Health inspection·April 27, 2023

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. Page 1 of 3 395729 395729 04/27/2023 Gardens at Easton, The 498 Washington Street Easton, PA 18042

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. 395729 Page 2 of 3 395729 04/27/2023 Gardens at Easton, The 498 Washington Street Easton, PA 18042

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. 395729 Page 3 of 3