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:

There are 150 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 14, 2026, for the initial abbreviated complaint survey completed on April 3, 2024, and subsequent revisit surveys completed on April 26, 2024, May 30, 2024, July 8, 2024, July 29, 2024, September 3, 2024, October 15, 2024, November 18, 2024, January 10, 2025, March 14, 2025, April 30, 2025, July 1, 2025, September 16, 2025, December 29,2025 and March 24, 2026, it was determined that Gardens at Stevens continues to be out of compliance with the following requirements 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. :

(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 ten days, a minimum of one nurse aide per 11 residents on the evening shift for nine days and a minimum of one nurse aide per 15 residents on the night shift for seven days for the period from July 1 through July 10, 2026.

Findings include:

Review of facility staffing data for the period from July 1 through July 10, 2026, revealed the following dates and shifts that did not meet the requirements of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents on the evening shift and one nurse aide per 15 residents on the night shift for three days.

Day shift
7/1/2026
7/2/2026
7/3/2026
7/4/2026
7/5//2026
7/6/2026
7/7/2026
7/8/2026
7/9/2026
7/10/2026

Evening shift
7/1/2026
7/3/2026
7/4/2026
7/5/2026
7/6/2026
7/7/2026
7/8/2026
7/9/2026
7/10/2026

Night shift
7/1/2026
7/2/2026
7/3/2026
7/4/2026
7/5/2026
7/7/2026
7/9/2026

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on July 14, 2026.

Plan of Correction - To be completed: 09/30/2026

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 09/30/2026.

§ 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 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 for five days on the day shift for the period from July 1 through July 10, 2026.

Findings include:

A review of facility staffing data for the period from July 1 through July 10, 2026, revealed the following dates that did not meet the minimum requirements of one LPN per 25 residents on the day shift.

Day shift
7/1/2026
7/4/2026
7/5/2026
7/6/2026
7/7/2026

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on July 14, 2026.

Plan of Correction - To be completed: 09/30/2026

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 09/30/2026.

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