F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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, it was determined that the facility failed to maintain residents' environment and equipment in a
safe, clean, comfortable, and homelike manner on two of three nursing units. (First and Second Floor
nursing units)
Findings include:
Observations on May 13, 2025, from 9:30 a.m. through 2:00 p.m., and May 14, 2025, from 8:45 a.m.
through 3:00 p.m., revealed the following environmental issues:
In room [ROOM NUMBER] (bed 1) there was paint peeling behind the resident's headboard.
In room [ROOM NUMBER] (bed 1) the privacy curtain was torn.
In the First Floor community shower room there was a black substance in the far left shower stall, in the
middle shower stall, there were chipped tiles in the floor and a missing shower head and faucet, the bottom
of the handle on the bathtub had a dark substance on it, and the toilet area had chipped paint on the right
side of the wall and a brown substance behind the toilet.
Resident 62's wheelchair had a broken and torn left arm rest, the back of the wheelchair was torn, and had
loose axles.
In the Second Floor dining room, there was dust was in the corners of the room, peeling tape around the
two air conditioning units and on the window sills, the curtain on the middle window had a brown stain, and
the dining room hand sanitizer dispenser was empty.
The heater in the hallway outside of room [ROOM NUMBER] was covered with a black substance and the
wall behind it was cracked.
The handrails between the dining room and room [ROOM NUMBER], and between rooms 202 to 205,
rooms 207 to 209, rooms 216 to 219, rooms 220 to 222, and between rooms [ROOM NUMBERS] had
cracked paint and were loose.
The bottom of the window curtains in resident rooms 223 (bed 3) and 226 (bed 1), were stained, and the
windows were cloudy with a black residue in corners.
28 Pa. Code 201.14(a) Responsibility of licensee.
(continued on next page)
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 6
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
05/15/2025
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 0584
28 Pa. Code 201.18(b)(1) Management.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 2 of 6
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
05/15/2025
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 0641
Ensure each resident receives an accurate assessment.
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, observation, and staff interview, it was determined that the facility failed to ensure
that the Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' current
status for two of 32 sampled residents. (Residents 27, 93)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 27 had diagnoses that included diabetes mellitus and
pulmonary embolism. A physician's order dated April 9, 2025, directed staff to administer an anti-coagulant
medication (dabigatran). Review of the MDS assessment dated [DATE], revealed that the resident was on
an anti-platelet medication in the last seven days, not an anti-coagulant medication. The MDS inaccurately
reflected the use of an anti-platelet medication, as the dabigatran was an anti-coagulant medication.
Clinical record review revealed that Resident 93 had diagnoses that included end stage renal disease and
chronic congestive heart failure. Review of the nurse practitioner's progress notes dated February 27, 2025,
and March 4, 2025, revealed that Resident 93 was on chronic oxygen via nasal cannula. Review of the
oxygen saturation summary dated November 18, 2024, through May 7, 2025, revealed that Resident 93
was on oxygen via nasal cannula. Observations on May 13, 2025, at 11:16 a.m. and again on May 14,
2025, at 12:09 p.m., revealed Resident 93 sitting up in bed with oxygen via nasal cannula. Review of the
MDS assessment dated [DATE], did not identify the resident was receiving oxygen therapy.
In an interview on May 15, 2025, at 2:05 p.m., the Director of Nursing confirmed that Resident 27's and 93's
MDS assessments were inaccurate and did not reflect the residents' current status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 3 of 6
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
05/15/2025
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, clinical record review, observation, and resident and staff interview it was
determined that the facility failed to obtain a physician's order for oxygen and provide appropriate care for
respiratory equipment for one of 32 sampled residents. (Resident 93)
Residents Affected - Few
Findings include:
Review of the facility policy entitled, Equipment Changing, last reviewed January 8, 2025, revealed that all
respiratory therapy equipment should be changed on a weekly basis and as needed when the equipment
came in contact with the ground.
Clinical record review revealed that Resident 93 had diagnoses that included end stage renal disease and
chronic congestive heart failure. Observations on May 13, 2025, at 11:16 a.m. and again on May 14, 2025,
at 12:09 p.m., revealed Resident 93 was sitting up in bed with oxygen being administered using a nasal
cannula. In an interview at that time, Resident 93 stated that he always wears oxygen except for when
going outside to smoke. Review of the nurse practitioner's progress notes dated February 27, 2025, and
March 4, 2025, revealed that Resident 93 was on oxygen at all times. Review of the oxygen saturation
summary dated November 18, 2024, through May 7, 2025, revealed that Resident 93 was using oxygen via
nasal cannula. Review of the May 2025 physician's orders revealed no order for oxygen therapy via nasal
cannula. There was also no documented evidence that staff changed the oxygen tubing weekly according
to facility policy.
In an interview on May 15, 2025, at 1:45 p.m., the Director of Nursing confirmed that the resident should
have had a physician's order for the oxygen and that tubing should be changed weekly.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 4 of 6
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
05/15/2025
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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 on a review of facility policy, staff interview, and observation, it was determined that the facility failed
to properly store medications on one of three nursing units. (Second Floor nursing unit)
Findings include:
Review of the facility policy entitled, Medication Storage and Labeling, last reviewed January 8, 2025,
revealed that medications requiring refrigeration were to be stored in a refrigerator located in the
medication room at the nurses' station or other secured location. Medications were to be stored separately
from food and were to be labeled accordingly. In an interview on May 14, 2025, at 10:19 a.m., the
Administrator stated that the acceptable temperature for a medication refrigerator was to be between 36
degrees Fahrenheit and 46 degrees Fahrenheit.
Observation of the Second Floor medication refrigerator on May 14, 2025, at 9:00 a.m., revealed a
temperature of 60 degrees Fahrenheit. At 10:02 a.m., the temperature was 58 degrees Fahrenheit. At 12:22
p.m., the temperature was 59 degrees Fahrenheit. At 1:26 p.m., the Maintenance Director confirmed the
refrigerator temperature was 54 degrees Fahrenheit. At each observation, there were two opened
medications that required refrigeration, Cefepime and Konvomep. Per manufacturer guidelines, these
medications were to be stored at a temperature between 36 degrees Fahrenheit and 46 degrees
Fahrenheit.
In an interview on May 14, 2025, at 3:01 p.m., the Administrator confirmed the temperatures of the Second
Floor medication refrigerator were above acceptable temperatures.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3)(e)(2.1) Management.
28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 5 of 6
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
05/15/2025
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 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 policy review, observation, and staff interview, it was determined that the facility failed to properly
store food and maintain sanitary conditions in the dietary department.
Residents Affected - Few
Findings include:
Review of the facility's policy entitled, Employee Sanitary Practices, dated January 8, 2025, revealed that all
staff were to cover all of their hair with a hair restraint.
Observations during the tour of the dietary department on May 13, 2025, at 10:22 a.m., revealed the
following:
There was a blender lid on the floor next to the pot rack. There were four large containers of dry cereal that
had a layer of sticky food debris on the outside of the lid and bottom of each container.
In the walk-in freezer, there was ice build up and condensation on the three fan vents on the wall. On the
floor below the fans, there were multiple spots of ice and condensation. On the two shelves below the fans,
there was a box of sherbet and peas that were covered with ice. Next to this, on another shelf, there were
two opened boxes of pretzels that were covered with ice. There was a large ice formation on each of two
shelves below the fans.
Observation during of the lunch meal service tray line on May 14, 2025, from 12:15 p.m. to 12:30 p.m.,
revealed Dietary Employee (DE) 1 was observed with a mustache that was not covered.
In an interview on May 14, 2025, at 12:55 p.m., the Food Service Director confirmed that DE 1 should have
been wearing a hair restraint to cover the mustache during the meal tray line.
CFR 483.60(i) Food Safety Requirement
Previously cited 4/18/24
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395729
If continuation sheet
Page 6 of 6