Gardens at Millville, The

In the surveyor’s words

From the most serious findings on record at Gardens at Millville, The, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 12, 2024

  Based on a review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the [NAME] Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns. Findings include: According to the U.S. Consumer Product Safety Commission, most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. […]

• Actual harm, isolatedF689Oct 15, 2025

  Based on a review of clinical records, select facility policy, facility investigative documentation, and staff and resident interviews, it was determined the facility failed to ensure necessary assistance with activities of daily living and supervision were provided to prevent an accident that resulted in a major head injury resulting in harm for one of ten sampled residents (Resident 1).Findings include: A review of facility policy entitled Fall Management System last reviewed [DATE] revealed, it is the facility policy to provide appropriate evaluations and interventions to prevent falls and minimize complications if a fall occurs. […]

• No harm, potential for more than minimal, widespreadF802Jun 9, 2026

  Based on observations, staff interviews, and review of the facility's meal service schedule, it was determined the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. This failure resulted in delayed meal service for all the residents in the B wing unit, C wing unit, D wing unit, and the main dining room.Findings include:A review of grievances revealed a grievance filed at the facility dated May 21, 2026, which indicated on May 21, 2026, Resident CR1 reported their dinner was delivered late around 7:00 PM and stated this had been occurring regularly.Interviews with nursing staff conducted on June 9, 2026, at 8:35 AM, revealed staff reported the meal carts… […]

• No harm, potential for more than minimal, widespreadF812Jun 9, 2026

  Based on review of select facility policy, observation, and staff interview, it was determined the facility failed to store, label, date, and maintain food in a sanitary manner to prevent contamination and the potential for microbial growth, placing residents at risk for food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]