Echelon Care & Rehab

In the surveyor’s words

From the most serious findings on record at Echelon Care & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF908Jun 25, 2025

  Based on observation and interview on 6/18/25 in the presence of the Maintenance Director (MD) and Regional Plant Operations Director (RPOD), it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in safe operating condition. This deficient practice was evidenced for 52 of 67 PTAC units observed by the following: Observations while touring the facility from 9:00 AM to 1:00 PM, revealed that PTAC filters were missing, clogged and dirty, bent frames and filters laying on the floor not properly installed. In an interview the MD and the RPOD both confirmed the findings. A policy and procedure and PTAC maintenance log was requested but not provided at the time of the LSC exit conference. […]

• No harm, potential for more than minimal, widespreadF755Dec 20, 2023

  Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure: a) accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately accounted for and documented the administration of controlled medications and b) medications were administered in accordance with the medication's cautionary statement and manufacturer specifications. This deficient practice was identified on 5 of 5 medication carts observed on 4 of 4 nursing units and for 2 of 3 nurses who administered medications to 2 of 6 residents (Resident #95 and Resident #179) observed during the medication observation pass. This deficient practice was evidenced by the following: 1. […]

• No harm, potential for more than minimal, widespreadF812Jan 31, 2022

  Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On [DATE] from 09:54 AM -11:55 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. […]

• No harm, potential for more than minimal, patternF921Jun 25, 2025

  Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 4 of 4 observed resident pantry rooms (200 Unit, 300 Unit, 400 unit and 500 Unit) as evidence by the following: On 6/18/25 at 12:26 PM, the surveyor toured the 200-Unit pantry room in the presence of the Regional Director of Nursing (RDON and observed the Packaged Terminal Air Conditioner (PTAC) unit had rust on the outside and black colored debris and yellow debris located inside the uncovered area. The RDON stated that housekeeping was responsible to clean the pantries including the PTAC. […]

• No harm, potential for more than minimal, patternF924Jun 25, 2025

  Based on observation and interview from 6/18/25 in the presence of the Maintenance Director (MD) and the Regional Plant Operations Director (RPOD), it was determined that the facility failed to ensure that wooden handrails were installed, secured and splinter free in all required locations. This deficient practice was identified for 3 of 6 areas observed, had the potential to affect all residents, and was evidenced by the following by the following: 1). An observation at 12:22 PM revealed that the handrail by resident rooms [ROOM NUMBERS] had sharp edges due to a missing edge guard. 2). An observation at 12:40 PM revealed that the smoking courtyard exit/egress wooden ramp had a handrail that was unfinished and dry. […]