Pennsylvania Department of Health
GARDENS AT MILLVILLE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT MILLVILLE, THE
Inspection Results For:

There are 139 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.


GARDENS AT MILLVILLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Revisit Survey completed on April 10, 2025, it was determined that The Gardens at Millville corrected the federal deficiencies cited during the survey of February 14, 2025, under the of 42 Part 483 Subpart B Requirements for Long Term Care Facilities, but remained out of compliance with the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 05/13/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of May 13, 2025.
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on 16 of 21 shifts reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts and call offs as needed and available.
Calculation of daily shift ratios will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the staffing ratio. If call offs occur, all efforts will be made to attempt to fill that position.
Daily staffing ratios will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:
April 4, 2025 - 3.04 direct care nursing hours per resident.
April 5, 2025 - 2.77 direct care nursing hours per resident.
April 6, 2025 - 3.06 direct care nursing hours per resident.
April 7, 2025 - 3.14 direct care nursing hours per resident.
April 8, 2025 - 3.08 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Nursing Home Administrator on April 10, 2025, at 2:40 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 05/13/2025

The facility cannot retroactively correct the deficiency cited by the surveyor related to not maintaining the required PPD on 5 of 7 days reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required minimum daily PPD. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off site recruiters. Agency will be utilized for open shifts and call offs as needed and available.
Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the PPD daily. If call offs occur, all efforts will be made to attempt to fill that position.
Daily PPD will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations.

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