Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Easton Health Care Center during CMS and state inspections, most recent first.
Failure to Prevent Left Heel Pressure Injury A resident with severe cognitive impairment, lower-extremity impairment, and dependence on staff developed a stage 3 left heel pressure injury. The care plan included a pressure-reducing mattress and wheelchair cushion, but it lacked heel-specific pressure reduction interventions and did not include direction for treatment and wound care. Nursing documentation identified the heel wound, but staff later stated the care plan had not been updated with the wound information or prevention measures such as heel floating.
Infection Control Failures During Care of a Resident With a Suprapubic Catheter: Staff did not use EBP consistently during high-contact care, handled soiled linen unsafely, allowed the catheter bag to drag on the floor, and failed to change gloves or perform hand hygiene appropriately during personal care. A resident with urinary retention, UTI, and a suprapubic catheter was observed with soiled linens, a reddened insertion site with drainage, and staff using the same soiled gloves while cleaning him, moving linens, and wiping the mattress with his shirt.
A resident with urinary retention, UTI, BPH, and an indwelling suprapubic catheter was provided personal care with the room door left open. Two CNAs assisted with incontinence care, catheter care, linen changes, and transfer while the resident was soiled with bowel movement, and the Administrative Nurse stated the door should have been shut and the privacy curtain used in a shared room.
A resident with urinary retention, UTI, BPH, and a suprapubic catheter had a care plan that addressed catheter positioning and monitoring but did not include EBP or PPE direction for staff during catheter-related care. During observed care, the resident was found soiled with stool, had a reddened catheter site with yellow drainage, and two CNAs provided care inconsistently, with one wearing a gown and the other only gloves, while handling the catheter bag, linens, and lift equipment without changing gloves.
Failure to protect a resident's scrotal skin during incontinence care resulted in two superficial open areas with bright red bleeding. The resident had chronic osteomyelitis, venous insufficiency, and DM2, and required staff assistance for toileting hygiene, lower body dressing, and personal hygiene. Staff later found the areas while cleaning the resident, and an LPN said they appeared to be from being pinched.
A resident with urinary retention, BPH, and a suprapubic catheter had a history of UTI and was ordered catheter-site care, bag changes, and catheter changes. Observation showed a reddened insertion site with yellow drainage, a soiled dressing in the abdominal folds, staff emptying the catheter bag without cleaning the valve, the bag placed on the floor, and CNAs continuing care with soiled gloves during incontinence care and transfer. Later, the site had thick yellow discharge, and the resident stated it had been oozing pus.
Incomplete PBJ Staffing Data Submission: The facility failed to submit complete and accurate PBJ staffing data. CMS PBJ reports for multiple FY 2025 quarters showed excessively low weekend staffing, while schedule review showed adequate staff were on duty. An admin staff member stated the data were pulled from the time clock in corporate, the facility was not short on weekends, did not use agency staff, and several payroll program changes may have caused the issue. The facility policy required timely and accurate staffing data submission through CMS PBJ.
A resident with Alzheimer's and muscle weakness was injured during a transfer using a Hoyer lift when the lift tipped, causing her to hit her head on a dresser. The incident involved a CNA and an LN who were unsure why the lift tipped, and it was found that there were gaps in staff training on lift use. The resident sustained a head laceration requiring staples and sutures.
The facility did not provide quarterly statements for resident trust fund accounts, as required by policy. A resident's representative reported not receiving any statements for the year and had trouble contacting the responsible staff. Administrative Staff B confirmed no statements were sent due to lack of training, risking uninformed decisions and potential misappropriation.
A resident's personal funds were inaccurately accounted for, resulting in an overcharge of $347.89 due to duplicate charges and a charge without a receipt. Administrative Staff B, responsible for managing the trust accounts, entered transactions twice due to a lack of training and oversight. The facility's policy for managing resident funds was not followed, leading to the mismanagement of the resident's funds.
The facility failed to convey personal funds within 30 days for three residents after discharge or death, risking impaired rights and misappropriation. Administrative Staff B was uncertain about procedures for handling trust funds, and the facility policy lacked guidance on this matter.
A resident with Huntington's disease and a history of trauma was mistreated by two CNAs who physically obstructed him from accessing the refrigerator, leading to a fall and subsequent self-harm attempt. The CNAs' actions escalated the situation, resulting in the resident's mistreatment and immediate jeopardy.
Failure to Prevent and Care for Left Heel Pressure Injury
Penalty
Summary
The facility failed to prevent the development of an avoidable stage three pressure injury on R25’s left heel. R25 had diagnoses including embolism and thrombosis of the vein, polyneuropathy, and a history of pressure ulcer of the left heel stage three. He had severely impaired cognition, impairment in both lower extremities, and was dependent on staff for care. A pressure ulcer/injury care area assessment documented that he was at risk for pressure injuries because of decreased mobility and prolonged time in bed or chair, with contributing factors including impaired sensory perception, friction/shear, and/or incontinence. R25’s care plan documented a pressure-reducing mattress, a cushion in his wheelchair, and that he could offload while up in his recliner and assist with turning and repositioning in bed with bed canes. The care plan also directed weekly skin assessments and monitoring of skin with all cares, but it lacked interventions to reduce pressure to the heels and elbows. It also lacked staff direction on treatment and cares for R25’s stage three pressure ulcer on his left heel. Nursing documentation showed that on 01/27/25 new open areas were identified on the left heel, including a deep tissue injury and a stage three pressure ulcer, and wound treatment orders were received from the physician. The record showed ongoing wound treatment orders for the left heel over time, including cleansing and various dressings, but the physician’s visit documentation on 02/24/25 did not mention the left heel wound. Later documentation showed the wound had resolved by 08/21/25, but weekly skin assessments continued. A subsequent skin check on 12/06/25 documented a scabbed area on the left heel that was a wound acquired in-house, and on 12/11/25 the left heel was documented as a new stage three pressure ulcer/injury, full-thickness skin loss, with measurements of 1.55 cm by 1.48 cm by 0.3 cm. Staff interviews indicated the care plan had not been updated with wound prevention interventions or wound information from the prior or current heel wound, and one nurse stated she would expect heel floating and barrier cream to be in place.
Infection Control Failures During Care of Resident With Suprapubic Catheter
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were used for a resident with a suprapubic catheter, failed to handle and transport soiled linen in a sanitary manner, failed to keep the catheter bag from dragging on the floor, failed to ensure appropriate glove changing and hand hygiene during personal care, and failed to disinfect a mattress after changing soiled linens. The resident had diagnoses including urinary retention, UTI, and BPH, and the quarterly MDS documented intact cognition, dependence for toileting hygiene and lower body dressing, substantial assistance with personal hygiene, partial assistance with mobility, and the presence of a urinary catheter and UTI during the lookback period. The care plan documented the suprapubic catheter and that the catheter bag and tubing should be positioned below the bladder, but it did not include documentation or direction to staff on PPE use during care. During observation, the resident was found sitting on the side of the bed with very soiled bottom sheets from bowel movement and stated he had been sitting in stool for a while and had asked staff to clean him up. The catheter insertion site was reddened with yellow drainage, and a soiled gauze dressing was found between folds of the abdomen. Two CNAs assisted with care; one wore a gown and gloves, while the other wore only gloves and did not close the room door. One CNA emptied the catheter bag and laid it on the floor, and the resident’s catheter bag was later placed under the wheelchair. Soiled sheets were removed and thrown onto the floor, then one CNA picked them up unbagged and carried them down the hall. During the same care episode, one CNA continued cleaning the resident with the same soiled gloves while rolling him and wiping under the abdominal apron without changing gloves. The resident’s shirt was used to wipe off the mattress, then placed on the bedside table, and new linens were put on the bed with the same soiled gloves. The resident asked for soapy water and a rag to wash his hands, and staff did not provide them. On a later observation, an LPN provided care without a gown, stating she had forgotten to put one on, and the resident’s shirt was stained at the catheter site with thick yellow stringy discharge. Additional staff later observed the catheter site and noted blood on the brief and two open areas on the scrotum that appeared to be from pinching.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to promote dignity and respect for one resident when staff did not close the door to the resident’s room before providing personal care. The resident had diagnoses including urinary retention, UTI, and BPH, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition. The resident was dependent on staff for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene, and also required partial assistance with mobility. The care plan documented that the resident had an indwelling suprapubic catheter and that staff were to monitor the catheter and signs and symptoms of discomfort and UTI, but it lacked documentation and direction regarding the use of PPE during care. During observation, the resident was sitting on the side of the bed wearing a shirt and incontinence brief, and the bottom sheet was very soiled with bowel movement. The resident stated he had sat in the bowel for a while and had asked staff to clean him up, but was told they would clean him after breakfast when they got him up into his wheelchair. Two CNAs entered to provide care, pushed the mechanical lift into the room, and did not shut the room door. While the resident was assisted back to bed, one CNA emptied the catheter bag and placed it on the floor, another removed soiled linens and cleaned bowel from the resident, and the resident was transferred to the wheelchair with the catheter bag hooked under it. The Administrative Nurse stated staff should have shut the resident’s door before providing cares and, in a shared room, should have pulled the privacy curtain.
Care Plan Missing EBP Direction for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure R4’s care plan was revised to include enhanced barrier precautions (EBP) for care of his suprapubic catheter. R4’s EMR documented diagnoses of urinary retention, UTI, and BPH. His quarterly MDS showed a BIMS score of 15, dependence on staff for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene, partial assistance with mobility, and the presence of a urinary catheter and UTI during the lookback period. R4’s care plan included interventions related to calling for assistance, catheter positioning, monitoring output, and monitoring for discomfort and UTI signs, but it did not include direction for staff to use PPE during catheter-related care. During observation, R4 was found sitting on the side of the bed with a shirt and incontinence brief on, with the bottom sheet very soiled with bowel movement. He stated he had been sitting in the bowel for a while and had asked staff to clean him up, but was told they would do so after breakfast when he was up in his wheelchair. He also stated he had a catheter and lifted the apron of his abdomen, where observation revealed a reddened catheter insertion site with yellow drainage and a soiled 4x4 gauze dressing between the folds of his abdomen. Two CNAs then provided care while handling the resident, linens, catheter bag, and mechanical lift. One CNA wore a gown and gloves, while the other wore only gloves and did not close the room door. The CNAs emptied the catheter bag, laid it on the floor and later on the bed, removed soiled linens, cleaned the resident’s bowel and under his abdominal apron without changing gloves, and transferred him using the same soiled gloves. Soiled sheets were thrown on the floor and later carried down the hall unbagged. The resident asked for soapy water and a rag to wash his hands, and they were not provided. An administrative nurse later stated that R4’s EBP status should be on the care plan and that it would be updated.
Failure to Protect Scrotal Skin During Incontinence Care
Penalty
Summary
The facility failed to prevent two superficial open areas on R4's scrotum during incontinence care. R4 had diagnoses of chronic osteomyelitis, venous insufficiency, and type 2 DM, and his quarterly MDS documented intact cognition, dependence on staff for toileting hygiene and lower body dressing, substantial assistance with personal hygiene, partial assistance with mobility, and risk for breakdown with use of nonsterile dressings and ointments. His care plan directed nursing staff to assess, measure, and monitor wound healing and to document the wound perimeter, wound bed, and healing progress. During incontinence care, staff observed bright red blood on the sheet and brief, and later on the brief again. When the brief was opened, two open areas were found on R4's scrotum, with one measured at 8.2 cm by 0.7 cm and the other at 0.9 cm by 0.6 cm. An LPN stated the areas looked like they were from being pinched. The facility's staff discussed contacting the physician and obtaining a treatment order, and an administrative nurse stated she would try to determine how to protect the skin from being pinched.
Failure to Provide Appropriate Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to provide appropriate catheter care and care to prevent UTI for a resident with urinary retention, BPH, and a suprapubic catheter. The resident’s record showed intact cognition, dependence on staff for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene, along with a history of UTI during the lookback period. The care plan directed staff to keep the catheter bag and tubing below bladder level, monitor and document output, and monitor for signs and symptoms of discomfort and UTI. The record also showed positive UTIs on 11/06/25 and 12/31/25, with physician orders for IV meropenem and oral Macrobid, as well as orders to change the catheter anchor, cleanse the catheter site daily and nightly, change the collection bag weekly, and change the suprapubic catheter every 28 days. On 01/11/26, observation showed the resident sitting on the side of the bed with an incontinence brief and a reddened catheter insertion site with yellow drainage. A soiled, wadded-up 4x4 gauze dressing was found between the folds of his abdomen. A CNA emptied the catheter bag without cleaning the drainage valve, laid the bag on the floor, and did not change gloves. Another CNA provided incontinence care and cleaned the resident while wearing soiled gloves, including wiping under the abdominal apron and assisting with clothing and a mechanical lift transfer without changing gloves. The catheter bag was then hooked under the resident’s wheelchair and he was taken to the dining room. On 01/12/26, a nurse observed the resident’s shirt stained at the catheter site and found thick, yellow, stringy discharge at the insertion site. The resident stated the site had been oozing pus. Staff observed that the mechanical lift battery was dead and multiple CNAs assisted with transfer and incontinence care. One nurse stated the site would be looked at in bed, and another nurse stated she would contact the physician for treatment. Staff interviews also showed awareness that the resident scratched and touched the catheter site, that the catheter bag sometimes went on the floor, and that gloves should be changed when moving from dirty to clean tasks. The facility’s catheter care policy required appropriate catheter care, keeping the drainage bag below bladder level, and hand hygiene when done.
Incomplete PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system based on payroll and other verifiable and auditable data. For FY 2025 Quarter 1, Quarter 2, Quarter 3, and Quarter 4, the CMS PBJ report showed excessively low weekend staffing, while review of the facility’s nursing staff schedules for those quarters showed that adequate staffing was provided on duty. During interview, Administrative Staff A stated the PBJ information was pulled in the corporate office from the time clock, that the facility had not been short on weekends and did not use agency staff, and that the DON and Administrative Staff A completed the schedule. She also stated the facility had gone through several different payroll programs, which may have caused the issue, and described a weekend staffing practice in which staff who work both Saturday and Sunday, 12-hour shifts earn an extra eight hours on their check unless they call in. The facility’s Sufficient Staff Policy stated the facility would provide sufficient staff with appropriate competencies and skill sets and was responsible for submitting timely and accurate staffing data through the CMS PBJ system.
Resident Injury Due to Improper Hoyer Lift Use
Penalty
Summary
The facility failed to ensure the safety of Resident 1 during a transfer using a Hoyer lift, resulting in an accident. Resident 1, who had a history of generalized muscle weakness, Alzheimer's Disease, cerebral infarction, and was dependent on a wheelchair, required total assistance for all activities of daily living, including transfers. During a transfer from her bed to her wheelchair, the Hoyer lift tipped, causing Resident 1 to hit the back of her head on a dresser, resulting in a laceration that required staples and sutures. The incident occurred when Certified Nurse Aide M and Licensed Nurse G were transferring Resident 1. The lift tipped during the transfer, and although the staff attempted to lower Resident 1 to the floor, they were unable to prevent her head from hitting the dresser. The staff involved were unsure of the cause of the lift tipping, and there was no indication that the lift was malfunctioning. However, it was noted that the legs of the lift should have been open to provide a stable base, and it was unclear if this was done correctly. Further investigation revealed that there were gaps in staff training regarding the use of the Hoyer lift. Administrative Nurse D was unsure if the staff involved had completed the necessary training, and records of such training were incomplete or missing. Additionally, another CNA reported not receiving lift training at the facility, relying instead on previous experience. This lack of proper training and documentation contributed to the unsafe transfer and subsequent injury to Resident 1.
Failure to Distribute Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to distribute quarterly statements to residents with trust fund accounts, as required by their policy. The facility had 23 active resident trust fund accounts, and a sample review included five residents. A review of the Trial Balance revealed that one resident had a trust fund balance of $681.35. The resident's representative reported not receiving any quarterly statements for the trust account throughout the year and had difficulty contacting the person responsible for the trust accounts. Administrative Staff B confirmed that no quarterly statements had been sent out for any trust accounts, citing a lack of training on the process. This failure placed residents at risk for uninformed decisions regarding their trust funds and potential misappropriation.
Inaccurate Accounting of Resident's Personal Funds
Penalty
Summary
The facility failed to provide a resident with an accurate accounting of her personal funds, resulting in an overcharge of $347.89. The issue arose from duplicate charges and a charge without a receipt in the resident's trust account. The transactions were documented on the Resident Statement Landscape, showing withdrawals with handwritten receipts and one withdrawal without a receipt. Administrative Staff B, who was responsible for managing the trust accounts, admitted to entering the same transactions twice, once in January and again in August, due to a misunderstanding of the process and lack of oversight. Interviews with facility staff revealed that Administrative Staff B had not received adequate training to handle the resident trust accounts and was learning on the job. Additionally, there was no review process in place for the trust accounts, as Administrative Staff B was the only one managing the receipts and withdrawals. The facility's policy required the Business Office Manager or designee to provide receipts for withdrawals and reconcile accounts quarterly, but this was not followed. The lack of training and oversight led to the mismanagement of the resident's funds, placing the resident at risk for impaired autonomy and misappropriation.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to ensure the timely conveyance of personal funds for three residents, identified as R3, R4, and R5, within 30 days of their discharge or death. The review of the Trial Balance revealed that R3 had a trust fund balance of $233.39 and was discharged from the facility, R4 had a balance of $178.95 and was also discharged, and R5 had a balance of $20.56 and died in the facility. These funds were not conveyed as required, placing the residents at risk for impaired rights and misappropriation. Administrative Staff B admitted uncertainty about the procedures for handling residents' trust funds upon their death, typically contacting the family to arrange for funeral expenses. She acknowledged a lack of training on conveying funds for accounts that were old or from previous months. The facility's policy on Transactions Involving Resident Funds did not provide guidance for handling funds upon discharge, eviction, or death, contributing to the deficiency.
Resident Mistreatment and Abuse
Penalty
Summary
The facility failed to ensure a resident remained free from abuse and mistreatment. The incident involved a resident with a history of trauma and Huntington's disease, who requested chocolate milk from two CNAs. The CNAs instructed the resident to ask for the milk correctly and physically obstructed him from accessing the refrigerator, leading to a struggle. During the struggle, the resident fell to the ground, kicked at the staff, and subsequently attempted to choke himself, verbalizing suicidal intentions. The resident's medical records indicated diagnoses of Huntington's disease, bipolar disorder, and major depressive disorder, with a documented need for substantial assistance with daily activities. The care plan directed staff to anticipate the resident's needs and intervene calmly to prevent agitation. However, the CNAs' actions escalated the situation, resulting in the resident's fall and subsequent self-harm attempt. Interviews with staff and administrative personnel revealed that the CNAs' approach was inappropriate and demeaning, as they insisted the resident use 'big boy words' and physically prevented him from accessing the refrigerator. The facility's policy on abuse and neglect was not followed, leading to the resident's mistreatment and immediate jeopardy.
Removal Plan
- An all-staff in-service on preventing abuse, neglect, and exploitation and reporting abuse.
- The facility updated R1's care plan to include his past trauma and relevant interventions for staff to follow.
- CNA N and CNA O were not permitted back into the facility and were subsequently terminated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| F W Huston Medical Center | 8.1 mi | ★★★★★ | 24 | 0 |
| Medicalodges Leavenworth | 10.2 mi | ★★★★★ | 0 | 0 |
| Nortonville Health Care Center | 11.6 mi | ★★★★★ | 49 | 4 |
| Lansing Care And Rehab | 13.2 mi | ★★★★★ | 22 | 0 |
| Twin Oaks Health And Rehab | 13.5 mi | ★★★★★ | 0 | 0 |
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