Inspection·April 16, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to afford a resident the right to participate in the resident's treatment and health care decision making, including the right to refuse specific treatment, for one resident out of 15 reviewed. (Resident B1) Residents Affected - Few Findings included: According to long term care regulatory requirements a resident has the right to select or refuse specific treatments options before the care plan is instituted, based on the information provided as required under §483.10(c)(1), (4)-(5), F552. A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included type two diabetes [is a condition that results from insufficient production of insulin, causing high blood sugar], cirrhosis of the liver [is a degenerative disease of the liver resulting in scarring and liver failure], and major depressive disorder. A review of Resident B1' s Annual MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 3, 2024, section C Cognitive Patterns revealed that the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 15, which indicated that the resident was cognitively intact. A Dietary Note completed by Employee B1, the facility's Registered Dietitian (RD), dated March 29, 2024, at 12:06 p.m., revealed that she and dietary manager met with the resident regarding therapeutic diet compliance. The resident's current diet order was, CHO (consistent carbohydrate diet) 2-gram Na (sodium) [therapeutic diets that limit foods higher in sugar and simple carbohydrates and limits sodium to 2,000 milligrams per day by removing the salt packet from each meal trays] regular texture/thin liquids with 1800 cc (is a unit of measurement that is used to determine the volume of a substance; 1 cc = 1 mL) fluid restriction in place. According to the entry, the facility's 4-week menu cycle was provided and explained to resident with diet education included in a handout that explained carbohydrate choices. The progress note by Employee B1 also noted that Resident B1 remained non-compliant with the therapeutic diet restrictions, despite education and encouragement. The risks of uncontrolled diabetes explained to the resident, including kidney disease, heart disease/stroke, neuropathy (loss of sensation/feeling), and retinopathy (is a complication of diabetes where blood vessels in the eye are damaged). Resident B1 stated, I'm already dying, I am going to eat whatever I want. The Assistant Director of Nursing (ADON) was also present for the resident's dietary education and further discussed risks and wishes and Resident B1 verbalized understanding risks of non-compliance and was agreeable for the ADON to discuss liberalizing diet and fluid restrictions with the attending (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 395899 Printed: 05/15/2026 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 395899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Orangeville, The 200 Berwick Road Orangeville, PA 17859 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)