Echo Lake.

“Resident records were unlocked, unattended, and accessible in staff areas. Two white binders of resident records were open on a cabinet visible from the doorway, resident support plans were laid out on a desk with wound and hospice information on a whiteboard, and additional binders labeled with resident information were on shelves and counters in common areas.”

“A resident with cognitive impairment on a secured memory care unit was able to identify and exit through secured doors, wandering into the community and ultimately found at a Wawa store approximately 20 minutes away in 33-degree weather. The resident's WanderGuard alert was cleared within 90 seconds but the resident was not immediately located, resulting in police involvement and the resident being in danger.”

“Staff person B, who does not reside in Pennsylvania, was hired without completion of a required FBI background check until after the date of hire, in violation of the Older Adult Protective Services Act requirements.”

“Multiple poisonous and hazardous materials were found unlocked and accessible to residents: Woolite Carpet and Upholstery cleaner in Studio 3 south room, Gold Bond lotion in a resident bedroom, and Onyx professional nail polish remover in an unlocked gray cabinet in the activities area. Not all residents had been assessed as capable of safely recognizing and using these substances.”

“Staff person A did not receive required training in fire safety, emergency preparedness procedures, resident rights, the Older Adult Protective Services Act, and falls and accident prevention during the training year January 1, 2024 to December 31, 2024.”

“Direct care staff person A received only 10 hours of annual training relating to job duties during the training year January 1, 2024 to December 31, 2024, falling short of the required 16 hours minimum.”

“Direct care staff person A did not receive required training in infection control and general principles of cleanliness and hygiene and areas associated with immobility, such as prevention of decubitus ulcers, incontinence, malnutrition and dehydration, nor training in assisted living service needs of the resident during the training year January 1, 2024 to December 31, 2024.”

“On 4/9/25 at 2:00 P.M., the main kitchen deep freezer bottom was stained with ice cream and food debris, failing to maintain sanitary conditions.”

“On 4/8/25 at 10:46 A.M., there was an uncovered trash can that was 1/3 full in the dining area of the special care unit, failing to prevent penetration of insects and rodents.”

“At 10:15 A.M., the lids were open on two dumpsters located behind the residence with trash inside, and pallets and a bedframe were located next to the dumpsters on the ground, failing to maintain covered receptacles that prevent penetration of insects and rodents.”

“There was no thermometer in the deep freezer in the 3rd floor kitchenette, which is required to monitor frozen food storage at or below 0°F.”

“Food was not stored in closed or sealed containers: ham and potato soup in the main kitchen refrigerator was opened and unsealed, and a Pacific Jade Indian Curry Sauce Starter container was damaged and open.”

“Resident who required assistance with toileting per their assessment and support plan did not receive this assistance as required.”

“Staff member neglected to provide proper care and assistance to resident during toileting transfer. Video evidence showed staff member handled resident roughly, yanked resident's arm, removed wheelchair without providing assistance, left resident struggling to stand, and pulled resident by the neck and arm, ultimately allowing resident to fall to the floor.”

“Facility placed a banner with a red stop sign on resident's doorway to prevent the resident from leaving the room and to alert staff when the resident had left. This constituted an improper method of confinement or restraint instead of utilizing positive interventions.”

“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, despite having a resident with foley care needs. This was a repeat violation from 8/7/23.”

“Room 313 had a very strong odor of urine with a yellow substance near and around the toilet and a sticky bathroom floor, indicating unsanitary conditions.”

“Tubs of strawberry, chocolate, vanilla ice cream, and orange sherbet were uncovered in the freezer of the kitchen.”

“The residence does not have documentation of an annual fire drill and fire safety inspection conducted by a fire safety expert. The most recent fire safety inspection was conducted on 1/27/23.”

“Fire drill records from 11/14/23, 12/30/23, 1/26/24, and 2/14/24 did not specify the exact location of the evacuation route as required.”

“The residence does not have a maximum safe evacuation time specified in writing within the past year by a fire safety expert. Evacuation times from four drills (11/14/23, 12/30/23, 1/26/24, 2/14/24) exceeded 2 minutes 30 seconds, ranging from 5 min 17 sec to 5 min 36 sec.”

“The home did not alternate evacuation routes during fire drills on 11/14/23, 12/30/23, 1/26/24, and 2/14/24, using only the exit route "behind the fire doors" for all drills.”

“Collagenase SANTYL Ointment 250 units/g belonging to resident #1 was unlocked, unattended, and accessible on top of the medication cart, exposing confidential resident information.”

“Resident abuse incident (resident #1 hit resident #2 with cane on 9/30/23) was not timely reported to the local Area Agency on Aging, in violation of mandatory reporting requirements under the Older Adult Protective Services Act.”

“Resident #1 physically assaulted resident #2 on 9/24/23 (punched in mouth) and 9/30/23 (struck with cane). The resident's ASP dated 3/24/23 indicated no agitation or aggressive behaviors problem, and the home failed to update the ASP or develop a plan following these aggression episodes.”

“On 5/27/23, resident #1 made a disruptive verbal statement with ethnic slurs against other residents in the dining room. Staff failed to utilize positive interventions to address this verbal aggression as required.”

“Collagenase SANTYL Ointment with manufacturer's label indicating "This medicine may be harmful if swallowed" was unlocked, unattended, and accessible to residents. Not all residents, including resident #1, have been assessed as capable of recognizing and using poisons safely.”

“Collagenase SANTYL Ointment 250 unit/g for resident #3 was unlocked, unattended, and accessible on top of the medication cart located in the secured unit of the home.”

“A discontinued medication (earwax removal drops) prescribed for Resident 1 was found in the residence's medication cart after the prescription was discontinued.”

“An OTC medication belonging to Resident 2 was in the medication cart and was not labeled with the resident's name.”

“Resident 1 was prescribed earwax removal drops to instill 5 drops in both ears two times a day for 4 days, but the medication was not administered on two of the scheduled days. This is a repeat violation from 8/25/22.”

“A resident-to-resident altercation occurred on 06/21/23 at 6pm where Resident #1's third and fourth fingers on their left hand were injured when Resident #2 bit them. This allegation of abuse was reported to staff but was not reported to the local Area Agency on Aging as required.”

“Resident #3 was admitted on an unspecified date in 2023. The resident's initial assessment/medical evaluation was not completed within 60 days prior to admission or within 15 days after admission as required.”

“On an unspecified date in 2023, staff person B recorded a video on their phone of staff person C verbally and physically harassing Resident #4, including derogatory comments, forcefully grabbing the resident's clothing (causing buttons to become unbuttoned and exposing undergarments), taking a fighting stance as if to spar with the resident, and staff person B laughing and shrieking throughout the incident. The resident became visibly upset and yelling, and attempted to defend themselves against the staff.”

“Resident #3 was admitted on an unspecified date in 2023. The resident's initial assessment/medical evaluation was not completed within 60 days prior to admission or within 15 days after admission as required.”

“On an unspecified date in 2023, staff person B recorded a video on their phone of staff person C verbally and physically harassing Resident #4, including derogatory comments, forcefully grabbing the resident's clothing (causing buttons to become unbuttoned and exposing undergarments), taking a fighting stance as if to spar with the resident, and staff person B laughing and shrieking throughout the incident. The resident became visibly upset and yelling, and attempted to defend themselves against the staff.”

“A resident-to-resident altercation occurred on 06/21/23 at 6pm where Resident #1's third and fourth fingers on their left hand were injured when Resident #2 bit them. This allegation of abuse was reported to staff but was not reported to the local Area Agency on Aging as required.”