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.
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 4
Event ID:
395708
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
395708
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens for Memory Care at Easton, The
500 Washington Street
Easton, PA 18042
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395708
If continuation sheet
Page 2 of 4
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
395708
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens for Memory Care at Easton, The
500 Washington Street
Easton, PA 18042
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395708
If continuation sheet
Page 3 of 4
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
395708
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens for Memory Care at Easton, The
500 Washington Street
Easton, PA 18042
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395708
If continuation sheet
Page 4 of 4