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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT EASTON, THE
Inspection Results For:

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GARDENS 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 May 28, 2026, it was determined that The Gardens at Easton 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) 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 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on observation and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Observations during the tour of the dietary department on May 26, 2026, at 9:26 a.m., revealed the following:

In the dry stockroom, there were seven dried brown splatters on the floor.

In the pot storage area, there was baseboard that was peeling from the wall and being held up by a kitchen cart's wheels. On the floor under the shelving, there was a butter packet and a condiment package. In the pot washing area, there was dried splatter on the wall.

In the food preparation area, under the table, there were three floor tiles that were loose and stacked on top of other tiles, exposing the subfloor. There were two holes in the wall near the floor. There was a large piece of brown food debris on the floor. There was dried red food splatter on the wall adjacent to the floor. On a condiment shelf, there was a baking soda container that had dried food debris on the lid. Under the oven, there was paper debris.

In the walk-in cooler, there were four large containers of cottage cheese that had a use-by date of May 22, 2026. Two of them were opened, with one that was noted as opened on May 20, 2026. In an interview on May 26, 2026, at 10:00 a.m., the Food Service Director confirmed the expired items should have been removed and were not.

CFR 483.60(i) Food Safety Requirement
Previously cited 5/15/25

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1) Management.

Plan of Correction - To be completed: 06/30/2026

F 0812- Food Procurement, Store/Prepare/Serve- Sanitary

1. Cottage cheese was thrown away immediately. Areas with housekeeping and maintenance issues noted were addressed by EOD 05/28/2026.
2. Full audit done to ensure all food in kitchen was labeled appropriately and were within the appropriate use by date. No further issues noted. Full audit done to ensure housekeeping and maintenance issues were found and addressed.
3. Education given to all dietary staff- All food items will be thrown away using the use by date. Food items will be checked daily for appropriate date. Dietary staff must keep sanitary and report any maintenance issues found.
4. Food service director/designee will perform weekly audits x4 weeks, then monthly x2 months- to ensure all food item dates are being monitored and discarded using the use by date and kitchen is being cleaned appropriately and no maintenance issues found or if found being reported. Findings will be reported to QAPI x3 months.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on observation, it was determined that the facility failed to provide a safe, clean, and homelike environment on three of three nursing units. (Annex, First, and Second Floors)

Findings include:

Observations on May 26, 2026, from 9:30 a.m. through 2:00 p.m., and May 27, 2026, from 8:45 a.m. through 2:00 p.m., revealed the following environmental issues:

In room 105, the closet doors were marred and the lower surface was chipped.

In room 106, behind the resident's bed there were three areas of scraped paint.

In room 116 (bed 2) there was paint peeling behind the resident's headboard, the wall adjacent to the bed was splattered with a brown substance, and the air conditioning vents had an accumulation of dirt and debris. The wall adjacent to the bathroom had surface damage and was missing paint.

In room 118, the air conditioning vents had an accumulation of dirt and debris and the wall below the air conditioning unit had multiple cracks and chipped paint.

In room 119 (bed 2), the adjacent wall was splattered with a brown substance next to the air conditioning unit, the wall was cracked with peeling paint, and the air conditioning vents had an accumulation of dirt and debris.

In room 120, the walls were marred and had peeling paint.

In room 121, the air conditioning vents had an accumulation of dirt and debris, the wall under the air conditioning unit had multiple cracks. The bathroom ceiling had brown stains, and there was a black substance above the vent.

In the First-Floor community shower room, there was a black substance in the far left shower stall.

Throughout 100 and 200 nursing units, residents' door frames were marred and with chipped paint.

The second-floor nurses' station was missing laminate on the face of the countertop and was chipped in three places with rough, unfinished wood exposed on the face and in the corners. The side walls of the nurses' station counter had chipped paint.

In the shared bathroom between rooms 202 and 203, the toilet seat was chipped and there were unpainted, spackled areas on the wall opposite the toilet.

In room 202, the main wall on the left was marred with black scrapes and the corner in the room by the bathroom door had chipped paint.

The ceiling in room 216 (bed 4) was cracked with small pieces of the ceiling exposed and hanging from the crack.

In room 209, the window curtain rod was observed to have loose screws and to be hanging from the wall.

In the second floor hallway across from room 217, a recliner was observed with white liquid stains on the seat and a black and gray metal storage cabinet was observed with dried liquid streaks along the bottom quarter of the front and right sides of the cabinet.

The baseboards throughout the hallway between rooms 223 and 230 were covered in a brown substance.

Across from room 223, there was a brown substance on the wall beneath the electrical outlet.

The ceiling overhang adjacent to the Second-Floor nursing station had three loose tiles.
In the hallway above the Annex shower room door, there was a ceiling tile with a brown circular stain.

The handrail and the baseboard along both sides of the hallway from room 301 to 315 were marred.

In the hallway adjacent to the Annex janitor's closet, there were three stained ceiling tiles.
In the hallway in front of room 305, the ceiling tile had a piece missing and the vent had a black substance on it.

The vent in the ceiling above the Annex nurses' station across from the dining room had a layer of a black substance.

Across from room 305, the door to the Annex TV lounge had a large area of wood chipped away from it on the hinge.

In the hallway, the ceiling tile adjacent to the Annex soiled utility room had cobwebs and dead insects attached to it that were dangling from the tile. The soiled utility room door had a piece of exposed wood.

In the hallway next to room 307, there was a dried brown substance on the wall behind the handrail.

In an interview on May 27, 2026, at 2:00 p.m., the Administrator and Director of Nursing confirmed the identified environmental issues were present.

CFR 483.10(i)(2) Safe Environment
Previously cited 5/15/25, 5/19/26

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(e )(2.1) Management.

The second-floor nurses' station was missing laminate on the face of the countertop and was chipped in three places with rough, unfinished wood exposed on the face and in the corners. The side walls of the nurses' station counter had chipped paint.

In the shared bathroom between rooms 202 and 203, chipped paint was observed on the toilet seat and unpainted, spackled walls on the wall opposite the toilet.

In room 202, the main wall on the left was marred with black scrapes and the corner in the room by the bathroom door had chipped paint.

The ceiling in room 216 over bed 4 was cracked with small pieces of the ceiling exposed and hanging from the crack.

In room 209 window curtain rod was observed to have loose screws and to be hanging out of the wall.

In the second floor hallway, across from room 217, a recliner was observed with white liquid stains on the seat and a black and gray metal storage cabinet observed to have dried liquid streaks all along the bottom quarter of the front and right side of the cabinet.

The baseboards throughout the hallway between rooms 223 to 230 were covered in brown substance.

Across from room 223 there was a brown substance on the wall beneath the electrical outlet.

The ceiling overhang adjacent to the Second-Floor nursing station had three loose tiles.

In the hallway above the Annex Shower Room door, there is a ceiling tile has a brown circular stain on it.

The handrail and the baseboard along both sides of the hallway from room 301-315 were marred.

In the hallway above the Annex Janitor Closet door, there were three stained ceiling tiles.

In the hallway in front of room 305, the ceiling tile had a piece missing and the vent had a black substance on it.

The vent in the ceiling above the Annex nurses station across from the dining room had a layer of a substance across it that was shaped as black circles.

Across from room 305, the door to the Annex TV lounge had a large area of wood chipped away from it on the hinge side that exposed some wood shards.

In the hallway, the ceiling tile above the Annex Soiled Utility Room had several cobwebs and dead insects attached to it that were dangling from the tile. The Soiled Utility Room door had a piece of wood sticking out into the hallway.

In the hallway next to room 307, there was a dried brown substance on the wall behind the handrail.

In an interview on May 27, 2026, at 2:00 p.m., the Administrator and Director of Nursing confirmed the environmental issues were present.

CFR 483.10(i)(2) Safe Environment

Previously cited 5/15/25, 5/19/26

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(e )(2.1) Management

Plan of Correction - To be completed: 06/30/2026

F 0584- Safe/Clean/ Comfortable Environment

1. Areas noted in POC addressed by the Maintenance Director/designee and Housekeeping Director/designee.
2. The Director of Maintenance/designee and Housekeeping Director/designee have done a house wide audit of the facility for environmental concerns. A list was developed and concerns addressed.
3. Housekeeping and maintenance department were educated on requirement to maintain a safe, clean and comfortable environment. Staff re-educated on properly reporting environmental issues so they can be addressed.
4. An audit was developed where 20 rooms will be audited per week x4 weeks then 10 rooms monthly x2 months to address any environmental issues. Findings will be reported to QAPI x3 months.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on clinical record review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for one of 33 sampled residents. (Resident 3)

Findings include:

Clinical record review revealed that Resident 3 was frequently incontinent of urine and stool, was able to communicate her needs, and was dependent on staff for toileting. According to the care plan, staff were to assist the resident to toilet as needed. On May 26, 2026, at 11:30 a.m., the resident turned on her call light. At that time, she stated, "I need to be changed." At 11:35 a.m., a nurse aide entered the room and turned off her call light without assisting the resident. Staff did not assist the resident until 12:45 p.m.

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

Plan of Correction - To be completed: 06/30/2026

F0550- Resident Rights/Exercise of Rights

1. Event in the past, so cannot be fixed for that resident. CNA no longer works at facility. SS met with resident for psychosocial support and educated to press call bell again if assistance is not timely and resident can ask for supervisor if needed. Resident understands education.
2. Interview conducted of alert and oriented residents in this assignment. No further complaints of long wait times for care reported.
3. New signature break sheets provided to nursing floors. This sheet requires nursing staff to sign out for break and the covering nursing staff to initial they received report from exiting nursing staff to ensure needs of residents are communicated and covered.
Education done with all CNAs and nurses- All nursing staff must give report to covering nursing staff before going on breaks and leaving the floor.
4. DON/ designee will conduct audits daily x7 days to ensure process is being carried out appropriately and effectively. Then will audit weekly x3 weeks, then monthly x2 months. Findings will be reported to QAPI x3 months.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide interventions to prevent new or worsened pressure ulcers for two of three sampled residents with wounds. (Residents 3, 15)

Findings include:

Clinical record review revealed that Resident 3 had diagnoses that included left heel deep tissue injury (damage to the underlying soft tissue from pressure and/or shear forces), malignant neoplasm of the brain, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated April 12, 2026, revealed Resident 3 required substantial assistance from staff for activities of daily living. Review of the comprehensive care plan revealed the resident was at risk for skin impairment. A physician's order dated April 16, 2026, directed staff to offload heels every shift. Observations on May 26, 2026, at 9:50 a.m., 12:15 p.m., and 2:37 p.m., revealed Resident 3 in bed, with heels directly on the bed.
In an interview on May 28, 2026, at 9:00 a.m., the Director of Nursing confirmed that staff did not follow the physician's orders for Resident 3.

Clinical record review revealed that Resident 15 had diagnoses that included a stroke with residual left-sided upper and lower extremity weakness. The MDS assessment dated April 24, 2026, indicated that Resident 15 was cognitively impaired, required substantial assistance from staff for activities of daily living, and had an advanced pressure wound on her sacrum. Review of the care plan revealed the resident had limited mobility, had actual skin breakdown, and was at risk for further skin impairment related to decreased mobility and included an intervention for staff to maintain pressure reducing devices as ordered. On March 10, 2025, the physician ordered for staff to apply bilateral heel boots to offload pressure so that both heels were not in contact with the mattress or pillows. Observations on May 26, 2026, from 10:07 a.m. to 1:52 p.m., and on May 28, 2026, at 10:30 a.m., revealed that Resident 15 was lying in bed, and her heels were observed to be directly on the bed, with no heel boots in place.

In an interview on May 28, 2026, at 10:06 a.m., the Director of Nursing confirmed that staff did not apply the heel boots as ordered by the physician for Resident 15.

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

Plan of Correction - To be completed: 06/30/2026

F 0686- Treatment/ Svcs to Prevent/Heal Pressure Ulcer

1. Resident 3 and Resident 15 heels were off loaded as per MD order by EOD of date notified. Heels for Resident 3 and Resident 15 were assessed and both residents areas were unchanged from previous assessment. Residents following up with wound care services.
2. House wide audit done on all residents who have MD orders for off loading heels to ensure compliance, ensure orders are in place and care planned.
3. Education given to all nursing staff of importance of following all MD orders including to off-load resident's heels.
4. DON/designee will perform weekly audit x4 weeks, then monthly x2 months to ensure all residents with MD orders to off-load heels are being followed appropriately. Findings will be reported to QAPI x3 months.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to provide copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman for one of three residents who were transferred from the facility. (Resident 1)

Clinical record review revealed that Resident 1 was discharged from the facility to her home on March 13, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.

In an interview on May 28, 2026, at 11:45 a.m., the Nursing Home Administrator confirmed that the written copies of the discharge notice were not sent to the Office of the State Long-Term Care Ombudsman.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 06/30/2026

I hereby acknowledge the CMS 2567-A, issued to GARDENS AT EASTON, THE for the survey ending 05/28/2026, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

F 0628- Discharge Process

1. Discharged resident was in the past, could not fix this event.
2. At the beginning of the month, transfer and discharge log emailed to Ombudsman, then printed and filed for confirmation of notification.
3. Education given to administration and social services- For all discharges, notification should be sent to ombudsman along with transfer logs.
4. Admin/designee will conduct audits monthly x3 months to ensure ombudsman was notified of all discharges from facility. Will report findings to QAPI x3 months.

§ 201.22(a) LICENSURE Prevention, control and surveillance of tuber:

(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:
Based on review of personnel files, review of facility policy, and staff interview, it was determined that the facility failed to obtain a baseline tuberculosis (TB) status on one of five newly hired employees. (Employee 5)

Findings include:

Review of the facility's policy entitled, "TB Screening and Testing for Employees," dated January 2, 2026, revealed that all new employees, including those that have been made a conditional offer of employment shall have an initial (first step) TST placed prior to beginning employment. Those that provide documented verification of a negative Tuberculin Skin Test (TST) or Blood Assay for Mycobacterium Tuberculosis (BAMT) result within the preceding 12 months, are the exception.

A review of Employee 5's personnel file revealed the employee was hired on April 14, 2026. There was no documented evidence that a baseline TB screening test was completed prior to beginning employment or that a BAMT was completed within 12 months preceding the hire date.

In an interview on May 28, 2026, at 8:58 a.m., the Administrator confirmed Employee 5 was a current employee and that there was no documented evidence that a TB screening test had been completed per facility policy.

Plan of Correction - To be completed: 06/30/2026

P 1690- Prevention, control and surveillance of TB

1. Employee 5 received a chest x-ray 05/28/2026 to rule out TB for baseline.
2. Audit done on last three month of newly hired employees to ensure TB done as per facility policy.
3. Education done with HR- TB documentation should be obtained for new employees according to the facility TB policy.
4. Admin/designee will audit all newly hired employees weekly x4 weeks then monthly x2 months to ensure following facility TB policy. Findings will be reported to QAPI x3 months.

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