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🔎 Gardens At Millville The

Inspection Results


Inspection Overview

Gardens At Millville The has been cited for a total of 71 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2025-02-14
Correction Date: 2025-03-25
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-08-27
Correction Date: 2024-09-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-05-21
Correction Date: 2024-06-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-05-21
Correction Date: 2024-06-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-05-21
Correction Date: 2024-06-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-05-21
Correction Date: 2024-06-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-05-21
Correction Date: 2024-06-21
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-04-12
Correction Date: 2024-06-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-04-12
Correction Date: 2024-06-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-12
Correction Date: 2024-06-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2024-04-12
Correction Date: 2024-05-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-02-15
Correction Date:
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2024-02-15
Correction Date: 2024-04-12
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2024-02-15
Correction Date: 2024-04-12
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Survey Date: 2024-01-12
Correction Date: 2024-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-01-12
Correction Date: 2024-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-01-12
Correction Date: 2024-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: B

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-05-12
Correction Date: 2023-06-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Perform COVID19 testing on residents and staff.

Survey Date: 2023-02-22
Correction Date: 2023-03-17
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: C

Ensure staff are vaccinated for COVID-19

Survey Date: 2023-02-22
Correction Date: 2023-03-17
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2023-02-22
Correction Date: 2023-03-17
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-08-23
Correction Date: 2022-09-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-08-23
Correction Date: 2022-09-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-06-17
Correction Date: 2022-07-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2022-04-27
Correction Date: 2022-06-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-11-02
Correction Date: 2021-11-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Give the resident's representative the ability to exercise the resident's rights.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-08-13
Correction Date: 2021-09-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-10-09
Correction Date: 2020-11-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2020-10-09
Correction Date: 2020-11-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2020-10-09
Correction Date: 2020-11-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-09
Correction Date: 2020-11-09
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**