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:

Findings of an Abbreviated Complaint Survey completed on October 29, 2025 at Gardens at Stevens, The identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on staff and resident interviews, it was determined that the facility failed to ensure residents were assisted out of bed in a timely manner to attend scheduled Sunday religious services.

Findings include:
An interview conducted with the Activities Director on October 29, 2025, at approximately 12:30 p.m. revealed that some residents are unable to attend Sunday services because nursing staff do not get them out of bed in time. The Activities Director stated that this occurs every weekend.

An interview conducted with the Activities Assistant on October 29, 2025, at approximately 12:40 p.m. revealed similar concerns. The Activities Assistant reported that 1-2 residents are unable to attend Sunday services weekly due to nursing staff not assisting them out of bed in time. She further stated that this issue occurs every weekend and that she reports it to nursing staff when it happens.

Both the Activities Director and Activities Assistant reported that they did not inform the Nursing Home Administrator (NHA) of the issue because they " did not think about it during the week. "

An interview conducted with Resident R1 on October 29, 2025, at approximately 1:30 p.m. revealed that she missed Sunday service on October 26, 2025, because nursing staff did not get her out of bed in time. Resident R1 stated that staff are aware in advance that she needs to be up before 9:30 a.m. to attend Sunday service.

An interview conducted with the NHA on October 29, 2025, at approximately 3:00 p.m. confirmed the above.

211.12(e) Nursing Services

201.14(b) Responsibility of licensee

Plan of Correction - To be completed: 12/04/2025

1. Facility cannot retroactively go back and correct for Resident R1 missing Sunday Service.

2. Current residents will be audited for preference to attend Sunday Services.

3. The Activities Director will be re-educated by the Administrator on the importance of offering activities of Resident choice.

4. The Activities Director will audit 5 current residents for Sunday Service attendance. This audit will be weekly for 4 weeks and then monthly for 2 months. The results of the Activity Director's audit will be reviewed monthly at the facility's Quality Assurance and Performance Improvement meeting.

5. Facility Date of Compliance will be 11/11/2025.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observations, staff interviews, and review of facility records and policies, it was determined that the facility failed to implement contact precautions for a resident diagnosed with scabies (Resident R3).

Findings include:

Review of Resident R3's clinical record on October 29, 2025, revealed a diagnosis of scabies (a skin infestation caused by microscopic parasites that results in intense itching) with a start date of October 28, 2025.

Review of the facility policy titled "Scabies Identification, Treatment and Environmental Cleaning," revised August 2016, indicated: "Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment."

Further review of the clinical record failed to reveal any physician orders for contact precautions.

Review of Resident R3's physician orders revealed an order for Permethrin 5% cream (a topical medication used to treat scabies) with a start date of October 28, 2025, and with a note to hold treatment until after a dermatology appointment scheduled for October 30, 2025.

Observations conducted of Resident R3's room revealed no signage indicating that the resident was on contact precautions.

An interview conducted with the Assistant Director of Nursing (ADON) on October 29, 2025, at approximately 1:45 p.m. revealed that she had not been informed of Resident R3's recent scabies diagnosis. The ADON stated that if she had been made aware of the diagnosis, she would have immediately implemented contact precautions and educated staff on appropriate procedures.

The ADON further reported that Resident R3's dermatology appointments in July and August 2025 indicated that the resident did not have scabies at that time.

Resident R3 was unavailable for interview due to cognitive impairment.

A follow-up interview with the ADON at approximately 2:00 p.m. confirmed that Resident R3 should have been placed on contact precautions upon diagnosis.

211.2(d)(5) Medical Director

211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 12/04/2025

1. Resident R3's room was immediately updated with signage indicating that the resident was on contact precautions.
2. Current residents will be audited for proper placement of signage indicating contact precautions.

3. The Infection Preventionist will be re-educated by the Director of Nursing on providing signage indicating contact precautions for resident rooms requiring it.

4.The Director of Nursing will audit 5 current residents needing signage indicating contact precautions. This audit will be weekly for 4 weeks and then monthly for 2 months. The results of the Director of Nursing's audit will be reviewed monthly at the facility's Quality Assurance and Performance Improvement meeting.

5. Facility Date of Compliance will be 11/11/2025.

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