F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation during environmental tours, it was determined that the facility failed to maintain residents'
environment and equipment in a clean, functional, sanitary, and homelike manner on three of three nursing
units. (First and Second floor nursing units and the Annex)
Findings include:
Observations on April 25, 2023, from 9:52 a.m., through April 26, 2023, at 10:05 a.m., on the first floor
nursing unit revealed that the walls were marred and scratched in resident rooms 111, 112, 117, 119, 122,
123, 124, 127, and 128. In resident room [ROOM NUMBER], the bottom corner of the wall between the
bathroom and the room was gouged, the baseboard was missing, the toilet paper holder was broken, and
the faucet for the bathroom sink was loose. In resident room [ROOM NUMBER] there was an orange
substance on the wall behind the resident's bed, and the privacy curtain between bed. The air conditioner in
resident room [ROOM NUMBER] was covered in dirt and a dried pink substance.
Observations on April 25, 2023, at 1:48 p.m., on the second floor nursing unit revealed that the walls in
resident room [ROOM NUMBER] were marred and scratched. In resident room [ROOM NUMBER] the
entire lower back wall underneath the windows was marred, scratched and missing paint.
Observations on April 25, 2023, between 9:57 a.m., and 10:14 a.m., on the Annex nursing unit revealed
that in room [ROOM NUMBER] there was a piece of molding that was peeling away from the wall by bed
four. In addition, the wall was marred. In resident room [ROOM NUMBER], the dresser between beds one
and two was missing the second, top drawer. The foot board on bed two and three was cracked. The towel
bar was off of the wall and observed on the sink.
CFR 483.10(i)(1-7)
Safe/Clean/Comfortable/Homelike Environment
Previously cited 5/5/22
28 Pa. Code 207.2 (a) Administrator's responsibility.
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 3
Event ID:
395729
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
395729
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Easton, The
498 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 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 implement the abuse prohibition policy related to employee screening for one of five newly
hired employees. (Employee 4)
Residents Affected - Few
Findings include:
Review of the facility policy entitled Abuse Policy, last updated February 1, 2023, revealed that to ensure
abuse protection, the facility was to have processes in place to include screening, training, prevention,
identification, protection, investigation, reporting and response to allegations of potential abuse and
neglect. The policy guidelines included a procedure in preventing abuse and neglect of residents. The
abuse prevention program provided policies included screening and protocols for conducting employment
background checks including state criminal background check and any other reviews required under the
state or federal regulation.
Any employee with a positive initial or annual background check was not to be permitted to work until the
issue was thoroughly investigated and a suitable determination was made by the facility. The facility policy
referenced an appendix that it was unconstitutional for the offenses listed in the Older Protective Services
Act to result in a lifetime employment ban without further evaluation. The appendix included the
recommendation that the facility perform an individualized risk assessment on a case by case basis and
consult with legal counsel regarding employment.
Review of the personnel file for Employee 4 revealed a state criminal background check was requested on
March 9, 2023. The state criminal background check was noted as compiled on March 21, 2023, with a
positive result for a criminal record. The actual start date for Employee 4 was March 29, 2023. The initial
background check had a result of pending for control. The final compiled report indicated that Employee 4
had a criminal background. This final report was not obtained until April 26, 2023. As a result, the
individualized risk assessment to determine if the employee was suitable for employment was not
completed by the facility until April 27, 2023.
In an interview on April 27, 2023, the Administrator confirmed that Employee 4 had been working in the
facility from March 29, 2023, through April 27, 2023.
28 Pa. Code 201.10 (1)(e) Management
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.19 Personnel policies and procedures.
28 Pa. Code 201.29(a) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 2 of 3
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
395729
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Easton, The
498 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 0922
Have enough backup water supply for essential areas of the nursing home.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of the facility disaster plan, observation, and staff interview, it was determined that the
facility failed to establish written procedures to ensure that potable (drinking) water was available to
essential areas during periods when there was a loss of normal water supply.
Residents Affected - Some
Findings include:
Review of the facility disaster preparedness assessment last reviewed February 1, 2023, revealed that the
facility was to conduct an assessment on an annual basis to determine the readiness of the physical plant
and associated supplies/provisions within the facility that would be utilized to manage a crisis or disaster
situation. An adequate supply of emergency items and equipment would be maintained in appropriate
quantities and in accordance with all applicable regulations to accommodate the needs of residents and
staff members. Supplies and equipment would be stored in clearly designated locations and easily
accessible during a crisis or disaster situation.
Further review of the facility's disaster preparedness assessment revealed that the facility determined a
need of 741 gallons of water per day were needed for residents and employees.
Observation of the dry storage room on April 26, 2023, at 9:18 a.m., revealed that there were 69 gallons of
emergency drinking water stored onsite. In an interview, the Director of Dining Services stated that the
facility's emergency water supply was accesible and stored in dry storage.
There was no evidence that the facility's disaster plan included provisions to obtain the minimum amount of
water required for staff and residents in the event of an emergency.
In an interview on April 27, 2023, at 11:04 a.m., the Administrator stated that the facility required a
minimum of 247 gallons of water to sustain staff and residents for 24 hours in the event of a loss of normal
water supply and that there was only 70 gallons of emergency water onsite.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 209.7(a) Disaster preparedness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 3 of 3