Health inspection·February 27, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for three of six hospitalizations reviewed (Resident 1, 6, 11) and one of three closed records reviewed (Resident CR75), and failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of three closed records reviewed (Resident CR8). Findings include: Review of Resident 1's clinical record revealed a nursing progress note dated December 12, 2025, indicated the resident was transferred to the local hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 1's facility-initiated emergency transfers to the hospital. Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed that the office of the state long-term ombudsman was not made aware of Resident 1's hospital transfer. Review of Resident 6's clinical record revealed a nursing progress note dated January 17, 2026, indicating that the resident was transferred to the hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 6's facility-initiated emergency transfers to the hospital. Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed the ombudsman was not made aware of Resident 6's hospital transfer. Review of Resident 11's clinical record revealed Resident 11 was discharged to the hospital on January 1, 2026, and re-admitted to the facility on [DATE]. Further review of Resident 11's clinical record failed to reveal evidence that the office of the State Ombudsman was notified of Resident 11's admission to the hospital. Interview with the Director of Nursing on February 26, 2026, at 11:00 a.m. confirmed that the Page 1 of 8 395575 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0628 office of the State Ombudsman was not notified of Resident 11's transfer to the hospital. Level of Harm - Minimal harm or potential for actual harm Review of Resident CR8's clinical record revealed a nursing progress note dated February 10, 2026, at 10:46 a.m. indicated the resident was discharged from the facility to their home. Residents Affected - Few Review of Resident CR8's Minimum Data Set, dated [DATE], indicated the discharge was planned. Interview conducted with the Nursing Home Administrator (NHA) on February 27, 2026, at 1:15 p.m. reported that the facility did not complete a discharge summary, including a recapitulation of the resident's stay for Resident CR8. The NHA also confirmed that the facility did not notify the Office of the State Long-Term Care Ombudsman of Resident 1's or Resident CR75's transfer to a hospital. Review of Resident CR75's clinical record revealed a nursing progress note dated February 2, 2025, indicated the resident was admitted to a local hospital for evaluation. Review of Resident CR75's Minimum Data Set (a standardized assessment tool used in Skilled Nursing Facilities to evaluate resident health, guide care planning, and support Medicare and Medicaid reimbursement) dated February 2, 2026, revealed the resident was transferred to a nearby hospital and subsequently discharged from the facility on the same day. Interview conducted February 26, 2026, at 11:54 a.m. with the Social Services Department, confirmed the ombudsman was not made aware of Resident CR75's hospital transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 395575 Page 2 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for one of 24 residents reviewed (Resident 3).Findings include: Review of Resident 3's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of February 2, 2025, section N0415 - High Risk Drug Classes, 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 Residents Affected - Few 395575 Page 3 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and an interview with the resident and staff, it was determined that the facility failed to invite the resident and/or the resident's representative to participate in the care plan process for one of 22 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed that the resident was admitted to the facility on [DATE]. Interview with Resident 37 on February 24, 2026, at 11:10 a.m. indicated that the resident had not been invited to participate in an interdisciplinary care plan meeting. 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 395575 Page 4 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based upon clinical record review and interviews with staff it was determined that the facility failed to provide treatment and care in accordance with standards of care for two of twenty-two residents reviewed (Residents 41 and 72). Findings include: Residents Affected - Few 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 395575 Page 5 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Many 395575 Page 6 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based upon observation, it was determined that the facility failed to ensure insulin pens were properly identified with open and expiration dates and failed to ensure unopened insulin pens were kept 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 395575 Page 7 of 8 395575 02/27/2026 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. 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 395575 Page 8 of 8