Health inspection·June 4, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one out of two nursing units (West Unit), including issues reported by two of seven sampled residents (Residents 5 and 6) and one resident representative (Resident 2's representative). Findings include: An observation conducted on June 4, 2025, at 10:45 AM in Resident 2's bathroom revealed a strong, musty urine odor. During an interview at that time, Resident 2's representative expressed concerns regarding the persistent smell of urine in the resident's bathroom. She reported that although the odor subsides temporarily following cleaning, it returns shortly thereafter. The representative stated that the recurring odor is unacceptable and affects the living experience of her family member. A follow-up observation at 1:20 PM that same day confirmed that the strong, musty urine odor remained present in Resident 2's bathroom. During a facility tour on June 4, 2025, live and dead insects were observed throughout the [NAME] Nursing Unit, including common areas, hallways, and resident rooms. At 11:05 AM, observation in Resident 5's room revealed several large black ants actively crawling on the bedside table, including on personal items such as tissues, papers, and an open orange beverage. Resident 5, who was seated at his bedside, stated the ants had been present for several weeks and continued to appear on his bed and table. He expressed frustration and distress about their ongoing presence. At 11:10 AM, Employee 1, a Licensed Practical Nurse (LPN), confirmed the presence of ants in Resident 5's room. Employee 1 removed the resident's drink from the bedside table and placed it, along with visible ants, into a trash receptacle. Employee 1 acknowledged that ants had been a recurring issue over the past week due to recent changes in weather. At 11:15 AM, observation of the long hall west exit area revealed several large, slender spiders with webs extending several feet from floor to ceiling in the corner near the exit. Numerous dead black ants were trapped in the webs. A thumbnail-sized flying insect was observed on the upper left corner of the exit door, and a half-inch spider was visible on the exit window glass. Additionally, a 2-inch dead worm was seen lying on the hallway floor several feet from the exit. During an interview at 11:20 AM, Resident 6 indicated that she often see ants crawling on the floor in her room. She explained she has killed several ants and throws them in the toilet after she (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 06/04/2025 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)