Health inspection·May 23, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to provide abuse prevention training with orientation in a timely manner for three of five newly hired employees as per facility policy. (Employees 1, 2, 4) Residents Affected - Some Findings include: Review of the facility policy entitled Abuse Protection, last reviewed January 25, 2023, revealed that the facility was to have a process in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The abuse training was to be provided at the time of hire, annually and as needed. Review of personnel files of newly hired employees revealed the following: Employee 1 was hired on January 24, 2023, as an activities assistant. There was no documentation that the employee had abuse training until April 29, 2023. Employee 2 was hired on February 7, 2023, as a Registered Nurse. There was no documentation that the employee had abuse training until April 28, 2023. Employee 4 was hired on February 7, 2023, as a Licensed Practical Nurse. There was no documentation that the employee had abuse training until May 4, 2023. In an interview on May 22, 2023, at 9:41 a.m., the Administrator stated that there was no documented evidence that the newly hired employees had been provided abuse training in a timely manner as per facility policy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.19 Personnel policies and procedures. Page 1 of 4 395708 395708 05/23/2023 Gardens for Memory Care at Easton, The 500 Washington Street Easton, PA 18042

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to monitor nutrition for one of 20 sampled residents. (Resident 72) Residents Affected - Few Findings include: Review of the facility policy entitled, Weight Assessment and Interventions, last reviewed January 25, 2023, revealed that staff was to confirm any weight change of more than five pounds. Clinical record review revealed that Resident 72 had diagnoses that included dementia, dysphagia (difficulty swallowing), and psychomotor deficits. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assistance with eating. Review of the current care plan revealed Resident 72 had a nutritional problem related to dementia, and was to be weighed as ordered. On April 25, 2023, the resident weighed 141.1 pounds (lbs). On May 3, 2023, she weighed 130.6 lbs, a difference of 10.5 lbs and a 7.44 percent loss. On May 4, 2023, the facility dietitian documented a recommendation for a reweight. On May 14, 2023, the facility dietitian documented the reweight was still pending. There was no documented evidence that Resident 72 was reweighed per facility policy or dietitian's recommendation. In an interview on May 23, 2023, at 10:09 a.m., the Director of Nursing confirmed the reweights are expected to be completed the same day as the identified weight change or dietitian's recommendation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395708 Page 2 of 4 395708 05/23/2023 Gardens for Memory Care at Easton, The 500 Washington Street Easton, PA 18042

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized, person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 20 sampled residents. (Resident 75) Residents Affected - Few Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, psychosis, and PTSD. A physician's order dated March 16, 2023, directed staff to administer an antianxiety medication, buspirone, twice daily for PTSD. Review of a social services admission assessment dated [DATE], revealed that information related to past trauma and a trauma related care plan was not completed. Review of the resident's clinical record revealed that there were no resident specific interventions to meet the resident's needs for minimizing triggers or re-traumatization. In an interview on May 23, 2023, at 11:11 a.m., the Administrator confirmed that the social services admission assessment that assessed history of trauma and development of a trauma related care plan was not completed. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.12 (e) Resident care plan. 28 Pa. Code 211.16(a) Social services. 395708 Page 3 of 4 395708 05/23/2023 Gardens for Memory Care at Easton, The 500 Washington Street Easton, PA 18042

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food under safe and sanitary conditions in the kitchen. Residents Affected - Many Findings include: Observation of the kitchen on May 21, 2023, at 9:32 a.m., revealed a container of diced pears that had been removed from the original packaging and not labeled or dated in a reach-in refrigerator. There was an accumulation of various particles of debris including crumbs on the shelf under the flat top grill. Observation of a second reach-in refrigerator revealed a container of eggs that was not dated, a container of prepared beans dated May 15, 2023, a container of egg salad, and a container of potato salad both dated May 13, 2023. The items were not clearly labeled with dates that indicated if they were dated at production or for the date to be discarded. There was an open bag of french toast that had been removed from the original box in the walk-in freezer that was not dated. In an interview Dietary Employee 1 stated that items removed from their original containers should be dated with a use by date. Prepared foods should be labeled and dated with the date of production and discarded after three days, and that the items identified in the reach in refrigerators were not clearly labeled but had exceeded their storage timeframe, and needed to be discarded. 28 Pa. Code 201.18(b)(3) Management. 395708 Page 4 of 4