Pennsylvania Department of Health
 GARDENS AT EASTON, THE
Building Inspection Results

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GARDENS AT EASTON, THE
Inspection Results For:

There are  53 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT EASTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 21, 2026, at The Gardens at Easton, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 140602

Component 01

Main Buildingon a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that The Gardens at Easton was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).
This is a two story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical enclosures affecting two of two floors in this component.

1. Observation on May 21, 2026, between 9:30 am and 10:30 am, revealed the vertical shaft enclosures lacked the required one-hour fire resistance rating due to a single layer of five eighths of an inch-thick gypsum board, affixed to internal metal support studding.
Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the vertical enclosure deficiency.






 Plan of Correction - To be completed: 06/29/2026

K 0311- NFPA 101 Vertical Openings- Enclosures


1. The Facility requests to use FSES
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview it was determined that the facility failed to maintain the kitchen hood system affecting one of one kitchen hoods.

Observation on May 21, 2026, at 9:32 am, revealed open gaps between the kitchen hood baffles.Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the kitchen hood baffles were not tight fitting.






 Plan of Correction - To be completed: 06/29/2026

K 0324- NFPA 101 Cooking Facilities


1. Kitchen hood baffles ordered for replacement of loose kitchen hood baffles. 7 new baffles to be replaced.

2. Education done with Maintenance department- Kitchen hood baffles should be tight fitting and replaced if found not tight fitting.

3. Weekly audits of kitchen hood baffles to be done x4 weeks then monthly x2 months to ensure proper tight fit.

4. Report findings to QAPI
NFPA 101 STANDARD Portable Space Heaters:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0781

Based on observation and interview it was determined that the facility failed to monitor for the unauthorized use of portable space heaters on one of three floors.



Observation on May 21, 2026, at 9:00 am revealed a space heater in resident room 224 on the 2nd floor.Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the space heater was in use in a resident room.






 Plan of Correction - To be completed: 06/29/2026

K 0781- NFPA 101 Portable space heaters


1. Space heater removed from room 224.

2. House wide Education to all staff- Space heaters are prohibited in facility and resident's rooms. Remove and/or Report to supervisor immediately if seen.

3. Weekly audits of all rooms to ensure no portable heaters are in resident rooms x4 weeks then monthly x2 months.

4. Report findings to QAPI
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview it was determined the facility failed to monitor for the use of unauthorized electrical devices on one of three floors.

Observation on May 21, 2026, at 9:20 am revealed a multioutlet plugin device was in use in resident room 118 on the 1st floor.Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the multioutlet device was in use.






 Plan of Correction - To be completed: 06/29/2026

K 920- NFPA 101 Electrical Equipment- Power cords and Extensions


1. Multi outlet plug in device was removed from room 118.

2. House wide Education to all staff- multi outlet plug ins and power strips are prohibited in facility and residents rooms. Remove and/or report to supervisor immediately if seen.

3. Weekly audits of all rooms to ensure no multi plug in outlets or power strips are in resident rooms x4 weeks then monthly x2 months.

4. Report findings to QAPI
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000
Facility ID# 140602Component 02AnnexBased on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that The Gardens at Easton was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a two story, Type II (222), fire resistive building, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0321 Based on observation and interview it was determined that the facility failed to maintain hazardous areas on one of two floors. Observation on May 21, 2026, at 10:00 am revealed the door to the Annex storage room failed to latch when in the corresponding frame when tested.Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the storage room door lacked positive latching.
 Plan of Correction - To be completed: 06/29/2026

K 0321- NFPA 101 Hazardous Areas – Enclosure


1. New closure system ordered for Annex storage door. Closure system will be replaced and door adjusted to ensure positive latching.

2. Education done with maintenance department- All doors must be positive latching in compliance with NFPA 101

3. Weekly audit of facility doors x4 weeks then monthly x2 months to ensure positive latching.

4. Report findings to QAPI
NFPA 101 STANDARD Corridors - Construction of Walls:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0362 Based on observation and interview it was determined that the facility failed to maintain wall construction in one of three smoke compartments. Observation on May 21, 2026, at 10:03 am revealed an approximately four by six-inch open hole in the resident bathroom wall on the bedroom side of the bathroom, below the ceiling, in room 301 of the Annex.Exit interview with the director of nursing and the maintenance representative on May 21, 2026, at 10:30 am, confirmed the open hole in the wall in the resident room.
 Plan of Correction - To be completed: 06/29/2026

K 0362- NFPA 101 Corridors- Construction of Walls


1. Maintenance fixed hole found in Annex room 301.

2. Housewide education to all staff- when maintenance issues are seen such as holes, etc. put in TELS system and report to maintenance.

3. Room audits to be done weekly x4 weeks then monthly x2 months to ensure no holes in room walls. Repairs to be done with any findings.

4. Report findings to QAPI.

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