Lecom At Presque Isle, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 4114 Schaper Avenue, Erie, Pennsylvania 16508
- CMS Provider Number
- 395404
- Inspections on file
- 26
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lecom At Presque Isle, Inc during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate documentation of ordered wound treatments and scheduled showers for multiple residents with complex medical conditions, including cerebral palsy, chronic respiratory failure, COPD, multiple sclerosis, diabetes, quadriplegia, and spina bifida. Physician-ordered wound dressings to areas such as the ischium, coccyx, and sacrum, as well as scheduled bathing tasks on specific shifts, were frequently not recorded on treatment and ADL records, despite facility policies requiring detailed charting of all procedures and hygiene care. The NHA in training confirmed that these wound dressings and showers were required to be completed as ordered and documented when provided.
A resident with cerebral palsy, chronic respiratory failure, and a gastrostomy had physician orders for continuous enteral nutrition at 55 cc/hr and a hydration flush at 70 cc/hr. Facility policy required verification of enteral feeding rates against the orders before administration. On multiple observations, the resident’s feeding pump was set to 50 cc/hr and the hydration flush to 80 cc/hr. An RN confirmed these incorrect settings and acknowledged they did not follow the physician’s orders.
The facility failed to follow its own policy and resident preferences for bathing routines, as documented concerns from Resident Council indicated showers were not being offered as scheduled. Record review showed that one resident with spina bifida, diabetes, and respiratory failure received only three baths/showers in a 28-day period, another resident with respiratory failure and epilepsy received only two, and two additional residents with cerebral palsy and chronic respiratory failure received only bed baths with no documented showers during the same timeframe. The NHA confirmed that baths/showers were not provided according to resident preferences for the reviewed period.
The facility did not complete federally required MDS assessments within the specified time frames for four residents with complex medical conditions, including those with tracheostomy, TBI, COPD, dementia, and respiratory failure. Required assessment and care planning documentation was signed off days to weeks late, as confirmed by the administrator.
The facility did not maintain proper documentation for the semi-annual visual inspection of its fire alarm system, with the last inspection recorded several months prior. The maintenance manager confirmed the missing documentation.
The facility did not maintain compliance with fire safety regulations due to missing documentation for the most recent sensitivity test results of the fire alarm system. The maintenance manager confirmed the absence of this documentation during a survey.
The facility was found deficient in maintaining NFPA 101 standards for ABHR dispensers, with one installed directly over an electrical outlet in the main floor wound care room. This was confirmed by the maintenance manager.
The facility was found to have deficiencies in maintaining smoke barriers, with issues observed in the main floor IT room and laundry boiler room. The IT room had cracked, broken, and missing ceiling tiles, while the laundry boiler room had loose, missing, and unsealed ceiling tiles. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to ensure GFCI protection in three areas: the main floor physical therapy room water cooler receptacle, and the eye wash station receptacles at the main floor south and north wing nurse stations. This deficiency was confirmed by the maintenance manager.
The facility was unable to provide a current certification for the fire extinguisher service technician as required by NFPA 10-7.1.2. During a document review, it was found that the certification was not available, and this was confirmed by the maintenance manager.
The facility was found to have deficiencies in exit signage, with four missing directional exit signs on the main floor. These deficiencies were observed during a survey and confirmed by the maintenance manager, indicating non-compliance with NFPA 101 requirements for continuous illumination and emergency lighting.
A facility failed to meet corridor door requirements when a door to a resident's room did not latch properly, as observed and confirmed by the maintenance manager. This deficiency was identified in one of over twenty corridor doors inspected, potentially compromising smoke passage prevention measures.
The facility failed to maintain respiratory care equipment properly for several residents, as oxygen concentrator filters were found unclean and humidification orders were missing. Observations revealed that filters were covered with a white/grey substance, and humidifier bottles were improperly managed. The Director of Nursing confirmed these deficiencies, highlighting a lack of adherence to facility policies and physician's orders.
The facility did not maintain a clean environment for two residents, as their privacy curtains were heavily soiled with a brown substance. This was against the facility's cleaning policy, which requires spot cleaning of curtains. The issue was confirmed by the Assistant DON.
Incomplete Documentation of Wound Care and Bathing
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate documentation of wound treatments and bathing in accordance with its own policies and accepted professional standards. Facility policies on Activities of Daily Living and Charting and Documentation require that residents who cannot perform ADLs independently receive appropriate hygiene care, and that all procedures and treatments be documented with date, time, and the signature and title of the person providing care. For one resident with cerebral palsy, chronic respiratory failure, and a gastrostomy, physician orders required wound dressings to the right ischium every morning and at bedtime, but the March 2026 treatment record lacked documentation of multiple ordered dressing changes. The same resident’s bathing task, scheduled for specific days on day shift, also lacked documentation that baths were provided on several scheduled dates. Additional residents were affected by similar documentation gaps. One resident with hypertension, COPD, and lumbar spine fusion had an order for a daily coccyx wound dressing on day shift, but the March 2026 treatment record lacked documentation of numerous dressing changes, and the bathing task, scheduled for specific evenings, lacked documentation of several baths. Another resident with chronic respiratory failure, multiple sclerosis, and hypertension had missing documentation for several scheduled baths. A resident with diabetes and quadriplegia had multiple scheduled baths without corresponding documentation. A fifth resident with spina bifida, anxiety, and diabetes had physician orders for daily wound dressings to the left ischium and right sacrum, but the March 2026 treatment record lacked documentation of several of these treatments. In an interview, the Nursing Home Administrator in training confirmed that the clinical records for all five residents did not contain complete documentation of wound dressing changes and/or showers and acknowledged that these should be done as ordered and documented when completed.
Incorrect Enteral Feeding and Hydration Rates Not Following Physician Orders
Penalty
Summary
The facility failed to provide enteral nutrition and hydration in accordance with physician orders for one resident receiving tube feeding. Facility policy on enteral tube feeding via continuous pump required staff to check the enteral nutrition label against the order before administration, including verifying the rate of administration in mL/hour. The resident, admitted with diagnoses including cerebral palsy, chronic respiratory failure, and a gastrostomy, had physician orders dated 12/31/25 for continuous pump feeding of Peptamen AF at 55 cc/hr and a hydration flush at 70 cc/hr over 24 hours. On multiple observations on 3/23/26 at 10:30 a.m., 12:30 p.m., and 1:25 p.m., the resident was observed in bed receiving enteral feeding via g-tube with the feeding pump set at 50 cc/hr and the hydration flush set at 80 cc/hr, which did not match the physician’s orders. During an interview at 1:30 p.m. the same day, an RN confirmed that the feeding rate and hydration flush settings were 50 cc/hr and 80 cc/hr, respectively, and acknowledged that these settings were not in accordance with the resident’s physician orders and should have been set per those orders.
Failure to Provide Weekly Baths/Showers According to Resident Choice
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to self-determination and to provide weekly baths or showers in accordance with resident choice and facility policy. The facility’s policy on Resident Self Determination and Participation, dated 10/30/25, states that each resident is allowed to choose a daily routine, including bathing schedules. Resident Council minutes from 12/16/25 documented resident concerns that showers were not being offered as scheduled. Despite this, review of clinical and bath/shower documentation for multiple residents showed that weekly baths/showers were not consistently provided during the review period of 1/06/26 through 2/02/26. One resident with lumbar spina bifida, diarrhea, diabetes mellitus, and respiratory failure received only three baths/showers in a 28-day period. Another resident with respiratory failure with hypoxia, epilepsy, hyponatremia, and hypokalemia had documentation showing only two baths/bed baths in the same 28-day period. A third resident with spastic quadriplegic cerebral palsy, chronic respiratory failure, vitamin deficiency, and epilepsy had only bed baths documented on five dates and no showers during the 28-day period. A fourth resident with cerebral palsy, chronic respiratory failure with hypoxia, asthma, and myopathy had documentation of bed baths but no evidence of any bath/shower during the same timeframe. In an interview, the Nursing Home Administrator confirmed that the facility did not provide baths/showers according to residents’ preferences for the identified period for these residents.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the federally required time frames for four out of sixteen residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments, quarterly MDS assessments, and discharge return anticipated MDS assessments must be completed within specific deadlines following admission, assessment reference dates, or discharge. For the residents identified, the MDS completion dates, Care Area Completion dates, and Care Plan Decision dates were all signed off several days to weeks after their required due dates. The residents affected had significant medical conditions, including tracheostomy, traumatic brain injury, seizures, COPD, lung cancer, dementia, anxiety, respiratory failure, and high blood pressure. The delays in completing the required MDS assessments were confirmed by the Nursing Home Administrator during a staff interview. The deficiency was cited under 28 Pa. Code 201.14(a) for failure to ensure timely completion of mandated resident assessments.
Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain its fire alarm system components as required, affecting the entire facility. During a document review on January 16, 2025, it was discovered that the facility could not provide documentation for the semi-annual visual fire alarm inspection. The last recorded inspection was dated May 30, 2024. An interview with the maintenance manager on the same day confirmed the absence of the necessary documentation.
Plan Of Correction
The semi-annual visual fire alarm inspection has been scheduled. The maintenance director and/or designee will ensure that all visual fire alarm inspections are completed semi-annually. The administrator and/or designee will monitor for compliance.
Fire Alarm System Documentation Deficiency
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations as evidenced by the absence of documentation for the most recent sensitivity test results of the fire alarm system. During a document review and interview conducted on January 16, 2025, it was revealed that the facility did not have the necessary documentation available. The maintenance manager confirmed that the sensitivity testing documentation was unavailable at the time of the survey.
Plan Of Correction
The sensitivity testing has been scheduled to be completed. The maintenance director and/or designee will ensure that the sensitivity testing is completed and documentation of the test results are obtained.
Improper Installation of ABHR Dispenser Over Electrical Outlet
Penalty
Summary
The facility failed to maintain compliance with the National Fire Protection Association (NFPA) 101 standards for alcohol-based hand rub dispensers (ABHR) in one of its five wings. During an observation on January 16, 2025, at 11:38 a.m., it was noted that the main floor wound care room had an ABHR dispenser installed directly over an electrical outlet. This installation does not meet the requirement that dispensers should not be installed within 1 inch of an ignition source. The maintenance manager confirmed the deficiency during an interview conducted at the same time.
Plan Of Correction
The main floor wound care room hand dispenser has been moved to a location in accordance with 8.7.3.1. The Maintenance Director and/or designee will audit all hand dispensers to ensure that they are placed in accordance with 8.7.3.1.
Smoke Barrier Deficiencies in Facility
Penalty
Summary
The facility failed to maintain smoke barrier requirements in two specific locations, as observed during a survey. On January 16, 2025, between 11:52 a.m. and 11:56 a.m., it was noted that the main floor IT room had cracked, broken, and missing ceiling tiles, compromising the smoke barrier. Additionally, the main floor laundry boiler room was found to have loose, missing, and unsealed ceiling tiles, further failing to meet the smoke barrier standards. These deficiencies were confirmed through an interview with the maintenance supervisor at the time of observation.
Plan Of Correction
Smoke barriers are now maintained in the following areas: a. Main floor IT room ceiling tiles have been replaced. b. Main floor laundry boiler room ceiling tiles have been replaced. The maintenance director and/or designee will complete an audit to ensure all smoke barriers are maintained.
Failure to Maintain GFCI Protection in Key Areas
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with safety standards in three specific areas. During an observation conducted on January 16, 2025, between 11:48 a.m. and 12:38 p.m., it was noted that ground fault circuit interrupter (GFCI) protection was not provided in the main floor physical therapy room water cooler receptacle, the main floor south wing nurse station eye wash station receptacle, and the main floor north wing nurse station eye wash station receptacle. This deficiency was confirmed through an interview with the maintenance manager on the same day at 12:38 p.m.
Plan Of Correction
Ground fault circuit interrupters (GFCI) have been installed in the following areas: a. Main floor physical therapy room water cooler receptacle b. Main floor south wing nurse station eye wash station receptacle c. Main floor north wing nurse station eye wash station receptacle The maintenance director and/or designee will complete a whole house audit to ensure electrical receptacles are all in compliance.
Lack of Certification for Fire Extinguisher Technician
Penalty
Summary
The facility failed to provide a current certification for the fire extinguisher service technician, which is a requirement under NFPA 10-7.1.2. During a document review on January 16, 2025, at 11:03 a.m., it was discovered that the facility could not produce the necessary certification for the technician responsible for servicing the fire extinguishers. An interview with the maintenance manager at the same time confirmed that the certification was unavailable during the survey.
Plan Of Correction
The facility received the certification for the fire extinguisher service technician on January 31, 2025. The maintenance director and/or designee will ensure that the certification for the fire extinguisher service technician is received before or at the time of inspection.
Exit Signage Deficiencies Noted in Facility
Penalty
Summary
The facility failed to maintain proper exit signage as required by NFPA 101, Section 7.10, which mandates continuous illumination of exit and directional signs, also served by the emergency lighting system. During an observation conducted on January 16, 2025, between 11:32 a.m. and 12:35 p.m., four deficiencies were noted in the exit signage on the main floor. Specifically, missing directional exit signs were observed in the main floor corridor from Ambassador to the North nurse station, the main floor entrance corridor to the North/South corridors, the main floor employee hall to the main corridor, and the main floor Northwest hall towards the North nurse station. An interview with the maintenance manager confirmed these deficiencies at the time of the survey.
Plan Of Correction
The directional exit signs for the following corridors have been installed: A. Main floor corridor to North Nurse station B. Main floor corridor to the North/South corridors C. Main floor employee hall to the main corridor D. Main floor Northwest hall toward the north Nurse station The maintenance director and/or designee will ensure that the facility directional signs will be maintained with continuous illumination.
Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to meet the corridor door requirements as evidenced by an observation and interview conducted on January 16, 2025. During the observation at 11:25 a.m., it was noted that the door to resident room #74 did not latch properly in the frame. This deficiency was confirmed through an interview with the maintenance manager at the same time, who acknowledged the issue with the door. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, as per the NFPA 101 standards and CMS regulations. However, the door in question did not meet these standards, as it failed to latch, potentially compromising the safety measures intended to prevent the spread of smoke in the event of a fire. The deficiency was identified in one of over twenty corridor doors inspected during the survey.
Plan Of Correction
Resident room #74 now positively latches. The Maintenance Director and/or designee will complete an audit of all doors to ensure that all doors positively latch. Audits will be completed quarterly for compliance.
Failure to Maintain Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain respiratory care equipment appropriately and in accordance with physician's orders for five residents. The facility's policies on oxygen concentrators and therapy were not followed, as evidenced by observations and staff interviews. Specifically, the oxygen concentrator filters for several residents were found to be covered with a white/grey fluffy substance, indicating they were not cleaned properly. Additionally, there was a lack of evidence in the clinical records for physician's orders regarding humidification and cleaning of the concentrator filters. Resident R4's clinical record did not show a physician's order for humidification or cleaning of the oxygen concentrator filter. Observations revealed that the external surface of the filter was initially covered with a white/grey substance, and later, the internal surface was also found to be unclean. The humidifier bottle was found empty and later placed on the floor, which was confirmed by the Director of Nursing as inappropriate. Similar issues were observed with Residents R40, R75, R95, and R205, where the internal surfaces of their oxygen concentrator filters were not clean, and it appeared that the filters had been turned around. The Director of Nursing confirmed the deficiencies during observations, and the Regional Director of Nursing acknowledged the lack of physician's orders and treatment records for cleaning the concentrator filters. The facility's failure to adhere to its policies and ensure proper maintenance of respiratory care equipment resulted in deficiencies for the residents involved, as documented in the report.
Plan Of Correction
Resident R4 now has a physician order/treatment to provide humidification to his/her supplemental oxygen. Resident R4, R40, R75, R95, and R205 oxygen concentrator filters were cleaned immediately, and orders verified that all concentrator filters are to be cleaned weekly and/or as needed. Resident R4's prefilled humidifier was immediately removed from the floor. All residents who have respiratory equipment have had their orders verified. All respiratory equipment has been checked to ensure cleanliness, which includes but is not limited to the filters. The respiratory therapists and all nursing staff will be inserviced to include but not limited to the policy and procedure for oxygen concentrators, Oxygen Therapy, Oxygen Therapy via Nasal Cannula as well as the policy and procedure for following physician orders. The Director of Nursing and/or designee will monitor physician orders for all residents on oxygen for use, flow rate, and oxygen concentrator cleanliness daily for two weeks, bi-weekly for two weeks, and weekly for four weeks, and monthly thereafter for compliance. The results will be taken to the Quality Assurance and Performance Improvement Committee for review and further recommendations.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, as observed during a survey. The facility's policy on Daily Resident Room and Bathroom Cleaning, dated 10/10/23, requires that privacy curtains be checked and spot cleaned as needed. However, during observations on 8/8/24, the privacy curtains in the rooms of two residents were found to be heavily soiled with a brown colored substance. This was confirmed by the Assistant Director of Nursing, who acknowledged that the curtains should have been cleaned or replaced, indicating a failure to adhere to the facility's cleaning policy.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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