 4.7% · Q4 4.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
6.5%
4.7 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 4.8% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
6.5%
3.4 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.9% · Q3 9.5% · Q4 3.7% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
19.9%
4.7 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 23.3% · Q3 22.6% · Q4 22.0% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
18.7%
4.5 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 28.6% · Q3 17.6% · Q4 15.5% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.9% |
19.6%
8.3 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 22.2% · Q3 38.1% · Q4 15.9% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.4% |
18.3%
10.1 pts worse
|
14.9%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 21.5% · Q3 38.3% · Q4 28.9% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.3% · Q3 2.3% · Q4 1.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
26.4%
2.6 pts better
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 23.9% · Q3 28.1% · Q4 23.5% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.3%
3.1 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.0% · Q3 0.8% · Q4 0.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.8% |
68.9%
13.1 pts worse
|
81.7%
25.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.5% · Q2 56.9% · Q3 42.1% · Q4 56.8% · 4Q avg 55.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.8%
2.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
68.7%
6.2 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
23.1%
9.5 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
15 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-06-27
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-01
C · Minimal harm
2024-06-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-08-01
E · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-01
B · Minimal harm
2023-07-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-18
D · Potential for more than minimal harm
2024-11-05
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-27
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-02-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-09-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-07-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-06
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-07-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-07-06
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-19
Penalties and ownership
What sits behind the stars
Ownership
Hashtag Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Hashtag-El-Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Samara Holdings Company LLC
5% Or Greater Indirect Ownership Interest · Organization
Strawberry Hill Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Blglpa LLC
5% Or Greater Indirect Ownership Interest · Organization
Fair Oaks Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sebbag, Gabriel
5% Or Greater Indirect Ownership Interest · Individual
Clabaugh, Tammy
Operational/Managerial Control · Individual
Clinical Consulting Services LLC
Operational/Managerial Control · Organization
Khan, Muzafar
Operational/Managerial Control · Individual
Priority Care Group LLC
Operational/Managerial Control · Organization
Schiowitz, Marc
Corporate Officer · Individual
Summation Financial Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Transitions Healthcare Gettysburg
Gettysburg, PA
3-star overall rating with 3-star inspections with $16,334 in total fines with 6 recent health deficiencies
#2
Spiritrust Lutheran The Village At Gettysburg
Gettysburg, PA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Gettysburg Center
Gettysburg, PA
2-star overall rating with 2-star inspections with abuse icon flag with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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