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 132 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 and abbreviated complaint survey completed on May 21, 2024, it was determined that The Gardens at Millville failed to correct the deficiencies cited during the surveys of February 15, 2024, and April 12, 2024, and continued to be out of 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.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and comfortable environment for residents.

Findings include:

Observations of resident room 111 during an environmental tour of the facility on May 21, 2024, at 10 AM revealed the floor surrounding and beneath the resident's bed was littered with dirt, paper debris and a brown sticky substance.

Observation of resident room 114 D, revealed a large amount of dirt, paper debris and a brown sticky substance on the floor, under the bed and around the bedside table.

The hot water temperature in the 200 hallway resident shower room on May 21, 2024 at 10 AM was 100 degrees Farenheit. The hot water temperatures in the locked dementia care unit shower room was only 98 degrees Farenheit.

The hot water temperatures in the 100 hallway shower rooms May 21, 2024, at 10 A.M. ranged from 90 degrees and 98 degrees Farenheit.

The facility failed to maintain water temperatures that were sufficiently warm enough for the comfort of residents during bathing/showering.

Interview with the Administrator on May 21, 2024, at approximately 2 PM confirmed that the resident environment was to be maintained in a clean manner and comfortable hot water temperatures are to be maintained for the residents' comfort.

28 Pa. Code 201.18 (e)(2.1) Management

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

0584
The floors in rooms 111 and 114 will be stripped and re-waxed. And water temperatures have been maintained to assure comfortable temperatures for bathing/showering.
The facility recognizes that all residents and staff have the potential to be affected by the deficient practice noted by the surveyor. See sections three and four for system changes and monitoring.
The Environmental Services Director and their staff will be re-educated on the need to provide and maintain a clean, sanitary and orderly environment and to have a schedule for resident rooms needing stripped and waxed. The Environmental Service Director with conduct rounds of the facility daily and weekly with the Nursing Home Administrator or designee for 4 weeks and then monthly for 2 months to verify a clean and orderly environment. The Administrator or designee will randomly audit residents weekly for 4 weeks and then monthly for 2 months to verify bathing/shower temperatures are at a comfortable level.
The results of the rounds/audits will be reviewed at the monthly Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain an environment free from accident hazards on one of two resident hallways.

Findings include:

Observations of the east hallway May 21, 2024 at 9 AM, 11 AM. and again at 1 PM on the upper end of the 100 hallway revealed 7 wheelchairs. a straight back chair, a large linen cart, dirty linen carts, a trash bin and a wheelchair charger plugged into a hallway outlet lining the left side of the hallway, obstructing access to the handrails on the wall on that side of the corridor.

Observations of the east hallway, May 21, 2024, at 9:10 AM and again at 1:10 PM on the lower end of the 100 hallway revealed 5 wheelchairs, a large linen cart, trash container and a double dirty linen cart, lining the left side of the hallway, obstructing access to the handrails on the wall on that side of the corridor.

Residents were observed to be out and about on the unit at those times, self-propelling in wheelchairs and/or ambulating with walkers.

During an interview May 21, 2024 at 2 P.M.,the Nursing Home Administrator confirmed that the hallway handrails should not be obstructed and residents should have unimpeded access to the handrails in the corridor.

28 Pa. Code 201.18 (e)(2.1) Management

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

0689
The facility can't retroactively correct the deficient practice as identified by the surveyor. Items that were impeding access to the handrails on the East Side of the facility have been moved.
The facility recognizes that all residents and staff have the potential to be affected by the deficient practice noted by the surveyor. See sections three and four for system changes and monitoring.
Staff will be re-educated to keep handrails in hallways unimpeded.
Random audits to verify handrails in hallways are unimpeded will be completed 5x weekly for 4 weeks and then weekly for 2 months to verify compliance.
All audits will be forwarded to the monthly quality assurance committee for review and any recommendations will be addressed immediately.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:
Based on a review of clinical records, select facility policy and investigative reports and staff and resident interviews it was determined that the facility failed to consistently implement sufficient measures to protect a resident (Resident A3 ) out of 16 sampled from sexual verbal abuse perpetrated by another resident (Resident A2 ).

Findings included:

A review of a facility policy for "Abuse" last reviewed by the facility on June 21, 2023, indicated that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians friends or other individuals.

Clinical record review revealed that Resident A2 was admitted to the facility on November 5, 2021, with diagnosis to include dementia, alcohol abuse with unspecified alcohol induced disorder, dementia, nicotine dependence and diabetes.

A review of a quarterly Minimum Data Set assessment (MDS, is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated February 13, 2024, revealed Resident A1 was moderately cognitively impaired with a BIMS score of 9 ( BIMS a test administered to all residents in skilled nursing facilities to assess patient cognitive patterns, behavior, and mood, a score of 8-12 suggests moderate cognitive impairment) and required minimal staff assistance with activities of daily living and independently ambulates.

A review of the resident's care plan revealed that Resident A2 The resident has an alteration in
neurological status related to Dementia, the resident is verbally aggressive with staff, sexual behaviors, touching female resident and exposing his penis to a resident

Interventions to include:
- 1:1 supervision of staff when out of his room
Frequent visual checks as needed
-resident door alarm

Nursing documentation and the residents care plan indicated that he had a history of exhibiting incidents of inappropriate sexual behaviors in the facility.

Clinical record review revealed that Resident A3 was admitted to the facility on November 30, 2021 with diagnosis to include dementia.

A Quartery MDS dated February 13, 2024 revealed her to be moderately, cognitively impaired with a BIMS score of 9.and she required staff assistance with activities of daily living.

Her current care plan did not include any mention of sexually inappriopriate behaviors.

Nursing documentation and a facility event investigation dated December 29, 2023 at 11:45 A.M., a nurse aide entered the East TV lounge and found Resident A2 seated on a chair in the front corner of the room with the front of his pants pulled down and Resident A3, seated directly in front of him in her wheelchair, had her hands on his genitals. Resident A2 immediately pulled up his pants and moved her hands away from him when the nurse aide entered the room. The residents were immediately separated and Resident A2 was laced on 1 to 1 supervision. A motion sensor alarm was placed in the residents entry door to alert staff when the resident leaves room.

Nursing documentation dated February 19, 2024 at 6:20 P.M. revealed, resident noted to continue to shut off motion sensor alarm. Alarm was moved out of residents reach by door but still in place it would sound upon exiting. Resident was being walked to smoke with NA following, resident again stated to NA " you are a fat slob, why are you following me, you need to lose weight."NA informed resident she was obligated to walk with resident for safety, resident stated " I don't want you to follow me, suck my dick." NA ignored residents words and continued to walk with resident a safe distance.

An Interdisciplinary Note dated February 20, 2024 at 08:42 A.M. revealed, ID Team met to discuss and review recent behaviors and appropriate interventions for resident safety as well as a safety of other residents on unit. Resident A2 noted to be disabling motion detector and going under the alarming stop sign thus defeating the purposefully these interventions.

Staff placed a clip alarm on outside of the doorway which will activate upon opening of door as well as the motion sensor placed at the bottom of the resident door.

A nurses note dated April 14, 2024 at 3:30 revealed, Resident A2 was observed by staff standing in his doorway, with his pants around his thighs and his penis and groin exposed. Female Resident A3 was observed touching his penis. Resident noted to be standing in his doorway just inside of where wireless door alarm is located, therefore wireless alarm did not sound at time of incident. When resident interviewed resident began cursing and yelling at staff,stating "Fuck you", resident telling staff members to "suck his dick". Staff went to separate residents immediately; Female resident removed from hallway and relocated to TV lounge with staff. Resident A2 became agitated and verbally aggressive towards staff, when staff intervened, Resident approached staff members in aggressive manner, screaming in their faces"Fuck you", "Go fuck yourself", and making nonsensical sounds, while sticking his tongue out and thrusting his pelvis towards staff. Resident observed lifting his cane up and threatening to hit staff members. Redirection provided, resident grabbed himself, and told staff to "suck his dick". After much encouragement RN supervisor was able to redirect resident to his room.

The noted intervention implemented at the time of the incident was to add a motion sensor to his bed. The resident was observed by staff to turn off the alarm. Staff then moved the alarm to the middle of the underside of the bed out of his reach.

During an interview May 21, 2024 at 3 P.M., the DON stated that on April 14, 2024, the date of the incident, purposefully stepped back from the doorway (the bottom of the doorway where the motion sensor alarm was located. Resident A3 was standing outside the doorway, feet away from the motion sensor. She reached across the middle portion of the doorway, out of the sensor detecton area and was noted to be touching Resident A2 inappropriately.) at Resident A2's direction. She confirmed that the door motion detectors were an ineffective intervention for this resident with repeated inappropriate sexual contact with female residents.

The DON further confirmed that the facility was aware of Resident A2's aggressive and sexual behaviors and failed to demonstrate that Resident A3 was free from abuse perpetrated by Resident A2.

28 Pa. Code 201.29 (a)(c) Resident rights

28 Pa. Code 211.12 (d)(1)(3) Nursing services

28 Pa. Code 201.18 (e)(1) Management

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

0600
The facility can't retroactively correct the deficient practice as identified by the surveyor. Resident A-2's door alarm was changed and relocated to detect any movement within the doorway. Resident A-3 has had a room change to the opposite side of the facility.
The facility recognizes that all residents and staff have the potential to be affected by the deficient practice noted by the surveyor. See sections three and four for system changes and monitoring.
Staff will be re-educated as to ways in which to avoid a negative response from resident, and resident's care plan has been updated after a interdisciplinary meeting discussing behaviors and possible interventions.
Resident's alarms which be audited q-shift for 2 weeks and then daily thereafter to verify they are functioning and effective.
All audits will be forwarded to the monthly quality assurance committee for review and any recommendations will be addressed immediately.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on observation, review of select facility policy and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication for one of 16 residents reviewed (Resident B1).

Findings include:

A review of facility policy titled "Administering Medications", provided by the facility on May 21, 2024, indicated it is the policy that medications shall be administered to in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Team (IDT) had determined that they have the decision-making capacity to do so safely.

A review of the facility policy titled "Self-Administration of Medications", provided by the facility on May 21, 2024, indicated it is the policy to promote the right of the resident to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe. The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Self -administered medications must be stored in a safe a secure place in the resident's room and if not, then the medications will be stored on a central medication cart or in the med room. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Review of Resident B1's clinical record revealed admission to the facility on August 31, 2023, with diagnoses to include chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe) and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). The resident was assessed as cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact).

A physician's order dated August 31, 2023, was noted for Combivent Respimat Inhalation
(inhaled medication used to treat chronic obstructive pulmonary disease) Aerosol Solution 20-100 MCG/ACT: one puff orally every 4 hours as needed for SOB (shortness of breath). The physician's order was discontinued on September 20, 2023.

During observation and interview with Resident B1 in his room on May 21, 2024, at 11:00 AM, the resident pulled from his left pant pocket an inhaler and stated that "this helps me breathe. I use it one or two times a day, but no more than three times." Observation revealed the resident was holding an inhaler labeled "Combivent Respimat." During the interview, the resident stated that nursing gave him the inhaler "awhile ago."

A second observation of Resident B1 on May 21, 2024, at 1:30 PM, in the presence of Employee 1, LPN (licensed practical nurse) revealed that the resident continued to have the inhaler in his pant pocket.

During an interview on May 21, 2024, at approximately 1:35 PM, with Employee 1, she confirmed that the resident's clinical record contained no current physician order for Resident B1 to continue to use, and self-administer the Combivent Respimat inhaler, no self-administration assessment of the resident's ability to self-administer, and no care plan indicating that the resident does self-administer the product. Employee 1 further confirmed that the physician's order for the resident's use of the Combivent Respimat inhaler was discontinued on September 20, 2023, but that the inhaler remained in the resident's possession for the resident's use.

28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.

28 Pa Code 211.10 (c)(d) Resident care policies

28 Pa Code 211.12 (d)(3)(5) Nursing services

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

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 June 18, 2024.

0554
The Combivent Respimat Inhaler was retrieved from resident B1.
The facility recognizes that all residents and staff have the potential to be affected by the deficient practice noted by the surveyor. See sections three and four for system changes and monitoring.
An audit will be completed that no other residents have medication for self-administration without proper orders. The Licensed Nursing staff will be re-educated on self-administration of medication by the Director of Nursing or designee.
Random weekly audits will be conducted for 4 weeks and then monthly for 2 months to verify that only residents with proper orders and meeting facility guidelines have medications for self-administration.
All audits will be forwarded to the monthly quality assurance committee for review and any recommendations will be addressed immediately.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observations and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection including for one of 16 sampled residents (Resident A1).

Findings include:

Observations on May 21, 2024 at 9 AM, 11 AM and 1 PM revealed Resident A1 was his bed, and upon each observation his urinary foley catheter collection bag was observed directly on the floor. The collection bag was not in a privacy bag at the time of these observations.

There were multiple uncovered, clean dressings, a opened box of clean dressings an open tube of Hydrocortisone cream (with the cap off), an open tube of Triamcinolone ( a topical steroid cream) with the cap off and an open bottle of sodium chloride solution (used for irrigation) with no open date on the bedside table in Resident A1's room. On top of these resident care and treatment supplies was an uncovered, clean incontinence brief.

On the resident's dresser was a wash basin containing multiple used hand towels, both sealed and unsealed dressings, gloves and dressing tape.

In resident room 114 D, there was an uncapped, open plastic gallon container of distilled water (used for humidification in the resident's oxygen concentrator) on the resident's dresser.

During an interview May 21, 2024 at 2 PM, the Director of Nursing confirmed that resident care equipment and supplies should be maintained in a sanitary manner.

28 Pa Code 211.12 (d)(5) Nursing Services

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

0880
The facility can't retroactively correct the deficient practice as identified by the surveyor. Resident A-1's catheter bag was picked up from being on the floor and dressings, creams, sodium chloride solution, briefs, hand towels and tape were removed from the room. The uncapped container of distilled water was removed from room # 114 and disposed of.
Any audit of all resident rooms will be completed to verify residents with catheters have bag secured off of the floor and no inappropriate item were being stored in the residents room.
Al staff will be re-educated on catheter bag placement and inappropriate items being stored in resident room.
Random audits to verify catheter bags are being placed off the floor and no inappropriate items are being stored in resident room will be conducted weekly for 4 weeks and the monthly for 2 months.
All audits will be forwarded to the monthly quality assurance committee for review and any recommendations will be addressed immediately.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on 1 of 7 days (May 19, 2024).

Findings include:

Review of facility census data indicated that on May 19, 2024, the facility census was 96, which required 8 nurse aides evening the day shift.

Review of the nursing time punch detail documentation revealed only 7.53 nurse aides provided care on the evening shift on May 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview May 21, 2024, at 2 PM., the Nursing Home Administrator confirmed that the facility did not meet state minimum staffing ratios for nurse aides.

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

P 5510
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on 1 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 nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility websites, indeed, social media websites, local newspaper, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed.
Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler, DON, and 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 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.

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