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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT STEVENS, THE
Inspection Results For:

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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 revisit survey completed on May 30, 2024, it was determined that The Gardens At Stevens, failed to correct the deficiencies identified during the revist survey of April 26, 2024 and original survey of April 3, 2024 and continued to be out of compliance with the following requirements of Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of facility staffing data, for one week May 9 -15, 2024, it was determined that the facility failed to meet a minimum requirement of one nurse aide per 12 residents on evening shift, on May 10, 2024.

Findings include:

Review of the week of May 9,-15, 2024, revealed the following that the minimum requirement was not met on evening shift May 10, 2024, that is, one nurse aide per 12 residents.

The facility census was 72, the minimum total hours required should be 206.64. But actual hours provided were 200.50
.
The PPD was 2.78 which is below the State Regulation requirment of 2.87 PPD.

Interview with the Nursing Home Administrator on May 30, 2024, at 2:35 p.m confirmed that the nurse aide staffing ratios were not met on evening shift May 10, 2024.

Plan of Correction - To be completed: 06/17/2024

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 06/17/2024.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 review of one week 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 day shift, one LPN per 30 residents on evening shift, and one LPN per 40 residents on night shift (Week of May 9-15, 2024).

Findings include:

Review of the week of May 9- 15, 2024, revealed that on May 12, 2024, day shift did not meet the minimum requirement of one LPN per 25 residents.

Review of the week of May 9-15, 2024, revealed. that on May 12, 2024, evening shift did not meet the minimum requirements of one LPN per 30 residents:

Review of the week of May 9-15, 2024, that on May 12, 2024, night shift did not meet the minimum requirements of one LPN per 40 residents:

The facility census for May 12, 2024 was 70 residents. The minimum total hours required should be 200.90 hours, but the Actual hours worked was 185.00.

The PPD was 2.64 which is lower than the State Regulation, of 2.87.

Interview with the Nursing Home Administrator on May 30, 2024, at 2:35 p.m. confirmed he was aware that the staffing ratios for LPNs were not met on May 12, 2024.

Plan of Correction - To be completed: 06/17/2024

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 and use agency when available.

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 06/17/2024.

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