Gardens at Stevens, The

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 3, 2024

  Based upon clinical record and facility documentation review, it was determined the facility failed to ensure adequate supervision of a resident to prevent resident from falling from a facility window resulting in physical harm and hospitalization for Resident 1. Findings include: Review of Resident 1's diagnosis list revealed diagnoses including left side Hemiplegia (paralysis or weakness to one side of the body), difficulty in walking, Vascular Dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability), muscle weakness, Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real.[3] Symptoms may include delusions and hallucinations), Alcohol abuse with… […]

• Actual harm, isolatedF686Feb 1, 2024

  Based on clinical record review, observations, and interviews with staff, it was determined that the facility failed to ensure that one of two residents (Resident 50) reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new ulcers from developing, resulting in actual harm of pressure ulcer development for Resident 50. Findings include: Review of Resident 50's diagnosis list revealed diagnoses including; Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Muscle Weakness (reduction in the power exerted by muscles… […]

• Actual harm, isolatedF686Mar 10, 2022

  Based upon clinical record review and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer causing actual harm to two of four residents reviewed (Resident 36 and Resident 53). Findings include: Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 36's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated November 18, 2021, revealed Resident 36 required the extensive assistance of two staff members for turning and repositioning in bed, transferring between surfaces and required total dependence on staff members for bathing. Review of Resident 36's Weekly Skin Review dated November 1, 2021, revealed open area to coccyx. […]

• No harm, potential for more than minimal, widespreadF730Feb 27, 2026

  Based on review of employee personnel records, it was determined that the facility failed to complete performance reviews at least once every 12 months for five of five nurse aides reviewed (Employees 5-9).Findings include: Review of personnel records for Employee E5-E9 revealed no evidence that performance reviews were completed at least once every 12 months. Interview with the Nursing Home Administrator on February 27, 2026, at 1:00 p.m. confirmed that there was no documentation of the performance reviews for the five employees. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.19(2) personnel policies and procedures

• No harm, potential for more than minimal, widespreadF947Feb 27, 2026

  Based upon review of employee records, it was determined the facility failed to ensure that nurse aides completed 12 hours of annual in-service training for five of five employee files reviewed (Employees E5-E), Findings include:Personnel files for Employees E5-E9 were reviewed for completion of the 12-hour annual in-service training.Review of the employee files failed to reveal evidence that the Employees E5-E9 completed the required 12-hour annual in-service training.Interview with the Nursing Home Administrator on February 27, 2026, at 1:00 p.m. confirmed that there was no evidence that Employees E5-E9 completed the required 12 hours of in-service training.483.95 Training RequirementsPreviously cited 3/14/2528 Pa. Code 201.19(7) Personnel polices and procedures