Inspection Reports for Echo Lake – SageLife Senior Living
900 N Atwater Dr, Malvern, PA 19355, United States, PA, 19355
Back to Facility Profile
Inspection Report
Renewal
Census: 74
Capacity: 104
Deficiencies: 12
Apr 8, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to staff training, sanitary conditions, food storage, fire drills, and staff training specific to dementia care. The submitted plan of correction was found to be fully implemented.
Complaint Details
The inspection included a complaint investigation component; the submitted plan of correction was fully implemented and compliance maintained.
Deficiencies (12)
| Description |
|---|
| Direct care staff person A received only 10 hours of annual training relating to job duties during the training year. |
| Direct care staff person A did not receive training in infection control, hygiene, and assisted living service needs during the training year. |
| Staff person A did not receive training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during the training year. |
| Main kitchen deep freezer bottom was stained with ice cream and food debris. |
| Uncovered trash can in the dining area of the special care unit. |
| Outside trash dumpsters lids were open with trash, pallets, and a bedframe next to dumpsters. |
| No thermometer in the deep freezer in the 3rd floor kitchenette. |
| Opened and unsealed food items in the main kitchen refrigerator, including damaged container. |
| Expired food items found in the main kitchen refrigerator. |
| Fire drill during sleeping hours not conducted as required; last drill was at 6:00 A.M. when residents were awake. |
| Fire drills routinely held between 5:30 A.M. and 4:00 P.M. without variation in days and times. |
| Direct care staff person A had only 2 hours of dementia care training during the training year. |
Report Facts
License Capacity: 104
Residents Served: 74
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 25
Hospice Residents: 9
Residents Age 60 or Older: 72
Residents with Mobility Need: 39
Staff Training Hours Required: 16
Staff Training Hours Received by Staff A: 10
Dementia Training Hours Required: 8
Dementia Training Hours Received by Staff A: 2
Inspection Report
Complaint Investigation
Census: 72
Capacity: 104
Deficiencies: 3
Sep 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review at the facility.
Findings
The inspection found multiple deficiencies including failure to provide required assistance with activities of daily living, neglect and rough treatment of a resident by staff, and improper use of a visual banner to confine a resident. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, triggered by family concerns after viewing video evidence of neglect and mistreatment of a resident by staff. The complaint was substantiated as neglect and abuse were documented.
Deficiencies (3)
| Description |
|---|
| Failure to provide required assistance with toileting as indicated in the resident’s assessment and support plan. |
| Neglect and rough handling of a resident by Staff Member A, including failure to assist with transferring and toileting, resulting in the resident falling to the floor. |
| Use of a banner on a resident’s door to confine or restrain the resident instead of utilizing positive interventions. |
Report Facts
Licensed Capacity: 104
Residents Served: 72
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 23
Residents Age 60 or Older: 69
Residents with Mobility Need: 41
Total Daily Staff: 113
Waking Staff: 85
Inspection Report
Renewal
Census: 68
Capacity: 104
Deficiencies: 9
Mar 12, 2024
Visit Reason
The inspection was conducted as a renewal, provisional review of the facility to determine compliance and implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies including issues with the quality management plan, staff training plan, sanitary conditions, food storage, and fire safety procedures such as fire drill documentation, evacuation times, alternate exit routes, and designated meeting places. All deficiencies had accepted plans of correction with completion dates by March 31, 2024, and were implemented by March 25, 2024.
Deficiencies (9)
| Description |
|---|
| The residence's quality management plan did not include the review of resident council meetings and licensing violations. |
| The residence's staff training plan for training year 2024 does not include training on the care of residents with foley care needs. |
| Room 313 had a very strong odor of urine and sticky bathroom floor with yellow substance near and around the toilet. |
| Tubs of strawberry, chocolate and vanilla ice cream and orange sherbet were uncovered in the kitchen freezer. |
| The residence did not have documentation of an annual fire drill and fire safety inspection conducted by a fire safety expert; last inspection was on 1/27/23. |
| Fire drill records did not specify the exact location of the evacuation route for drills on 11/14/23, 12/30/23, 1/26/24, and 2/14/24. |
| The residence does not have a maximum safe evacuation time specified in writing by a fire safety expert and exceeded 2 minutes 30 seconds evacuation time during multiple drills. |
| The home did not alternate evacuation routes during fire drills on 11/14/23, 12/30/23, 1/26/24, and 2/14/24. |
| The home did not evacuate all residents to a designated meeting place/fire safe area during fire drills on 11/14/23, 12/30/23, 1/26/24, and 2/14/24. |
Report Facts
Residents served: 68
License capacity: 104
Special care unit capacity: 38
Special care unit residents served: 22
Residents 60 years or older: 68
Residents with mobility need: 22
Fire drill evacuation times: 5
Residents present during fire drills: 65
Residents present during fire drills: 22
Residents present during fire drills: 70
Residents present during fire drills: 66
Residents evacuated during fire drills: 8
Residents evacuated during fire drills: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| General Manager | Responsible for ongoing compliance and reeducated on multiple deficiencies | |
| Regional Director of Health & Wellness | Reeducated General Manager on quality management plan and training plan | |
| Health & Wellness Director | Responsible for ongoing compliance with staff training and sanitary conditions | |
| Dining Director | Reeducated on food storage and responsible for ongoing compliance | |
| Building Engineer | Reeducated on fire safety inspections, fire drill documentation, evacuation procedures, and responsible for ongoing compliance |
Inspection Report
Monitoring
Census: 69
Capacity: 104
Deficiencies: 0
Jan 11, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 69
License Capacity: 104
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 22
Hospice Current Residents: 9
Residents Age 60 or Older: 69
Residents with Mobility Need: 58
Inspection Report
Census: 72
Capacity: 104
Deficiencies: 0
Dec 11, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 12/11/2023.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 122
Waking Staff: 92
License Capacity: 104
Residents Served: 72
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 22
Hospice Current Residents: 11
Residents Age 60 or Older: 70
Residents with Mobility Need: 50
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 71
Capacity: 104
Deficiencies: 8
Oct 2, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility, to review the submitted plan of correction and ensure compliance.
Findings
The report found multiple deficiencies related to resident abuse reporting, confidentiality breaches, abuse/neglect incidents, dignity/respect violations, improper storage of poisonous materials and medications, prohibited use of chemical restraints, and failure to complete significant change assessments. The facility submitted plans of correction which were accepted and deemed fully implemented by the date of the report.
Deficiencies (8)
| Description |
|---|
| Failure to immediately report suspected abuse to the local Area Agency on Aging. |
| Resident records confidentiality breach due to unlocked, unattended medication accessible on medication cart. |
| Resident physically assaulted another resident multiple times without updating the resident's ASP or developing a plan. |
| Resident made disruptive and racially insensitive statements without use of positive interventions. |
| Poisonous materials (Collagenase SANTYL Ointment) left unlocked and accessible to residents. |
| Prescription medications and syringes were not kept locked as required. |
| Use of Lorazepam as a chemical restraint to control aggressive behavior, which is prohibited. |
| Failure to complete additional written assessments after significant changes in resident condition. |
Report Facts
License Capacity: 104
Residents Served: 71
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 25
Hospice Residents: 8
Residents Age 60 or Older: 69
Residents with Mobility Need: 54
Total Daily Staff: 125
Waking Staff: 94
Inspection Report
Monitoring
Census: 71
Capacity: 104
Deficiencies: 3
Sep 11, 2023
Visit Reason
The visit occurred as a monitoring inspection to review the facility's compliance with regulations and to verify the implementation of the submitted plan of correction.
Findings
The inspection found deficiencies related to medication management, including discontinued medications remaining in medication carts, unlabeled OTC medications, and failure to follow prescriber’s orders for medication administration. The submitted plan of correction was determined to be fully implemented as of the review date.
Deficiencies (3)
| Description |
|---|
| Discontinued earwax removal drops were found in the medication cart. |
| An OTC medication belonging to a resident was not labeled with the resident's name. |
| Medication prescribed for ear wax removal was not administered to the resident as ordered. |
Report Facts
License Capacity: 104
Residents Served: 71
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 26
Residents Age 60 or Older: 68
Residents with Mobility Need: 63
Total Daily Staff: 134
Waking Staff: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health & Wellness Director | Responsible for re-educating nurses and medication technicians and auditing medication administration and labeling compliance |
Inspection Report
Renewal
Census: 71
Capacity: 104
Deficiencies: 15
Jul 10, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation at the assisted living facility Echo Lake.
Findings
The inspection identified multiple violations including resident abuse, neglect, failure to report abuse, medication errors, improper labeling, privacy violations, and deficiencies in training and support plans. Several staff members were terminated due to abuse findings, and plans of correction were submitted and partially implemented.
Complaint Details
The inspection included complaint and incident investigations related to abuse, neglect, dignity, respect, and privacy violations involving staff and residents. Several staff members were terminated due to substantiated abuse and neglect findings.
Deficiencies (15)
| Description |
|---|
| Resident-to-resident abuse was not reported to the local Area Agency on Aging. |
| Resident #3's initial medical evaluation was not completed within required time frames. |
| Staff person B recorded and shared a video of staff person C harassing resident #4, including physical contact and verbal abuse. |
| Resident #4 was treated without dignity and respect, including taunting and harassment by staff. |
| Resident #4's privacy was violated by unauthorized video recording and sharing on social media. |
| Unlabeled and undated leftover food was found in the walk-in refrigerator. |
| Lint accumulation found in the lint trap of the second-floor dryer. |
| Fire drills were not held on different days and times as required. |
| Discontinued medication was still present in the medication cart. |
| Medication label for resident #4 did not match physician's order. |
| Refusal of medication by resident #5 was not reported to the prescriber within 24 hours. |
| Positive interventions were not used to manage resident #4's behavior; staff taunted and harassed the resident. |
| Resident #3's preliminary support plan was not completed within 30 days prior to admission. |
| Resident #2's assessment did not include a significant mental status change related to a resident-to-resident altercation. |
| Resident #3's assessment did not include specific body positioning needs. |
Report Facts
License Capacity: 104
Residents Served: 71
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 26
Staffing Hours - Total Daily Staff: 119
Staffing Hours - Waking Staff: 89
Fine Per Day: 355
Census at Inspection: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in findings related to resident abuse, neglect, dignity violations, privacy violations, and was terminated. | |
| Staff person C | Named in findings related to resident abuse, neglect, dignity violations, privacy violations, and was terminated. | |
| Staff person D | Named in findings related to resident abuse and neglect and was terminated. | |
| Health & Wellness Director | Responsible for education, compliance, and corrective actions related to multiple deficiencies. | |
| Vice President Operations | Mentioned in relation to enforcement and re-education efforts. |
Inspection Report
Renewal
Census: 71
Capacity: 104
Deficiencies: 14
Jul 10, 2023
Visit Reason
The inspection was conducted as a licensing inspection including renewal, complaint, and incident reasons for the facility Echo Lake.
Findings
The inspection identified multiple violations including resident abuse, neglect, improper medication management, incomplete assessments, and failure to follow support plans. Several staff members were terminated due to abuse and neglect violations. Plans of correction were accepted with proposed completion dates mostly by August 31, 2023, but many were noted as not implemented as of October 2, 2023.
Deficiencies (14)
| Description |
|---|
| Resident-to-resident altercation with injury not reported to local authorities. |
| Resident initial medical evaluation not completed within required timeframe. |
| Staff physically and verbally abused resident, including recording and sharing video on social media. |
| Resident treated without dignity and respect; staff taunted and laughed at resident. |
| Resident's right to privacy violated by staff recording and sharing video without consent. |
| Unlabeled and undated leftover food found in refrigerator. |
| Lint accumulation in dryer lint trap not cleaned after use. |
| Fire drills not conducted on different days and times as required. |
| Discontinued medication still present in medication cart. |
| Medication label did not match physician's order. |
| Resident refusal to take medication not reported to prescriber within 24 hours. |
| Positive interventions not used; staff taunted and harassed resident contrary to support plan. |
| Preliminary support plan not completed within 30 days prior to admission. |
| Additional written assessments not completed after significant resident condition changes. |
Report Facts
License Capacity: 104
Residents Served: 71
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 26
Staffing Hours: 119
Waking Staff: 89
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 355
Mandated Correction Date: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Named in multiple abuse, neglect, dignity, privacy violations and was terminated. | |
| Staff Member C | Named in abuse, neglect, dignity violations and was terminated. | |
| Staff Member D | Named in abuse violations and was terminated. | |
| Health & Wellness Director | HWD | Responsible for education, compliance, and correction plans. |
| Vice President Operations | Recipient of licensing letters and enforcement notices. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 104
Deficiencies: 0
Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 04/11/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 104
Residents Served: 61
Special Care Unit Capacity: 38
Special Care Unit Residents Served: 24
Resident Support Staff: 0
Total Daily Staff: 106
Waking Staff: 80
Residents Age 60 or Older: 61
Residents with Mobility Need: 45
Inspection Report
Follow-Up
Census: 65
Capacity: 96
Deficiencies: 4
Nov 9, 2022
Visit Reason
Partial announced inspection conducted on 11/09/2022 as a follow-up to verify plan of correction submissions.
Findings
The inspection identified multiple deficiencies including uncovered trash cans in the kitchen, hot water temperatures exceeding 120°F in several resident areas, missing emergency telephone numbers at the front desk, and lint accumulation in dryer lint traps. Plans of correction were accepted and implemented by 11/28/2022.
Deficiencies (4)
| Description |
|---|
| Two trash cans without lids in the service kitchen on the 3rd floor. |
| Hot water temperature exceeded 120°F in multiple locations including 3rd floor bathrooms and resident rooms. |
| No emergency telephone numbers posted at the home's front/reception desk. |
| Thick accumulation of lint in the lint traps of two dryers in the 1st floor launderette. |
Report Facts
License Capacity: 96
Residents Served: 65
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 29
Hot Water Temperatures: 134.6
Staffing Hours - Resident Support Staff: 114
Staffing Hours - Waking Staff: 86
Inspection Report
Renewal
Census: 68
Capacity: 96
Deficiencies: 13
Aug 25, 2022
Visit Reason
The inspection was conducted as a renewal inspection with complaint and provisional reasons, including an unannounced full inspection on August 25 and 26, 2022.
Findings
The facility was found to have multiple deficiencies including unlocked resident records, inadequate food safety certification coverage, delayed resident refund after death, physical hazards in the building, missed fire drills, incomplete medical evaluations, medication administration errors, incomplete staff medication training documentation, and incomplete resident support plan signatures. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (13)
| Description |
|---|
| First Floor Service Plans were unlocked, unattended, and accessible on a desk in the first floor nursing station. |
| Only one ServSafe Certified person in the kitchen during the week and not always onsite while kitchen is open. |
| Residence did not provide refund in accordance with Elder Care Payment Restitution Act within 30 days after resident's death. |
| Hole in the wall in the first floor bathroom creating a hazard. |
| Unannounced fire drills with evacuation were not held during December 2021 through March 2022. |
| Medical evaluation for resident #2 did not indicate need for dementia-related care in secured area. |
| Resident #3's glucometer readings were struck out on MAR stating documentation on wrong MAR. |
| Resident #3 did not receive prescribed blood sugar check on a specified date as per MAR adjustments. |
| Staff person C had not maintained compliance with annual medication administration practicum requirements for 2020 and 2022. |
| Medication administration training records for staff persons C and E did not include documentation of successful course completion. |
| Resident #4 participated in support plan development but did not sign and date the support plan. |
| Resident #4 did not sign support plan and no notation of inability or refusal to sign was documented. |
| Resident #5's written cognitive preadmission screening was completed after admission to special care unit. |
Report Facts
License Capacity: 96
Residents Served: 68
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 28
Hospice Residents: 2
Total Daily Staff: 116
Waking Staff: 87
Residents 60 Years or Older: 67
Residents with Mobility Need: 48
Inspection Report
Monitoring
Census: 64
Capacity: 96
Deficiencies: 3
Jun 28, 2022
Visit Reason
The inspection was an unannounced interim provisional visit conducted for provisional licensing and monitoring purposes.
Findings
The inspection identified three deficiencies: unlocked poisonous materials accessible to residents, unlabeled resident medication, and missing posted directions for key-locking devices. All deficiencies had accepted plans of correction and were addressed promptly.
Deficiencies (3)
| Description |
|---|
| The tall cabinet in the activities room in the Connections SDCU area was unlocked with a bottle of nail polish remover accessible to residents who were not assessed capable of safely using poisons. |
| A bottle of Vitamin D3 belonging to resident #1 was in the medication cart and was not labeled with the resident's name. |
| Directions for operating the residence's locking mechanism were not conspicuously posted near the door to exit stairwell 8 in the special care unit. |
Report Facts
License Capacity: 96
Residents Served: 64
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 28
Total Daily Staff: 112
Waking Staff: 84
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Inspection Report
Monitoring
Census: 64
Capacity: 96
Deficiencies: 1
Apr 13, 2022
Visit Reason
The inspection was a monitoring visit conducted on April 13, 2022, to review compliance with licensing requirements and the plan of correction submission.
Findings
The inspection found a violation related to furniture and equipment where an enabler bar in resident bedroom 224 was not properly maintained, posing a hazard. A plan of correction was accepted and implemented to address the issue.
Deficiencies (1)
| Description |
|---|
| The enabler bar in resident bedroom 224 had legs not extended to the floor and a missing rubber foot, posing a hazard to the resident. |
Report Facts
License Capacity: 96
Residents Served: 64
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 28
Current Hospice Residents: 1
Total Daily Staff: 96
Waking Staff: 72
Inspection Report
Complaint Investigation
Census: 49
Capacity: 96
Deficiencies: 9
Nov 3, 2021
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident at the facility, with multiple on-site and off-site inspection dates spanning from November 3, 2021, through February 22, 2022.
Findings
The inspection found multiple violations related to failure to provide requested documentation, failure to report suspected resident abuse and incidents timely, inadequate assistance with activities of daily living, improper use of restraints including bed rails without proper assessment or physician orders, incomplete medical evaluations, and insufficient staff training on use of enablers and restraints.
Complaint Details
The inspection was complaint-related, triggered by an incident involving Resident #1. The report details failures in abuse reporting, incident reporting, and resident care related to this complaint.
Deficiencies (9)
| Description |
|---|
| Failure to provide requested payroll records to the Department upon request. |
| Failure to immediately report suspected resident abuse to the local Area Agency on Aging. |
| Failure to report an incident involving Resident #1 to the Department within 24 hours. |
| Resident #1 did not receive total assistance with turning and positioning as required by the assessment and support plan. |
| Resident #1 was subjected to neglect and unsafe use of a positioning device without proper assessment or removal after unsafe use. |
| Use of bed rail restraint on Resident #1 without proper assessment, physician order, or removal after unsafe use. |
| Medical evaluation for Resident #1 did not include required tuberculin skin test results or chest X-ray. |
| Direct care staff did not receive training on the proper use and risks of the bed rail device used as an enabler/restraint. |
| Resident #1's assessment did not include use of bed rail, physical diagnoses, or symptoms to support its use, and no additional written assessment was completed after significant change. |
Report Facts
License Capacity: 96
Residents Served: 49
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 20
Hospice Residents: 2
Total Daily Staff: 73
Waking Staff: 55
Inspection Report
Renewal
Census: 47
Capacity: 96
Deficiencies: 1
Aug 31, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction related to a violation involving unlocked poisonous materials was found to be fully implemented, with continued compliance required.
Deficiencies (1)
| Description |
|---|
| Weiman Stainless Steel Cleaner was unlocked, unattended, and accessible to residents, including those in the special care unit who were not assessed capable of safely using or avoiding poisonous materials. |
Report Facts
License Capacity: 96
Residents Served: 47
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 20
Current Hospice Residents: 1
Total Daily Staff: 69
Waking Staff: 52
Inspection Report
Complaint Investigation
Census: 42
Capacity: 96
Deficiencies: 1
Aug 2, 2021
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations at the facility.
Findings
The inspection found that on 8/2/21, the bathrooms on the first floor did not have hand soap available for residents. A plan of correction was submitted and later accepted and implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection information section. The plan of correction was accepted and implemented, indicating resolution of the complaint.
Deficiencies (1)
| Description |
|---|
| Bathrooms on the first floor did not have hand soap available for the residents. |
Report Facts
License Capacity: 96
Residents Served: 42
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 22
Total Daily Staff: 64
Waking Staff: 48
Inspection Report
Complaint Investigation
Census: 42
Capacity: 96
Deficiencies: 0
Jul 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies or citations were found, and follow-up was not required.
Report Facts
License Capacity: 96
Residents Served: 42
Staffing Hours: 64
Waking Staff: 48
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 22
Residents Age 60 or Older: 42
Residents with Mobility Need: 22
Residents with Physical Disability: 2
Inspection Report
Monitoring
Census: 26
Capacity: 96
Deficiencies: 3
Mar 29, 2021
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/29/2021 to review the facility's compliance and plan of correction implementation.
Findings
The submitted plan of correction was determined to be fully implemented. Three deficiencies were noted related to food storage, dryer lint removal, and exit door accessibility, all of which had corrective actions accepted and completed.
Deficiencies (3)
| Description |
|---|
| Two dessert pies in the walk-in freezer were opened and unsealed without an opened date on the packaging. |
| Approximately 1/4 inch accumulation of lint was found in the lint trap of both dryers in the Connections SCU laundry room. |
| The courtyard gate exit door could not be easily opened from the inside without a code; the code was not posted near the door. |
Report Facts
Residents Served: 26
License Capacity: 96
Staffing Hours - Total Daily Staff: 36
Staffing Hours - Waking Staff: 27
Residents with Mobility Need: 10
Residents Age 60 or Older: 26
Document
Capacity: 96
Deficiencies: 0
Jul 14, 2021
Visit Reason
This document serves as a Certificate of Compliance granting license to operate the Assisted Living-Special Care facility Echo Lake and includes a renewal letter acknowledging receipt of the renewal application and advising of the requirement for an annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application and outlines the Department's obligation to conduct an annual onsite inspection.
Report Facts
Maximum capacity: 96
Special Care Unit capacity: 30
Loading inspection reports...
