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Complaint Investigation

Gardens At Millville, The

Inspection Date: October 15, 2025
Total Violations 2
Facility ID 395872
Location MILLVILLE, PA
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Actual Harm

F 0689 Level of Harm - Actual harm

[DATE REDACTED], and the resident expired (died) on [DATE REDACTED], at 9:45 PM. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on [DATE REDACTED], at approximately 4:00 PM. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gardens at Millville, The

48 Haven Lane Millville, PA 17846

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0755

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

1, 2025, at 1:00 PMSeptember 2, 2025, at 12:00 PMSeptember 3, 2025, at 12:00 AMSeptember 8, 2025, at 8:30 PMSeptember 10, 2025, at 1:00 PMSeptember 12, 2025, at 10:41 AMSeptember 15, 2025, at 8:00AMSeptember 20, 2025, at 1:00 PMSeptember 22, 2025, at 9:00 PMSeptember 23, 2025, at 11:00 PMSeptember 24, 2025, at 8:00 AMSeptember 24, 2025, at 6:00 PMSeptember 26, 2025, at 7:45 AMSeptember 27, 2025, at 3:20 PMSeptember 28, 2025, at 7:00 PMSeptember 30, 2025, at 11:45 PMA

review of a September 2025 MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. The residents' October 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled drug for administration to the resident on the following dates and times: October 5, 2025, at 8:00 AMOctober 10, 2025, at 9:00 AMOctober 12, 2025, at 12:00 AM A

review of an October 2025 MAR, MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered.

During an interview October 15, 2025, at 4:00 PM, the Director of Nursing confirmed the above inconsistencies between the controlled drug records and medication administration records. The above noted doses of the antianxiety medication were documented as given on the narcotic reconciliation record; however, they were not signed out as administered on the MAR. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies.

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📋 Inspection Summary

GARDENS AT MILLVILLE, THE in MILLVILLE, PA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLVILLE, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GARDENS AT MILLVILLE, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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