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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GARDENS FOR MEMORY CARE 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, 2025, at The Gardens for Memory Care 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# 163802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that The Gardens For Memory Care 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 483.70(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:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

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 openings, affecting 4 of 6 smoke compartments.

Findings include:

1. Observation on May 21, 2025, between 12:00 p.m., and 1:00 p.m., revealed resident room exhaust shaft enclosures, located at the first and second floor levels, lacked the required one-hour fire resistive integrity.

Interview at the time of the exit conference with the Facility Administrator and the Maintenance Director on May 21, 2025, at 1:15 p.m., confirmed the shaft enclosures lacked the required fire resistance rating.

Plan of Correction - To be completed: 06/10/2025

Administrator and Maintenance Director Request the Department of Health
Life Safety reaffirm and acknowledge the existing FSES.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of six smoke compartments.

Findings include:

1. Observation on May 21, 2025, at 12:18 p.m., revealed the lower level, Therapy Storage Room door required adjustment to fully latch.

Interview at the time of the exit conference with the Facility Administrator and the Maintenance Director on May 21, 2025, at 1:15 p.m., confirmed hazardous area enclosure deficiency.

Plan of Correction - To be completed: 06/10/2025

The lower-level Therapy Storage Room door was adjusted to fully latch.

A facility-wide check of all hazardous area doors was completed to ensure full latching and compliance with Life Safety Code standards.

Maintenance staff received re-education on inspection and adjustment of doors for hazardous area enclosures to ensure they latch and provide the required protection.

Monthly door inspections will be performed by the Maintenance Department and reviewed at QAPI for continued compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting 2 of 6 smoke compartments.

Findings include:

1. Observation on May 21, 2025, between 11:55 a.m., and 12:12 p.m., revealed the following:

a. 11:55 a.m., a hole in a ceiling tile, located closest to the lower level Administrative Suite.
b. 12:12 p.m., a "loaded" sprinkler head assembly, located within the lower level Dietary Department.

Interview at the time of the exit conference with the Facility Administrator and the Maintenance Director on May 21, 2025, at 1:15 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/10/2025

The ceiling tile with a hole near the Administrative Suite was replaced, and the loaded sprinkler head in the Dietary Department was cleaned and tested for functionality.

A building-wide visual inspection of all sprinkler heads and ceiling tiles was conducted no similar issues identified.

Maintenance staff were retrained on recognizing signs of sprinkler obstruction and ceiling tile deficiencies and instructed to correct them immediately.

Monthly sprinkler system inspections will be performed by the Maintenance Department and reviewed during QAPI meetings for continued compliance.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in two of twelve instances, affecting six of six smoke compartments.

Findings include:

1. Observation on May 21, 2025, at 12:55 p.m., revealed the facility lacked a second shift, second quarter fire drill, as well as third shift, third quarter fire drill.

Interview at the time of the exit conference with the Facility Administrator and the Maintenance Director on May 21, 2025, at 1:15 p.m., confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 06/10/2025

Fire drills for all three shifts have been scheduled and will be completed on a quarterly basis going forward.

All shifts are now included in the updated fire drill tracking schedule.

Maintenance staff received re-education on fire drills being conducted quarterly per shift.

Fire Drill compliance will be reviewed monthly by the Administrator and findings presented at QAPI meetings for continued compliance.

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