Pennsylvania Department of Health
GARDENS FOR MEMORY CARE AT EASTON, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS FOR MEMORY CARE AT EASTON, THE
Inspection Results For:

There are 127 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


GARDENS FOR MEMORY CARE AT EASTON, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on June 13, 2024, it was determined that The Gardens for Memory Care was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on clinical record review, facility policy review, observation, and staff interview, it was determined that the facility failed to ensure that assessed safety measures were in place for one of six sampled residents at risk for falls. (Resident 20) In addition, the facility failed to ensure that a resident at risk for elopement did not leave the secured nursing unit without staff knowledge for one of three sampled residents who were at risk for elopement. (Resident 75)

Findings include:

Clinical record review revealed that Resident 20 was admitted to the facility on March 24, 2023, with diagnoses that included Alzheimer's disease, insomnia, and history of falling. Review of the Minimum Data Set (MDS) assessment dated May 24, 2024, revealed that the resident had cognitive impairment. On August 23, 2023, the physician ordered for the resident to have bilateral (both sides) fall mats next to her bed. Review of the care plan revealed that Resident 20 was at risk for falls with an intervention for bilateral fall mats. Observations on June 11, 2024, from 9:09 a.m. through 12:00 p.m., revealed Resident 20 in bed with no fall mats.

Review of the facility policy entitled, "Elopement" last reviewed January 31, 2024, revealed the facility was to provide a safe and secure environment for residents and to be proactive in preventing resident elopements. Elopement was defined as a resident leaving a safe area of the facility without authorization and without the facility's knowledge and supervision.

Clinical record review revealed that Resident 75 had diagnoses that included Alzheimer's disease, dementia with severe psychotic disturbance, anxiety, hallucinations, and psychosis. The MDS assessment dated March 26, 2024, revealed that the resident had memory impairment. A review of the care plan revealed that the resident was at risk for elopement due to dementia. There was an intervention for staff to distract her from wandering by offering diversional activities. On December 7, 2023, a physician documented that the resident "frequently wanders." Review of the monthly psychoactive medication evaluations for March and April 2024, revealed that the resident had wandering behaviors that included going in and out of rooms, looking for her husband, and checking door knobs. The elopement risk evaluation dated March 3, 2024, indicated that the resident was disoriented, ambulated independently and was considered a high risk for elopment. On April 4, 2024, a nurse documented that the resident had exit-seeking behaviors that included touching alarm buttons, watching staff while opening doors and standing by the front door.

Review of an incident report dated May 6, 2024, at 11:10 a.m., revealed that the resident had been found outside of the secured nursing unit in a vestibule area near the front door to the nursing unit, alone without supervision The investigation into the incident revealed that a nurse aide had left the unit and failed to ensure that the door was locked and that no residents followed her out the door. Review of a witness statement from licensed practical nurse (LPN1) revealed that as she was coming into the building she found the resident standing in front of the doors to the second floor nursing unit. LPN1 stated that the Resident 75 said she got locked out and that she was waiting for her husband. Review of a witness statement from a registered nurse RN1 revealed that the resident had been exit-seeking, wandering, and asking where her husband was prior to leaving the secured nursing unit.

In an interview on June 13, 2024, at 9:08 a.m,. RN2 stated that the resident had been at risk for elopement and did leave the secured nursing unit without staff knowledge or supervison.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/09/2024

1. Fall mats were placed on the floor for resident while in bed. Resident was immediately
returned to unit at time of elopement.
2. Run audit of fall mat orders and placement. Fall mats are placed at time of order received. The units are secured by locked doors. Alarm time delay was decreased immediately after elopement. Mirror was installed in lobby to see the unit entry doors behind you.
3. Staff are re-educated on Fall Mat and Elopement.
4. NHA or designee will audit fall mat placement and daily for 5 days, then weekly for four weeks. NHA or designee will audit staff entering and exiting of units daily for 5 days, then weekly for four weeks. Results will be reported to QAPI.
5. July 9, 2024

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement