Easton Skilled Nursing: Opioid Dosing Error Repeated - PA
The patient is identified in inspection records only as Resident 1, a person living at Easton Skilled Nursing and Rehabilitation Center with heart failure and obesity. Their physician had been direct: the as-needed pain medication, Percocet 5-325 mg, was not to be administered at the same time as the scheduled extended-release opioid, Oxycontin 15 mg. The order had been in place since August 18, 2025. It was specific. It was documented.
At 9 p.m. on September 21, both medications were administered simultaneously.
Inspectors reviewed the Medication Administration Record for September and found the overlap. The finding was cited under F0684, which covers a facility's obligation to follow physician orders, resident preferences, and care goals. CMS rated the harm level as minimal or potential for actual harm.
What the rating doesn't capture is the pharmacological reality of what was handed to this resident. Oxycontin 15 mg extended-release is a scheduled, around-the-clock opioid. Percocet, which combines oxycodone with acetaminophen, is a shorter-acting opioid meant to address breakthrough pain. A physician who orders a mandatory gap between the two is doing so to manage the combined opioid load on the patient's system. Heart failure already complicates how the body processes medications. The physician's order existed for a reason. Nobody followed it.
This was not the first time inspectors found this kind of failure at Easton Skilled Nursing.
The same federal tag, F0684, was cited at this facility on September 28, 2024. It was cited again on November 7, 2024. It was cited a third time on May 24, 2025. The opioid dosing error found in September 2025 is now the fourth citation under this tag in less than thirteen months.
Four times, inspectors have documented that care was not provided in accordance with physician orders or resident goals. Four times, the facility has been required to submit a plan of correction. The September 2025 inspection was triggered by a complaint, not a routine survey.
Inspectors reviewed five residents' records. The dosing failure appeared in one of them.
Easton Skilled Nursing and Rehabilitation Center is located in Easton, Pennsylvania. The inspection was conducted on September 24, 2025.
There is no indication in the inspection record that the facility identified the error before inspectors arrived. There is no indication anyone flagged it internally on the night it happened. The Medication Administration Record simply showed both medications logged at 2100, and the physician's order showed they were not supposed to be.
A resident with heart failure, already managing a complex medication regimen, received a combined opioid dose that their own doctor had taken steps to prevent. Whether that resident experienced any consequence from it, the inspection record does not say. What it does say is that the order was clear, the window was specific, and the gap was ignored.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Easton Skilled Nursing and Rehabilitation Center from 2025-09-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
Easton Skilled Nursing and Rehabilitation Center in EASTON, PA was cited for violations during a health inspection on September 24, 2025.
The order had been in place since August 18, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.