Gardens At Stevens, The

reviewed (Resident 3).Findings include: Review of Resident 3's quarterly MDS (Minimum Data Set -

indicated that the resident was receiving an anticoagulant.

Further review of the physician's orders and Medication Administration Record revealed no evidence that the resident received an anticoagulant during the assessment lookback period.

Interview with licensed staff, E3, on February 27, 2025, at 12:10 p.m. confirmed that the assessment was coded inaccurately. 483.20 Accuracy of AssessmentsPreviously cited 3/14/25 28 Pa.

Code 211.5(f) Clinical recordsPreviously cited 6/4/25, 3/14/25

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Review of the clinical record revealed no evidence that the resident or the resident's representative had been invited to participate in care plan meetings.Interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m. confirmed that there was no evidence that the resident or resident's representative had been invited to an interdisciplinary care plan meeting.28 Pa.

Code 201.29(a) Resident rights28 Pa.

Code 211.12(d)(3)(5) Nursing services

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Review of Resident 41's diagnosis list included a diagnosis of but not limited to secondary malignant neoplasm of unspecified lung (cancer that has spread to the lungs from a primary tumor elsewhere in the body).

Review of Resident 41's progress note dated February 17, 2025, revealed that resident was to receive 4 mg (milligrams) of decadron (corticosteroid) to be given the day before the infusion, the day of the infusion, and the day after the infusion.

Review of the February 2026 Medication Administration Record revealed that the decadron was administered on February 24, 2026.

Review of Resident 41's progress note of February 25, 2026, revealed that resident had an appointment on this date at Cancer Center, but transportation was not available.

Additional progress note of February 25, 2026, revealed that the CRNP gave order to discontinue three days of decadron since infusion was not given.

Review of Resident 41's progress note of February 26, 2026, revealed that the cancer center rescheduled appointments for labs and office visit.

Interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m, confirmed that transportation had not been set up for Resident 41 and the appointment had to be rescheduled.

Review of Resident 72's clinical record revealed an order for Resident 72 to remain NPO (nothing by mouth) after midnight prior to cataract surgery scheduled for Monday, February 16, 2026.

Further review of Resident 72's clinical record revealed that the appointment for cataract surgery was cancelled after the resident received a breakfast tray from the kitchen and ate breakfast.

Review of a Diet Order and Communication slip sent from nursing to the kitchen on January 28, 2026, revealed Resident 72 was not to receive a breakfast tray on February 16, 2026.

Interview with the Director of Nursing on Thursday, February 26, 2026, at 1:00 p.m. confirmed that Resident 72 received a breakfast tray while the NPO order was in place. 483.25 Quality of Care Previously cited 12/16/25, 3/14/25 28 Pa.

Code 211.5(f) Clinical recordsPreviously cited 12/16/25, 6/4/25, 3/14/25 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing ServicesPreviously cited 12/16/25,6/4/25, 3/14/25

5-9).Findings include: Review of personnel records for Employee E5-E9 revealed no evidence that

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 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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professional principles; and all drugs and biologicals must be stored in locked compartments,

Based upon observation, it was determined that the facility failed to ensure insulin pens were properly

refrigerated according to package directions for two of three medication carts observed (Second Floor Back Hall Medication Cart and First Floor Medication Cart).Findings include:Observation of the Second Floor Back Hall Medication Cart on February 27, 2026, at 11:15 a.m. revealed one open Toujeo (long-acting insulin) Insulin Pen with an open date of January 18, 2026, and no expiration date.

Further observation of the Second Floor Back Hall Medication Cart revealed one Toujeo Insulin Pen unopened and not stored in the refrigerator as recommended by the manufacturer.Observation of the First Floor Medication Cart on February 27, 2026, at 11:25 a.m. revealed one opened Lantus Insulin Pen with no open or expiration date and one Lantus Insulin Pen unopened and unrefrigerated as recommended by the manufacturer.Interview with the Director of Nursing on February 27, 2026, at 11:30 a.m. confirmed the above medication was not properly identified with open and expiration dates. 28 Pa.

Code 211.12(c)(d)(1)(2)(5) Nursing Services

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dementia care and abuse prevention.

aides completed 12 hours of annual in-service training for five of five employee files reviewed

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

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