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

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GARDENS AT MILLVILLE, THE
Inspection Results For:

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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 February 15, 2024 it was determined that The Gardens at Millville corrected the federal deficiencies cited during the survey of January 12, 2024, but was not in 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 interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of four nursing units (Nursing Hall A, B, C and D).

Findings include:

An observation on February 15, 2024, at 11:47 AM in the resident TV room lounge revealed two dead bugs, approximately an inch in length, behind a red recliner. Cobwebs, dust, and debris were observed on the floor near the bugs. Multiple white stains and discolorations were observed on the arm rest and seat cushion. Dust, debris, peeling paint, and black scuff marks extending the length of the heating unit. Tan stains were observed on wall below the center window.

An observation on February 15, 2024, at 12:08 PM in the C Hall shower room revealed small live black ants on the floor. A bathtub was observed with black pieces of debris on the base of the white tub near the drain. Hair and a rubber band were stuck in the metal strainer in the drain. Cobwebs were observed near the red floor border in the right corner of the shower room. with a buildup of dirt and food debris was visible in the corner underneath the cobwebs.

An observation on February 15, 2024, at 12:11 PM in the A Hall shower room revealed multiple live black ants on a piece of food debris on the floor.

Observations of the A hall and B hall nursing unit on February 15, 2024, at approximately 2:00 PM revealed the following"

Dirt, debris, and food particles throughout the hallways on the A hall and B hall.

Observation in resident room 210 revealed a used foley catheter and urine graduate cylinder coated with a dried-urine like brown yellow substance along with a bottle of mouthwash in basin on the floor in the bathroom of the room.

Dirt, debris, and food particles were observed on the floor throughout the room.

Food particles were observed on the floor in A hall TV room.

There was a brown substance splattered on the walls by the door.

Observation in resident resident room 221 revealed dust and debris on the floor.

A dried brown/yellow substance was observed around the bottom of the toilet in the resident's bathroom. A brown substance was observed on the bathroom door.

A dried brown substance was observed on the walls of resident room 214.

An observation on February 15, 2024, at 2:02 PM in the C Hall near the exit revealed a hole in the wall measuring approximately two inches by one inch. The hole was observed above a green floor molding. The green floor molding to the left of the C Hall exit was observed to be peeling from the wall. Rust stains and peeling paint were observed on the door frame.

Several chairs in the C Hall exit corridor were observed with stained and discolored seat cushions.

An observation on February 15, 2024, at 2:04 PM in resident room 105 revealed a bathroom ceiling tile with a broken corner, a black and gray scuffed bathroom door, live black ants on the floor, and multiple dead bugs in the ceiling light. The floor molding in the bathroom was stained and discolored.

An observation on February 15, 2024, at 2:07 PM in resident room #119 revealed a closet door with gray scuff marks. The wall to the left of the closet door was observed to be scrapped, discolored, and chips of paint were missing, revealing white plaster and drywall. The resident's window shades were observed to have brown debris and stains. The window sill was observed to have a buildup of dirt and dust.

An observation on February 15, 2024, at 2:11 PM in resident room 118 revealed bathroom dead bugs in the ceiling lights with and chipped bathroom floor tiles.

An observation on February 15, 2024, at 2:15 PM outside of resident room 118 revealed brown liquid stains on the green cover of the laundry cart.

During an interview on February 15, 2024, at approximately 2:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility should be maintained in a clean and sanitary manner.

Refer F925


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






 Plan of Correction - To be completed: 03/19/2024

Preparation and/or execution of this plan of correction does not institute 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 March 19, 2024.

F 0584
The areas noted in the resident TV rooms on the East Side and West Sides, A and B Hallways, Rooms 210, 214, and 221 and their bathrooms, C-Hall shower room, A-Hall shower room, Small hole in C-Hall wall, C-Hall green floor molding and stained peeling paint on/ by exit door/frame, stained/discolored chair seat cushion of chairs in C-Hall exit corridor, Room 105, 118, and 119, D-Hall laundry cart cover will be cleaned, painted, repaired or replaced as needed to address the deficiencies noted. In addition, the facility's contracted Pest Control provider will address the areas where ants were noted to be observed.
The facility recognizes that other residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The Environmental Services Director, Maintenance Director and their staff will be re-educated on the need to provide and maintain a clean and orderly environment. Both the Environmental Service Director and Maintenance Director with conduct rounds of the facility with the Nursing Home Administrator or designee weekly for 4 weeks and then monthly for 2 months to verify compliance and any pest concerns will be forwarded to the Pest Control Provider to be addressed and documented.
The results of the rounds will be reviewed at the month Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
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.
Observations:

Based on a review of the facility's abuse policy, select investigative reports, and clinical records, and staff interview, it was determined that the facility failed to ensure four residents out of 11 sampled was free from misappropriation of resident property, medications (Resident 7, 9, 10, and 11).

Findings included:

A review of the facility policy entitled "Abuse Policy" revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy noted that misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residence belongings or money without the resident's consent.

A review of the clinical record review revealed that Resident 7 was admitted to the facility on October 11, 2021, with diagnoses which include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and anxiety disorder. The resident had a physician order dated January 24, 2024, for Ativan 0.5 mg give 0.25 mg (half tablet) by mouth every 6 hours as needed for anxiety.

A review of the clinical record review revealed that Resident 9 was admitted to the facility on July 23, 2010, with diagnoses which include dementia and anxiety. The resident had a physician order dated December 7, 2023, for Ativan (an antianxiety drug) 0.5 mg give 0.25 mg (half tablet) by mouth three times a day.

A review of the clinical record review revealed that Resident 10 was admitted to the facility on August 25, 2023, with diagnoses which include major depressive disorder. The resident had a physician order dated December 21, 2023, for Ativan 0.5 mg give 0.5 mg every four hours as needed for agitation or restlessness.

A review of the clinical record review revealed that Resident 11 was admitted to the facility on December 11, 2014, with diagnoses which include dementia and anxiety disorder. The resident had a physician order dated February 21, 2022, for Ativan 0.5 mg give 0.25 mg (half tablet) by mouth two times a day.

A review of a facility investigative report dated February 10, 2024, at 10:00 AM revealed Employee 1 LPN (licensed practical nurse) was completing medication administration pass. The employee noticed the Ativan tablet was much easier than normal to pop out of the blister pack of medications. When Employee 2 RN (registered nurse) reviewed the Ativan cards, it was found the pills were Claritin (an antihistamine), not Ativan as labeled. All medication carts were checked for similar concerns. Five cards of Ativan dispensed for Residents 7, 9, 10, and 11 were found to have the Ativan replaced with Claritin.

A review of Employee 1's statement (no date or time indicated when the statement was obtained) revealed while the employee was passing medications, she went to get the Ativan for one of her residents and noticed the medication was not the right medication. The employee indicated that she brought the card to Employee 2 and upon checking the other controlled substance cards, it was found that 5 cards contained the incorrect medications.

A review of Employee 3's LPN statement (no date or time indicated when the statement was obtained), revealed that on Friday February 9, 2024, when the employee was working the A hall medication cart, she noticed the Ativan cards were easier to "pop." She further stated that she spoke with Employee 1 about this concern and indicated Employee 1 felt the same way and she made the nursing supervisor aware.

An interview with Employee 1 on February 15, 2024, at approximately 11:30 AM revealed while she was preparing Resident 9's medications, the Ativan tablet "looked different." The employee indicated that the pill was easy to pop out of the medication card. The employee stated she took the card right to Employee 2 and let her know that someone switched out the resident's medication. Employee 1 stated that she was off on February 7, 8, and 9, 2024, but she did provide the medication to Resident 9 on February 6, 2024, and she knew the pills were the right pills on February 6, 2024. Further Employee 1 stated she was the one who had received Resident 19's Ativan card delivered from the pharmacy and the card was correct with the correct pills in it when it was received at the facility.

An interview with Employee 3 on February 15, 2024, at 11:36 AM revealed the employee stated on February 9, 2024, she worked on the A hall medication cart. At that time, she noticed the Ativan pills were easier to pop out of the cards. When alerted on February 10, 2024, by Employee 1 that the pills in the Ativan cards appeared different, Employee 3 voiced her concerns that the Ativan was easy to pop, and they notified Employee 2.

An interview with Employee 2 on February 15, 2024, at 11:47 AM revealed the employee stated it was brought to her attention by Employee 1 that Resident 1's Ativan card had been tampered with and the pills in the card were not Ativan. Employee 2 stated they started an investigation and determined that Resident 7, 9, 10, and 11's Ativan pills had all been swapped out with Claritin. The employee stated the misappropriated medications were only identified in the A hall medication cart.

An interview with the NHA on February 15, 2024, at approximately 2:30 PM confirmed the facility failed to ensure all residents were free from misappropriation of resident property, their medications.


28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

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

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




 Plan of Correction - To be completed: 03/19/2024

F 0602
The facility recognizes that they can't retroactively correct the deficiency as sited for residents 7,9,10, and 11. The medications (Ativan) noted for the residents have been replaced at no cost to the residents.
The Director of Nursing or designee will audit residents with orders for Ativan to verify that the medications within their blister packets are the medications ordered.
The Director of Nursing of Designee will re-educate the licensed nursing staff on visual inspection of blister cards at time of shift change and narc count and the Registered Nursing Supervisor or Designee will visually audit and document the blister packets for residents containing Ativan each morning for 3 months to verify that the medications within their blister packets are the medications ordered and no sign or tampering. The pharmacy will assure that all controlled medications are transported via courier in a plastic tote secured with a zip tied lock containing a serial number which will also be on the manifest. Facility staff will verify that the lock number matches the number on the manifest prior to opening. Once opened staff will visually verify that there are no obvious signs of tampering prior to accepting.
Audits will be reviewed at the monthly Quality Assurance meeting and any concerns directed to the Director of Nursing.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations, a review of facility provided documents, and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program, including observations made on two of the four nursing units (Nursing Halls A and C).

Findings include:

A review of the facility's Pest Sighting Log revealed an entry dated November 27, 2023, indicating that live ants were observed in resident room #203. The number of ants was listed as "a lot."

A pest sighting entry dated December 10, 2023, indicated that residents reported killing three brown bugs in resident room #121.

A pest sighting entry dated December 14, 2023, indicated that black bugs were observed in the bathroom in resident room 201.

A review of the facility's pest control service inspection report dated December 15, 2023 revealed two services were provided, "drain service" and "pest management." The service inspection report indicated that no conditions were added for this service and no conditions were resolved for this visit. The report indicated that eight rodent bait stations were inspected and maintained. The report failed to indicate any services that targeted "bugs" or rooms identified with pests that were reported by residents or staff and noted in the facility's pest sighting logbook.

A pest sighting entry dated December 16, 2023, indicated that ants were in the hallway coming from the SS \ office.

A pest sighting entry dated December 25, 2023, indicated that ants were in resident room #106. The number of ants was indicated as "many."

A review of the facility's pest control service inspection report dated January 22, 2024, revealed two services were provided, "drain service" and "pest management." The service inspection report indicated that no conditions were added or updated for this service, and no conditions were resolved for this visit. The report indicated that seven rodent bait stations were inspected and maintained. The report failed to indicate any services that targeted "bugs" or rooms identified with pests that were reported by residents or staff and noted in the facility's pest sighting logbook.

A pest sighting entry dated January 28, 2024, indicated that were observed ants in resident room #113. The number of ants was indicated as "a lot."

An observation on February 15, 2024, at 11:47 AM in the resident TV room lounge revealed two dead bugs approximately an inch in length behind a red recliner.

An observation on February 15, 2024, at 11:50 AM in the kitchen revealed multiple dead bugs in the ceiling light fixtures.

A clinical record review revealed Resident 5 was admitted to the facility on September 17, 2021. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 7, 2024 revealed that Resident 5 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview on February 15, 2024, at 12:00 PM, Resident 5 stated that she had her room was changed because "there were ants all over the room." She described the pests as small black ants and stated that some had wings. Resident 5 explained that one day the ants were all over the floor, her bed, and crawling on her body, which upset her.

An observation on February 15, 2024, at 12:08 PM in the C Hall shower room revealed small live black ants on the floor.

An observation on February 15, 2024, at 12:11 PM in the A Hall shower room revealed multiple live black ants on a piece of food debris on the floor.

An observation on February 15, 2024, at 2:04 PM in resident room 105 revealed live black ants on the bathroom floor, and multiple dead bugs in the ceiling light.

An observation on February 15, 2024, at 2:11 PM in resident room 118 revealed multiple dead bugs in the bathroom ceiling light.

During an interview on February 15, 2024, at approximately 2:30 PM, the Nursing Home Administrator and Director of Nursing failed to provide evidence of effective functioning pest control program.


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



 Plan of Correction - To be completed: 03/19/2024

F 0925
The facility recognizes that they can't retroactively correct the deficiency as sited and has spoken to the Pest Control provider to provide and document appropriate services so that the facility is free of pests and rodents.
The Pest Control Provider will treat the entire facility as needed and document to best assure a facility free of pests and rodents.
The Environmental Services Director, Maintenance Director and their staff will be re-educated on the need to provide and maintain a pest and rodent-free environment by maintaining a clean and comfortable environment as well as maintaining a regularly scheduled and as needed contracted pest control service. Both the Environmental Service Director and Maintenance Director will conduct rounds of the facility with the Nursing Home Administrator or designee weekly for 4 weeks and then monthly for 2 months to verify compliance.
The results of the rounds will be reviewed at the monthly Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

§ 211.12(c) LICENSURE Nursing services.:State only Deficiency.
(c) The director of nursing services shall have, in writing, administrative authority, responsibility and accountability for the functions and activities of the nursing services personnel and shall serve only one facility in this capacity.
Observations:

Based on a review of facility investigation reports and staff interviews, it was determined that the facility's Director of Nursing failed to demonstrate accountability for the functions of nursing personnel as evidenced by failure to appropriately address a nurse's fitness for duties to ensure resident safety.

Findings include:

A review of an undated witness statement signed by Employee A1, Registered Nurse (RN), revealed that on Sunday, January 28, 2024, at around 4:30 PM, Employee A1 indicated that she tripped over a doorway at her house and fell, hitting her left eye on the dining room table leg, and later fell again, hitting the left side of her neck and face. Employee A1 explained that when she arrived at work on that date, the Director of Nursing (DON) told her to work as a Nurse Aide instead of a nurse. Employee A1 indicated that at 2:00 AM she was doing rounds, and the next thing she recalled was being in her car because something was wrong. Employee A1 indicated that she went to the hospital and had a tear on her left carotid artery and a concussion.

Witness statements provided by three nurse aides (Employees A2, A5, and A6), a Licensed Practical Nurse (Employee A7), and a Registered Nurse Supervisor (Employee A4) revealed that each employee had voiced concerns regarding Employee A1's fitness to safely and competently provide care and services for residents on that night.

A witness statement dated February 1, 2024, provided by Employee A6, a nurse aide, indicated that Employee A1 was "walking like she was drunk" down the hall, forgetting where the light switches were, and almost losing her balance a few times. Employee A6 explained that Employee A1 was not changing residents \ when wet \ but was stating that those residents were dry.

A witness statement dated February 1, 2024, signed by Employee A2, NA, revealed that Employee A1 was "incoherent, not talking right, and needed assistance walking because she was staggering on her own." Employee A2 indicated that she may have smelled alcohol on Employee A1.

A witness statement dated February 1, 2024, provided by Employee A4, RNS (registered nurse supervisor), revealed that on Sunday,Employee A1, RN, arrived at work with a black eye, a bump on her forehead, was not making much sense, and was crying. Employee A4 indicated that she smelled alcohol and believed that Employee A1 was drunk. Employee A4 told the DON that Employee A1 could not take a \ (to administer medications to residents). Employee A4 indicated that when Employee A1 was questioned about drinking, Employee A1 denied drinking alcohol, but began to cry, and explained that she fell outside. Employee A4 indicated that Employee A1 was "not making sense." Employee A4 stated that Employee A1 was assigned to work as a nurse aide for the shift. Employee A4 indicated that later in the night, Employee A1 agreed to go to the hospital.

A witness statement dated February 3, 2024, provided by Employee A5, a nurse aide, revealed that Employee A1 was sitting down, had a black eye, was not acting her normal self, was slurring her words, was loud, and was belligerent. Employee A5 indicated that she smelled alcohol when she was near Employee A1.

A witness statement dated February 7, 2024, provided by Employee A3, a nurse aide, indicated that Employee A1 was searching for the words she was trying to say. Employee A3 indicated that she observed Employee A1 crying, searching for her words, and pushing the RNS away.

A witness statement provided by the Director of Nursing indicated that she worked on January 28, 2024, because Employee A1, RN, called off. The DON indicated that Employee A1, RN, came into work around midnight. The DON explained that she noticed bruising on her neck and face but indicated that Employee A1, RN, did not smell like alcohol, presented with clear speech, was able to follow directions, and did not appear impaired.

The DON indicated that Employee A4, Registered Nurse Supervisor (RNS), reported that she smelled alcohol on Employee A1. The DON indicated that Employee A1, RN, denied drinking alcohol and was assigned to work as a nurse aide for the evening.

The DON indicated that around 2:45 AM she was notified that Employee A1 was cognitively altered. The DON explained that Employee A1 was asked to go to the emergency department. The DON indicated that Employee A1 became cognitively worse; emergency services and local police were notified. The DON indicated that Employee A1 did go to the emergency department for evaluation and treatment.

During an interview on February 15, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that the DON has administrative authority, responsibility, and accountability for the functions and activities of the nursing services personnel. The DON confirmed that Employee A1, RN, was assigned to work as a nurse aide for the night shift on January 28, 2024, despite the reports from multiple other employees on the employee's unfitness for duty regardless of the nursing assignment. The DON was unable to provide evidence that Employee A1, RN, was fully evaluated for her ability to safely and competently provide nursing care and services to residents on the night shift on January 28, 2024, as assigned by the DON.



 Plan of Correction - To be completed: 03/19/2024

5420
The facility recognizes that they can't retroactively correct the deficiency as sited by the surveyors. No negative outcomes or concerns were voiced by any resident related to the Director of Nursing determination in the matter addressed and police officer confirmed employee was negative for alcohol.
The facility recognizes that residents have the potential to be affected if a staff member is not fit for duty. Please see sections 3 and 4 for system changes and monitoring.
The Nursing Home Administrator or designee will educate the Director of Nursing and Registered Nurses on the signs of impairment as well as considering facts and personal observations not the options of others when questioning a staff members fitness for duty. Any questions of a staff members fitness for duty should be immediately addressed by the Registered Nurse Supervisor, employee in question kept from any resident care till fitness for duty is confirmed and ran by the Nursing Home Administrator or designee at the time of questioning.
Any situation involving the questioning of a staff member's fitness for duty will be reviewed at the monthly Quality Assurance Meeting and any concern forwarded to the Nursing Home Administrator.


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