Health inspection·October 17, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care for one resident (Resident 1) out of 5 residents reviewed. Residents Affected - Few According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of clinical record revealed Resident 1 was admitted to the facility on [DATE] with diagnosis to include acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body), atrial fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly and often rapidly), bradycardia (a condition where the heart beats slower than 60 beats per minute while at rest), and adult failure to thrive (a syndrome that describes a gradual decline in a person's physical and mental health). A Quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 6, 2024, revealed Resident 1 to be cognitively intact and required staff assistance for activities of daily living. The resident's clinical record revealed on August 26, 2024, at 7:30 PM nursing staff tried to arouse Resident 1 by using a sternal rub (a firm rub on someone's sternum used when testing an unconscious person's responsiveness). Further it was indicated at 9:30 PM, Resident 1 was in respiratory distress. The resident's blood oxygen level (SPO2) was noted to be 60% (normal levels are 90% to 100%) on room air. Four liters of oxygen was administered via nasal canula (a device that delivers extra oxygen through a tube and into your nose). The residents SPO2 came up to 78%. The physician was notified, and the resident sent to the hospital for evaluation and treatment. The resident was admitted to the hospital for acute respiratory distress and pneumonia. (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 2 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 10/17/2024 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)