Pennsylvania Department of Health
GARDENS AT STEVENS, THE
Patient Care Inspection Results

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GARDENS AT STEVENS, THE
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT STEVENS, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a follow-up survey completed on July 29, 2024, it was determined that Gardens at Stevens continues to be out of compliance for staffing ratios from the original survey date of April 3, 2024, and cited under the updated regulations of July 2024 of the Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for two days for the period of July 16 through July 25, 2024, a minimum of one nurse aide per 11 residents for one day for the period of July 16 through July 25, 2024 and a minimum of one nurse aide per 15 residents for three days for the period of July 16 through July 24, 2024.

Findings include:

Review of the facility staffing data for the period of July 16 through July 25, 2024, revealed the following dates and shifts that did not meet the requirements of 1 nurse aid per 10 residents for day shift, one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on night shift.

Day shift
7/17/2024
7/18/2024

Evening shift
7/20/2024

Night shift
7/16/2024
7/20/2024
7/21/2024

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on July 29, 2024.



 Plan of Correction - To be completed: 08/13/2024

1. Facility cannot retroactively go back and correct past CNA to patient ratios.

2. The facility did not find any negative resident outcomes associated with staffing deficiency.

3. NHA educated DON and Scheduler on staffing ratios as of July 1st. Facility implemented process of daily scheduling meeting to ensure nursing hour coverage meets new regulation. Facility continues to hire for open CNA positions.

4. NHA will audit nursing CNA ratios daily to ensure nursing coverage meets new regulations. Findings of Audits will be submitted to QAPI for review.

5. Facility Date of Compliance will be 08/13/2024.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on a review of facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift, one LPN per 30 residents on the evening shift and one LPN per 40 residents on the night shift for the 10 day period from July 16 through July 25, 2024.

Findings include:

A review of facility staffing data for the 10 day period from July 16 through July 25, 2024, revealed the following dates and shifts that did not meet the minimum requirements of one LPN per 25 residents on the day shift, one LPN per 30 residents on the evening shift and one LPN per 40 residents on the night shift.

Day shift
7/20/2024
7/21/2024

Evening shift
7/17/2024
7/19/2024
7/20/2024
7/21/2024

Night shift
7/23/2024

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on July 29, 2024.






 Plan of Correction - To be completed: 08/13/2024

1. Facility cannot retroactively go back and correct past LPN to patient ratios.

2. The facility did not find any negative resident outcomes associated with staffing deficiency.

3. NHA educated DON and Scheduler on staffing ratios as of July 1st. Facility implemented process of daily scheduling meeting to ensure nursing hour coverage meets new regulation. Facility continues to hire for open LPN positions.

4. NHA will audit nursing LPN ratios daily to ensure nursing coverage meets new regulations. Findings of Audits will be submitted to QAPI for review.

5. Facility Date of Compliance will be 08/13/2024.


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