Transitions Healthcare Gettysburg
595 Biglerville Road, Gettysburg, PA 17325 · Adams County · 135 certified beds · avg 127 residents/day · certified since Aug 1, 1989
Part of chain: TRANSITIONS HEALTHCARE (6 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 11, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 20, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 11, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 20, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 18, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 18, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 11, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 11, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 11 | 0 | E |
| 2024 | 8 | 2 | G ▲ |
| 2025 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $16,334.
| Date | Type | Amount / length |
|---|---|---|
| Jun 11, 2024 | Fine | $8,167 |
| Jun 11, 2024 | Fine | $8,167 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.15 | 3.94 | 3.95 | top 32% in Pennsylvania; top 34% in the U.S. |
| Registered Nurse hours | 0.56 | 0.80 | 0.69 | bottom 37% in Pennsylvania; bottom 46% in the U.S. |
| Weekend total nurse staffing | 3.77 | 3.58 | 3.50 | top 32% in Pennsylvania; top 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.56 | 0.48 | bottom 28% in Pennsylvania; bottom 36% in the U.S. |
| Total nursing staff turnover (%) | 49.6 | 44.5 | 45.8 | bottom 34% in Pennsylvania; bottom 38% in the U.S. |
| RN turnover (%) | 53.3 | 39.9 | 42.9 | bottom 24% in Pennsylvania; bottom 31% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.74, RN 0.51, weekend 3.40. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Aviv Financing II LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 08/09/2011 |
| Aviv Healthcare Properties Operating Partnership I LP | Organization | 5% or Greater Indirect Ownership Interest | — | 08/09/2011 |
| Aviv Op Limited Partner LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2016 |
| Feldman, Marc | Individual | 5% or Greater Direct Ownership Interest | 33% | 08/09/2011 |
| Maurano, Matthew | Individual | 5% or Greater Direct Ownership Interest | 33% | 08/09/2011 |
| Ohi Healthcare Properties Holdco, INC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2016 |
| Ohi Healthcare Properties Limited Partnership | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2016 |
| Williams, Kevin | Individual | 5% or Greater Direct Ownership Interest | 33% | 08/09/2011 |
| Biglerville Road LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/09/2011 |
| Corley, Lisa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/16/2025 |
| Corley, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/16/2025 |
| Corley, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 04/16/2025 |
| Decort, Ryan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/01/2023 |
| Decort, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2023 |
| Decort, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2023 |
| Feldman, Marc | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/09/2011 |
| Feldman, Marc | Individual | ADP of the SNF | NOT APPLICABLE | 08/09/2011 |
| Maurano, Matthew | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/09/2011 |
| Maurano, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/09/2011 |
| Maurano, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 08/09/2011 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Concordia at Spiritrust Gettysburg | 0.9 mi | Gettysburg, PA | ★★★★★ | 4/5 | |
| Gettysburg Center | 1.0 mi | Gettysburg, PA | ★☆☆☆☆ | 2/5 | abuse |
| Gardens at Gettysburg, the | 1.4 mi | Gettysburg, PA | ★★★★☆ | 4/5 | |
| Cross Keys Village-Brethren Home Community, the | 8.8 mi | New Oxford, PA | ★★★★☆ | 4/5 | |
| Paramount Nursing and Rehab at Fayetteville, LLC | 11.9 mi | Fayetteville, PA | ★☆☆☆☆ | 1/5 | |
| South Mountain Restoration Cen | 12.9 mi | South Mountain, PA | ★★★★★ | 5/5 | |
| Hanover Hall for Nursing and Rehabilitation | 13.3 mi | Hanover, PA | ★★☆☆☆ | 2/5 | |
| Homewood Living Plum Creek, INC | 13.3 mi | Hanover, PA | ★★★★★ | 4/5 | |
| Lorien Taneytown, INC | 14.0 mi | Taneytown, MD | ★★★☆☆ | 3/5 | |
| Concordia at Spiritrust Utz Terrace | 16.9 mi | Hanover, PA | ★★★★★ | 4/5 | |
| Quincy Retirement Community | 18.6 mi | Waynesboro, PA | ★★★★☆ | 4/5 | |
| Concordia at Spiritrust Luther Ridge | 19.4 mi | Chambersburg, PA | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 395798.