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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT ORANGEVILLE, THE
Inspection Results For:

There are 93 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 ORANGEVILLE, 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 30, 2024, it was determined that The Gardens at Orangeville failed to correct federal deficiencies cited during the surveys of February 2, 2024, and April 16, 2024, and continued to be out of compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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.

§483.25(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 clinical record review and staff interview, it was determined that the facility failed to provide adequate supervision to monitor one resident's whereabouts and activities to prevent access to potential accident hazards for one of eight sampled residents. (Resident A1)

Findings include:

A review of clinical record revealed that Resident A1 was admitted April 3, 2024, with diagnoses that included fracture of the femur. Review of the resident's current care plan revealed that Resident A1 was at risk to elope and an intervention was for staff to apply a wander guard (a bracelet like device that is placed on an extremity that assisted with the location of a resident who may wander). Review of resident A1's nursing progress notes since admission April 3, 2024, revealed the resident had displayed consistent behaviors of exit seeking, was repeatedly attempting to self-transfer and was to have increased visual supervision.

During an interview with Employee 1 (nurse aide) during the survey of May 30, 2024, she stated that on May 28, 2024, during the 3 PM to 11 shift, staff found Resident A1 unsupervised in the shower room. She and other staff members assisted him back to his room. She was not aware of how he got in the shower room unassisted.

During an interview with Employee 2 (RN), during the survey of May 30, 2024, Employee 2 stated that during the 3-11 shift on May 28, 2024, he was aware that staff found Resident A1 unsupervised in the shower room on the 300 Hallway. He was not aware of how the resident got in the room but did not believe the resident had the code for the key pad (on the door to gain entry to the room).

During an onsite survey May 30, 2024, at approximately 12:30 p.m., this surveyor was able to enter the closed shower room on the 300 hallway without entering a code on the keypad on the door.

During an interview on May 30, 2024, at 2:00 p.m., the Director of Nursing and Nursing Home Administrator confirmed the facility's expectation is that the shower rooms are to be locked to prevent unsupervised access.

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

28 Pa. Code 201.18 (e)(1)(2.1) Management

Plan of Correction - To be completed: 06/21/2024

The 300 hall shower room was locked at the time of the survey.
The facility recognizes that all residents have the potential to be affected the noted practice. See section 3 and 4 for system changes and monitoring. Residents will be reviewed in morning meeting to determine if an increase in supervision is needed and plan of care will be addressed accordingly.
Staff will be re-educated on ensuring shower room doors are locked and increasing supervision to residents when applicable. Weekly audits by the IDT will include auditing key padded doors to be locked.
Maintenance/designee to perform facility rounds to ensure shower rooms doors are locked weekly x4, then monthly x2. DON/designee will audit 20% of resident medical records weekly to ensure if increased supervision was warranted, that it was completed and plan of care updated accordingly. Results to QAPI for review and recommendations.

§ 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.

Plan of Correction - To be completed: 06/21/2024

Facility cannot retroactively correct this deficiency.
Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Referral bonuses for current staff. "Buddy" bonus offered if a friend is also brought in and hired.
Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA . All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position.
Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio of 1:25 on the day shift and 1:40 on the night shift for 7 shifts of 17 days reviewed from May 13 through May 29, 2024.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse staff to resident ratio of 1:25 on the day shift and 1:40 on the night shift based on the facility's census.

May 15, 2024 - 1.18 LPN on the night shift, versus the required 1.90 for a census of 76.
May 17, 2024 - 2.06 LPN on the day shift, versus the required 3.04 for a census of 76.
May 17, 2024 - 1.05 LPN on the night shift, versus the required 1.88 for a census of 75.
May 18, 2024 - 1.09 LPN on the night shift, versus the required 1.88 for a census of 75.
May 23, 2024 - 1.02 LPN on the night shift, versus the required 1.80 for a census of 72.
May 25, 2024 - 2.67 LPN on the day shift, versus the required 2.96 for a census of 74.
May 26, 2024 - 2.76 LPN on the day shift, versus the required 2.88 for a census of 72.

An interview with the Nursing Home Administrator on May 30, 2024, at approximately 2:00 PM confirmed the facility had not met the required LPN to resident ratio on the shifts on the above dates.

Plan of Correction - To be completed: 06/21/2024

Licensed staff ratio cannot be corrected as this is a past event.
Recruitment of nursing staff will continue via facility website, Indeed, social media websites, local newspaper, job fairs and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Referral bonuses for current staff. "Buddy" bonus offered if a friend is also brought in and hired. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position.
Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by scheduler and back up scheduler, DON/ADON and NHA.
Daily PPD'S will be audited weekly x4, then monthly x2 with results to QA for review and recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing schedules, the daily 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 weekly staffing records from May 13 through May 29, 2024, revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

May 17, 2024 - 2.71 nursing hours per resident per 24 hours.
May 18, 2024 - 2.72 nursing hours per resident per 24 hours.
May 19, 2024 - 2.51 nursing hours per resident per 24 hours.

Interview with the administrator on May 30, 2024, at approximately 2:00 PM confirmed that on the above dates, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.

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