F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
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.S 211.12(e) Nursing Services S 201.14(b) Responsibility of
licensee
Residents Affected - Some
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395575
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395575
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Stevens, The
400 Lancaster Avenue
Stevens, PA 17578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
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.S 211.2(d)(5) Medical DirectorS
211.12(d)(5) Nursing Services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395575
If continuation sheet
Page 2 of 2
