Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lecom At Elmwood Gardens, Llc during CMS and state inspections, most recent first.
A resident admitted with DM, A-Fib, and HTN was seen by the CRNP on multiple occasions, but the record lacked evidence of the required initial comprehensive visit by the physician. The NHA confirmed the physician did not complete the assessment.
The facility failed to maintain food safety standards in resident refrigerators on the Melrose Unit and Linden Lane. Observations showed expired and unlabeled food items, along with unsanitary conditions in the refrigerators. LPNs and a Registered Nurse confirmed the presence of expired items and the need for cleaning, indicating non-compliance with facility policies on food storage and labeling.
The facility failed to monitor and prevent Legionella in its water system. Despite positive test results for Legionella in specific areas, no further testing was conducted after initial remediation efforts. The Maintenance/Environmental Services Director confirmed that additional testing should have been performed to ensure water safety.
A facility failed to ensure that physicians signed and dated all orders during their visits for four residents. The facility's policy requires compliance with regulations, but clinical records showed that orders were not reviewed, signed, and dated as needed. Interviews with staff confirmed the oversight, with the DON acknowledging that orders for three residents were not signed every sixty days and the fourth resident's orders were not signed at admission and every thirty days thereafter.
A facility failed to ensure timely physician visits for a newly admitted resident with conditions such as diabetes and congestive heart failure. The resident was seen by a Certified Registered Nurse Practitioner twice, but there was no evidence of a required physician visit in January, as confirmed by the DON.
A facility failed to accurately complete the MDS assessment for a resident with an indwelling catheter. The MDS inaccurately indicated "None of the above" for appliances and "Always Incontinent" for urinary continence, despite the resident having an indwelling catheter. The RN Assessment Coordinator confirmed the error, highlighting a failure to document the resident's status accurately.
The facility failed to maintain documentation and awareness of kitchen suppression systems in two kitchens, with the last documented tests occurring over a year ago. In the Elmwood kitchen, staff were also unaware of the manual pull activation location for the hood suppression system.
The facility failed to provide necessary documentation for its generator, including a 90-minute load bank test and a fuel quality test, as required by NFPA 110. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the unavailability of the documentation.
The facility did not maintain proper hazardous area enclosures, as observed in the east wing lift storage room, which lacked a self-closing device on the door. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain the smoke barrier in the east wing staff lounge, where loose, misaligned, broken, and non-fitting ceiling tiles allowed smoke passage. This was confirmed by the maintenance supervisor.
The facility did not adhere to the construction type and height regulations for a Type III (200) building, as it exceeded the permissible height. This was observed and confirmed during an interview with the director of facilities.
The facility failed to maintain the sprinkler system as required, with observations revealing dust and lint covering sprinkler heads in the laundry room and near the nurse station. This accumulation can affect the sprinkler's activation and spray coverage, as confirmed by the maintenance supervisor.
The facility did not maintain portable fire extinguishers according to NFPA 10 standards, failing to provide documentation for annual maintenance and service technician certification. This deficiency was confirmed during a survey and an interview with the maintenance supervisor.
The facility failed to properly maintain gas equipment storage requirements, as observed in the skilled hall corridor's oxygen storage room. Oxygen cylinders were not separated or labeled as full or empty, which was confirmed by the maintenance supervisor.
The facility failed to maintain electrical receptacles according to NFPA 70 standards, as two water coolers were found plugged into outlets without GFCI protection near nurse stations. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including diabetes and obstructive sleep apnea. The resident was prescribed Seroquel for depression, anxiety, and delusions, but the clinical record lacked a care plan addressing these behaviors and medication use. This deficiency was confirmed during a staff interview.
A resident with anxiety and depression was administered Clonazepam 18 times without documented attempts of non-pharmacological interventions, contrary to facility policy. The DON confirmed the lack of evidence for such interventions.
Failure to Ensure Physician Initial Comprehensive Visit
Penalty
Summary
The facility failed to ensure that a physician completed the initial comprehensive visit for one of ten new admissions reviewed, Resident R17. The resident was admitted on 9/14/25 with diagnoses including diabetes, atrial fibrillation, and high blood pressure. Review of the clinical record showed progress notes documenting visits by the Certified Registered Nurse Practitioner on 9/15/25, 10/6/25, 11/4/25, and 12/30/25, but there was no evidence that the resident was seen by the physician. During an interview on 2/13/26 at 9:45 a.m., the Nursing Home Administrator confirmed that Resident R17 was not seen by the physician for the initial comprehensive assessment as required.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to food safety standards in the storage and labeling of food items in two resident refrigerators located on the Melrose Unit and Linden Lane. Observations revealed that the Melrose Unit refrigerator contained a sandwich without a 'use by' date, another sandwich past its 'use by' date, and six expired Activia yogurts. Additionally, the refrigerator had a pink sticky liquid substance, and the freezer contained a blue sticky substance and old, discolored ice cubes. On a subsequent observation, the same refrigerator contained five sealed cottage cheese cups that were past their 'use by' date. Interviews with LPNs confirmed these findings and acknowledged the need for discarding the expired items and cleaning the refrigerator. On the Linden Lane, a refrigerator contained a sealed plastic container of blueberry cobbler with a 'use by' date that had passed, and an Ensure nutritional drink with an expiration date indicating it was expired. The blueberry cobbler was intended for a resident who had already been discharged from the facility. A Registered Nurse confirmed these items were expired and should have been discarded. The facility's policies on food brought by family/visitors and food receiving and storage were not followed, leading to these deficiencies in food safety practices.
Plan Of Correction
All refrigerators were checked, and proper cleaning and disposal of items was completed immediately upon discovery by the surveyors. All staff were educated on the importance of checking and cleaning refrigerators. Family members and residents were provided with a copy of the Outside Food policy. Refrigerator cleaning logs were immediately put into place. The dietary department or designee will clean and properly dispose of any undated, unlabeled, or expired supplies in the refrigerators and keep log. The nursing home administrator or designee will conduct audits weekly for 4 weeks, and then monthly for 3 months. This will include checking to ensure logs are being kept and properly completed as well as observing refrigerators to ensure compliance. Results of these audits will be reviewed at the quarterly quality assurance meeting; any unfavorable auditing results will result in immediate corrective action step(s).
Failure to Monitor and Prevent Legionella in Water System
Penalty
Summary
The facility failed to ensure adequate measures were in place to monitor and prevent the presence of Legionella in the facility's water system. The facility's infection prevention and control plan, dated 11/14/24, outlined the process for detecting, preventing, and controlling healthcare-associated infections, including the testing of water for pathogens like Legionella at least quarterly. However, after receiving positive test results for Legionella rubrilucens in Linden Lane Room 27 and L. pneumophila in the Skilled Hall Med Room on 10/10/24, the facility did not conduct further testing to confirm the safety of the water system. An interview with the Maintenance/Environmental Services Director revealed that although the facility flushed the water system with 160-degree water following the positive test results, no subsequent testing was performed to ensure the effectiveness of this measure. The director confirmed that additional testing should have been conducted to verify the safety of the water for all individuals in the facility. This oversight indicates a lapse in the facility's infection prevention and control program, specifically in the monitoring and management of waterborne pathogens.
Plan Of Correction
Water was retested by the Maintenance Director on 02/14/2025. Samples were sent to Special Pathogens Lab, and results were obtained by the facility on 02/21/2025. All tests came back negative. Education was provided to the Maintenance Director regarding Legionella testing and the facility water management plan by the Nursing Home Administrator. Legionella testing will be completed as indicated in the Infection Control plan. The Nursing Home Administrator will audit to ensure Legionella testing is being completed quarterly, as indicated in the Infection Control plan. Results of these tests will be reviewed at the quarterly quality assurance meeting.
Physician Order Signing Deficiency
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders during their visits for four residents. The facility's policy, titled "Physician Services," mandates that physician orders and progress notes comply with current regulations. However, the clinical records of four residents revealed that their physician orders were not reviewed, signed, and dated as required. Specifically, the last recorded review, signature, and date for three residents occurred on the same date, while one resident's orders had not been reviewed, signed, or dated at all. Interviews with facility staff, including a Registered Nurse Assessment Coordinator and the Director of Nursing (DON), confirmed the oversight. The DON acknowledged that the physician orders for three residents should have been signed every sixty days, but were not signed in the months of September 2024, November 2024, or January 2025. Additionally, the DON confirmed that the orders for the fourth resident should have been signed at admission and every thirty days thereafter for the first ninety days, which did not occur in November 2024, December 2024, or January 2025.
Plan Of Correction
Residents R26, R36, R37, and R42 orders have all been signed/dated by the Elmwood medical staff. Nursing Home Administrator notified the Elmwood medical staff of this noncompliance, and the medical team immediately reviewed, signed, and dated all applicable orders. All other residents' orders have been reviewed by the Elmwood medical staff, and all other residents' orders are in compliance with being signed/dated by the applicable Elmwood medical staff. Physician orders education has been provided to the Elmwood medical staff regarding the requirement of timeliness in reviewing and signing off on resident orders; education was conducted by Nursing Home Administrator. Director of Nursing or designee will conduct whole house audits to ensure compliance with the signing and dating of all orders. Audits will be conducted weekly for 4 weeks, biweekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reviewed at the quarterly quality assurance meeting; any unfavorable auditing results will result in immediate corrective action step(s).
Failure to Conduct Timely Physician Visits for New Admission
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least every 30 days for the first 90 days after admission for a resident. The facility's policy, titled "Physician Services," mandates that physician visits and their frequency comply with current regulations. However, a review of the clinical records for a resident admitted with diagnoses including diabetes, high blood pressure, and congestive heart failure, revealed a lapse in compliance. The resident was seen by a Certified Registered Nurse Practitioner on two occasions, but there was no evidence of a required physician visit in January 2025. During an interview, the Director of Nursing confirmed that the resident was not seen by a physician as required in January 2025. This deficiency was identified based on the review of facility policy, clinical records, and staff interviews, indicating a failure to adhere to the mandated schedule for physician visits within the first 90 days of admission.
Plan Of Correction
Resident R42 was seen by the physician on 02/25/2025. All other resident records have been reviewed for their last physician visit date to ensure ongoing compliance with the timeliness of their physician visits. Education has been provided to the Elmwood Medical Staff regarding the minimal frequency of physician visits requirements; education was conducted by the Nursing Home Administrator. The Director of Nursing or designee will conduct whole house audits to ensure compliance with frequency/timeframes of required physician visits. Whole house audits will be conducted weekly for 4 weeks, then biweekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reviewed at the quarterly quality assurance meeting; any unfavorable auditing will result in immediate corrective action step(s).
Inaccurate MDS Assessment for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, identified as Resident 37, which did not accurately reflect the resident's status. The MDS is a federally mandated standardized assessment used to plan resident care. The deficiency was identified during a review of the MDS, clinical records, and staff interviews. Specifically, the MDS for Resident 37, with an assessment reference date of November 7, 2024, was inaccurately coded in Section H "Bladder and Bowel". The subsection H0100 "Appliances" was marked as "None of the above", and subsection H0300 "Urinary Continence" was coded as "Always Incontinent". However, Resident 37 had an indwelling catheter for the entire seven-day look-back period, which should have been reflected in the MDS coding. Resident 37's clinical record indicated an admission date of October 10, 2023, with diagnoses including congestive heart failure, multiple sclerosis, and neurogenic bladder. A physician's order dated October 21, 2024, confirmed the use of an indwelling catheter. During an interview, the Registered Nurse Assessment Coordinator confirmed that the MDS was inaccurately coded and should have indicated the presence of an indwelling catheter, with urinary continence coded as "not rated". This inaccuracy in the MDS assessment reflects a failure to accurately document the resident's status, as required by the regulations.
Deficiencies in Kitchen Suppression System Documentation and Awareness
Penalty
Summary
The facility failed to maintain proper documentation and awareness of the kitchen suppression systems in two of its kitchens, leading to deficiencies in compliance with NFPA 101 standards. In the Melrose kitchen, there was a lack of documentation confirming that the semi-annual kitchen suppression testing and maintenance had been completed, with the last recorded test occurring over a year prior. This was confirmed during an interview with the maintenance supervisor, who acknowledged that the necessary documentation was not available on-site during the survey. Similarly, in the Elmwood kitchen, the facility also failed to provide documentation of the semi-annual kitchen suppression testing and maintenance, with the last test documented over a year ago. Additionally, the kitchen staff members were unaware of the location of the manual pull activation for the kitchen hood suppression system, indicating a lack of training or communication regarding emergency procedures. These deficiencies were confirmed through observation and interviews conducted with the maintenance supervisor during the survey.
Plan Of Correction
The maintenance director provided supporting documentation to the inspector on 02/10/2025. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting. All dietary staff were reeducated on the Ansul system on 02/06/2025. Ansul system education will be included in the new hire building orientation for dietary department employees. Verbal drills will be conducted by the dietary manager or designee weekly for 1 month.
Generator Documentation Deficiency
Penalty
Summary
The facility failed to meet the electrical system requirements for its generator, as evidenced by the absence of necessary documentation. During a document review and interview conducted on February 6, 2025, it was revealed that the facility could not provide annual generator documentation for a 90-minute load bank test and a fuel quality test. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the unavailability of the required documentation at the time of the survey. The generator and associated equipment are required to supply service within 10 seconds, and maintenance and testing must be performed in accordance with NFPA 110. The generator sets should be inspected weekly, exercised under load for 30 minutes 12 times a year, and exercised once every 36 months for 4 continuous hours. Additionally, written records of maintenance and testing must be maintained and readily available. The facility's failure to provide documentation for the 90-minute load bank test and fuel quality test indicates non-compliance with these requirements.
Plan Of Correction
The maintenance director provided supporting documentation to the inspector on 02/10/2025. The maintenance director contacted Cleveland Brothers and obtained copies of the documentation for the fuel quality testing completed. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures in one of over five hazardous areas. During an observation on February 6, 2025, at 11:53 a.m., it was noted that the east wing lift storage room did not have a self-closing device on the door, which is required for a hazardous room enclosure. This deficiency was confirmed through an interview with the maintenance supervisor at the same time and date.
Plan Of Correction
The maintenance Director installed a self-closing device on 02/20/2025. The maintenance Director and team will monitor daily for 2 weeks and weekly for 3 months. Education was provided to staff and proper signage posted on door.
Smoke Barrier Deficiency in Staff Lounge
Penalty
Summary
The facility failed to maintain the smoke barrier in one of over ten rooms. During an observation on February 6, 2025, at 12:01 p.m., it was noted that the east wing staff lounge had loose, misaligned, broken, and non-fitting ceiling tiles, which allowed smoke to pass through. This deficiency was confirmed in an interview with the maintenance supervisor at the same time.
Plan Of Correction
The maintenance director immediately corrected the loose-fitting ceiling tiles upon discovery by the inspector. The maintenance director or designee will complete routine checks of ceiling tiles to ensure proper fit and compliance. This will be completed weekly for 3 months during environmental rounds completed by the maintenance director or designee.
Facility Exceeds Height Requirements for Type III (200) Building
Penalty
Summary
The facility failed to comply with the construction type and height regulations as outlined in NFPA 101 for a Type III (200) building. During an observation conducted on February 6, 2025, at 10:30 a.m., it was noted that the facility exceeded the permissible height for this construction type. This observation was confirmed through an interview with the director of facilities at the same time, who acknowledged that the building's height surpassed the requirements specified for a Type III (200) structure.
Plan Of Correction
The facility will submit a Time Limited Waiver to the Division of Safety Inspection.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in accordance with NFPA 25 standards, as evidenced by observations made on February 6, 2025. During an inspection, it was found that the sprinkler heads in the laundry room were covered with a layer of dust and lint. This accumulation of material can insulate the sprinkler's thermal element, potentially impacting the temperature activation and response time of the sprinkler, and may also cause inadequate spray coverage. The maintenance supervisor confirmed the deficiency during an interview conducted at the time of the observation. Additionally, another deficiency was noted in the skilled hall near the nurse station, where a sprinkler head was similarly covered with dust and lint. This finding was also confirmed by the maintenance supervisor. The presence of dust and lint on the sprinkler heads indicates a failure to properly maintain the sprinkler system, which is crucial for ensuring the system's effectiveness in the event of a fire.
Plan Of Correction
Air dusters were purchased, and all heads were sprayed clean on 02/07/2025. The maintenance director or designee will audit once a month for 3 months.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by a lack of documentation for annual maintenance and service technician certification. During a survey conducted on February 6, 2025, at 10:25 a.m., document review and observation revealed that the facility could not provide the necessary documentation for the fire extinguishers in two of two building components. An interview with the maintenance supervisor at the same time confirmed these deficiencies.
Plan Of Correction
The maintenance director provided supporting documentation to the inspector on 02/10/2025. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting. The maintenance director provided supporting documentation to the inspector on 02/10/2025. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.
Oxygen Cylinder Storage Deficiency
Penalty
Summary
The facility failed to maintain proper gas equipment storage requirements in one of its two storage areas. During an observation on February 6, 2025, at 11:49 a.m., it was noted that the oxygen storage room located in the skilled hall corridor contained oxygen cylinders that were not separated or labeled as full or empty. This lack of organization and labeling is a direct violation of the storage requirements for gas equipment. An interview with the maintenance supervisor at the same time confirmed the deficiencies related to the oxygen cylinder storage. The supervisor acknowledged the issues with the storage of the oxygen cylinders, which were not in compliance with the necessary safety standards. This deficiency highlights a failure in maintaining the required safety protocols for gas equipment storage within the facility.
Plan Of Correction
The maintenance director provided education to staff immediately regarding proper storage of the oxygen tanks. Additional signage was posted in the oxygen storage room designating the proper storage of the full and empty oxygen tanks. Red tape was also put on the floor to provide a visual line/designation for full and empty oxygen tanks. The maintenance director or designee will complete weekly audits for 3 months to ensure compliance and proper storage.
Failure to Maintain GFCI Protection for Electrical Receptacles
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 70 standards, as evidenced by observations made during a survey. On February 6, 2025, at 12:10 p.m., it was observed that a water cooler near the east wing nurse station was plugged into an outlet that was not protected by a ground fault circuit interrupter (GFCI). This deficiency was confirmed through an interview with the maintenance supervisor at the same time. A similar deficiency was noted later the same day, at 12:49 p.m., near the north hall nurse station. Here, another water cooler was found plugged into an outlet lacking GFCI protection. This observation was also confirmed by the maintenance supervisor. These findings indicate a failure to ensure that electrical receptacles, particularly those used in areas where water is present, are equipped with the necessary safety features to prevent electrical hazards.
Plan Of Correction
Maintenance director replaced the outlet with a proper GFCI immediately following discovery and purchasing of proper supplies. A full in-house audit was completed by maintenance director on 02/10/2025. Maintenance director or designee will complete inspections every 6 months for one year to ensure compliance.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident R27, who was admitted with diagnoses including diabetes, transient ischemic attack (TIA), and obstructive sleep apnea. The resident had a physician's order for Seroquel to manage depression, anxiety, and delusions, with the dosage increased over time. However, the clinical record lacked evidence of a care plan addressing the resident's behaviors and the use of Seroquel. This deficiency was confirmed during an interview with staff, who acknowledged that a care plan had not been developed for these specific needs.
Failure to Attempt Non-Pharmacological Interventions Before Administering PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for a resident. Specifically, Resident R158, who had diagnoses including anxiety and depression, was administered Clonazepam 18 times between 3/19/24 and 3/28/24 without any documented attempts of non-pharmacological interventions. The facility policy dated 3/20/24 indicated that non-pharmacological interventions should be considered and used when indicated, but this was not followed in the case of Resident R158. During an interview on 3/28/24, the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Clonazepam for Resident R158. This deficiency was identified based on the review of the facility policy, clinical records, and staff interviews, highlighting a failure to adhere to the policy of attempting non-pharmacological interventions before administering PRN psychotropic medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sarah Reed Senior Living | 1.3 mi | ★★★★★ | 4 | 0 |
| Lecom At Village Square, Llc | 1.4 mi | ★★★★★ | 3 | 0 |
| Lecom At Presque Isle, Inc | 1.4 mi | ★★★★★ | 17 | 0 |
| Greenfield Healthcare And Rehabilitation Center | 1.9 mi | ★★★★★ | 25 | 0 |
| Millcreek Manor | 2 mi | ★★★★★ | 5 | 0 |
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