Gardens at Orangeville, The

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 31, 2026

  Based on a review of clinical records, facility policy, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of 23 residents reviewed (Resident 110) from neglect by failing to ensure staff implemented the resident's individualized care plan requiring the assistance of two staff members for transfers resulting in actual harm in the form of a fracture of the right distal tibia and fibula (the two bones of the lower leg located between the knee and ankle) that required hospital evaluation and treatment. […]

• Actual harm, isolatedF689Dec 7, 2021

  Based on a review of clinical records and select facility investigation reports and staff interviews, it was determined that the facility failed to timely review and revise a resident's fall prevention plan and provide necessary staff supervision and individualized person-centered approaches to maintain resident safety for a resident identified at risk for falls and known unsafe behaviors to prevent a fall with serious injury, a subarachnoid hemorrhage, for one resident out of 10 residents reviewed (Resident CR1). Findings include: A review of the Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with heart failure, [CONDITION(S)], and [CONDITION(S)] (temporary loss of consciousness caused by a fall in blood pressure) and collapse. […]

• Actual harm, isolatedF726Jun 29, 2021

  Based on employee training and nursing competencies, select incident/accident reports and clinical records and staff interviews, it was determined that the facility failed to assure the proficiency of nurse aides in demonstrating the necessary skills and competencies to perform safe transfers using a mechanical lift to prevent injuries to a resident, fractured ribs, during the transfer of one out of five residents reviewed (Resident 25). Findings include: A review of the clinical record revealed that Resident 25 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF801Dec 6, 2024

  Based on staff interview, a review of personnel files and employee credentials, it was determined the facility failed to ensure the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility… […]

• No harm, potential for more than minimal, widespreadF801Feb 2, 2024

  Based on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian. Findings include: Current regulatory guidance requires that if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. […]