Easton Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Pennsylvania.
- Location
- 2600 Northampton Street, Easton, Pennsylvania 18045
- CMS Provider Number
- 395540
- Inspections on file
- 30
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Easton Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with heart disease, impaired mobility, incontinence, and a history of MASD was care planned as at risk for altered skin integrity and had a physician’s order for preventative barrier cream to be applied to the buttocks twice daily. Despite facility policy requiring medications to be administered as prescribed, documentation showed that a NA removed a cream from the treatment cart and applied capsaicin cream, a topical analgesic for muscle and joint pain, instead of the ordered barrier cream. The DON confirmed that the physician’s order was not followed, resulting in a failure to administer medications as ordered.
A resident with heart failure and obesity received two opioid medications at the same time, despite a physician's order requiring at least one hour between doses. Staff administered both the as-needed and routine opioid medications together, as documented in the MAR.
Staff did not follow physician's orders for insulin administration for two residents with diabetes, including giving insulin when blood glucose was below the ordered threshold and failing to notify the physician when blood glucose exceeded specified levels.
A resident with Parkinson's disease and depression was not offered or assisted to attend a preferred bingo activity, despite the care plan indicating such support. The Activities Director confirmed the oversight, and the resident was observed in her room during the activity.
A facility failed to implement a physician's order for a resident with chronic respiratory failure and quadriplegic cerebral palsy. The order required Prevalon boots to be applied at all times except during care to prevent skin breakdown. Observations revealed the resident without the boots, and the Administrator confirmed the oversight.
The facility failed to implement interventions to prevent further decline in range of motion for two residents with limited mobility. One resident, with senile degeneration and malnutrition, was observed without prescribed bilateral palm guards. Another resident, with Parkinson's and dementia, was seen without a recommended left palm guard. The DON confirmed staff were to apply these devices as per care plans, but this was not consistently done.
A resident with dementia sustained a skin tear after a fall, and a physician ordered daily wound care. However, the facility failed to change the dressing for six days, as confirmed by the Assistant DON.
The facility failed to honor resident preferences and allergies during meal service for two residents. One resident did not receive the food she ordered, and another resident with a mushroom allergy was served a meal containing mushrooms.
Failure to Follow Physician’s Order for Barrier Cream Application
Penalty
Summary
The facility failed to implement a physician’s order for a resident requiring skin protection. Facility policy on Medication Administration, last reviewed in September 2025, required that medications be administered as prescribed and in accordance with written prescriber orders. The resident had diagnoses including heart disease, was alert and oriented, and was identified on the Minimum Data Set as being at risk for pressure sores. The care plan documented risk for altered skin integrity related to impaired mobility, incontinence, and a history of moisture associated skin damage (MASD), and included an intervention for staff to administer medications as ordered by the physician. A physician’s order effective in late December 2025 directed staff to apply a preventative barrier cream to the resident’s buttocks twice daily. A skin assessment documented MASD to both buttocks. Facility documentation from early January 2026 showed that a nursing assistant took a cream from the treatment cart and applied a topical analgesic (capsaicin cream), intended for relief of muscle and joint pain, instead of the ordered preventative barrier cream to the resident’s buttocks. In a subsequent interview, the Director of Nursing confirmed that staff did not follow the physician’s order and applied the incorrect cream. This constituted a failure to administer medications in accordance with facility policy and the prescriber’s written orders, as cited under 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
Failure to Follow Physician's Orders for Opioid Administration
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order regarding the administration of opioid medications for a resident with diagnoses including heart failure and obesity. The physician had directed that the resident's as-needed opioid medication (Percocet 5-325 mg) should not be given at the same time as the routine every 12-hour opioid medication (Oxycontin 15 mg ER), and that there should be at least one hour between the two medications. However, review of the Medication Administration Record (MAR) showed that both medications were administered simultaneously at 2100 on September 21, 2025, contrary to the physician's instructions.
Failure to Follow Physician's Orders for Insulin Administration
Penalty
Summary
Facility staff failed to follow physician's orders for two residents with diabetes mellitus and other significant diagnoses. For one resident, staff administered 24 units of insulin (Lispro) subcutaneously three times a day even when the resident's blood glucose was below 150 mg/dl, contrary to the physician's order to hold the medication under those circumstances or if the resident had not eaten. For another resident, staff administered insulin based on a sliding scale when the blood glucose was above 351 mg/dl but did not notify the physician as required by the order. These failures were confirmed by review of clinical records and staff interview.
Failure to Facilitate Resident Participation in Preferred Activities
Penalty
Summary
The facility failed to provide an activities program that met the needs and interests of a resident diagnosed with Parkinson's disease and depression. The resident, who did not have cognitive impairment and required assistance for activities of daily living, expressed a preference for attending bingo activities. The care plan indicated that staff should offer activities consistent with the resident's interests and assist with transport to and from these activities. However, on the day of a scheduled bingo activity, the resident was not offered the opportunity to attend nor was assistance provided for transport, as confirmed by the resident and observed by surveyors. The Activities Director confirmed that staff should have offered the resident the opportunity to attend the bingo activity, but there was no evidence that this was done. The resident was observed in her room during the bingo activity, indicating a failure by the staff to adhere to the care plan and provide the necessary support for the resident to participate in her preferred activity. This deficiency was identified through clinical record review, observation, and interviews with the resident and staff.
Failure to Implement Physician's Order for Pressure Relief
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with chronic respiratory failure and quadriplegic cerebral palsy. The order, dated September 25, 2024, required the application of Prevalon boots at all times except during care to reduce pressure and prevent skin breakdown. However, during multiple observations on November 5 and 6, 2024, the resident was found in bed without the Prevalon boots applied. This was confirmed by the Administrator during an interview on November 7, 2024, acknowledging that the staff did not follow the physician's order.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline in range of motion for two residents with limited mobility. Resident 59, diagnosed with senile degeneration of the brain and protein-calorie malnutrition, was cognitively impaired and required extensive assistance for personal hygiene and dressing. The care plan included an intervention for staff to apply bilateral palm guards during morning care and remove them at night. However, observations on multiple occasions revealed that the resident was in bed without the palm guards in place, indicating a failure to follow the care plan. Similarly, Resident 63, who had Parkinson's disease and dementia, was also cognitively impaired and had limitations in range of motion in both upper and lower extremities. The care plan and occupational therapy discharge summary recommended applying a left palm guard during morning care and removing it at night. Observations showed that the resident was in her wheelchair without the left palm guard, demonstrating non-compliance with the prescribed intervention. The Director of Nursing confirmed that staff was expected to apply the palm guards as per the care plans, but this was not consistently done.
Failure to Implement Physician's Wound Care Order
Penalty
Summary
The facility failed to implement a physician's order for wound care for one of the residents. The resident, who had a diagnosis of dementia, fell in her room and sustained a skin tear on her left shin. On the same day, a physician ordered that the wound be cleaned and a sterile gauze dressing be applied every evening. However, the Treatment Administration Record indicated that the dressing was not changed until six days later. An interview with the Assistant Director of Nursing confirmed the absence of documented evidence of wound care during this period.
Failure to Honor Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to honor resident preferences and allergies during meal service for two of five sampled residents. Resident 4, who had no memory impairment and could communicate clearly, reported not receiving the food she ordered. Despite requesting hot coffee, apple juice, and angel food cake, she was served hot chocolate and ice cream, which she did not like. Resident 5, who had a documented allergy to mushrooms, was served Salisbury steak with mushroom gravy, which he could not eat due to his allergy. These deficiencies were identified through clinical record reviews, resident interviews, and observations.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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