Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 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.
Failure to Provide Baseline Care Plan Summary: The facility did not document that a written summary of the baseline care plan and order summary were provided to seven residents and/or their representatives. The affected residents had diagnoses including dysphagia, anxiety, depression, oxygen dependence, diabetes, asthma, ESRD, pain, and muscle wasting, and the RN confirmed there was no evidence the required summaries were given.
A facility failed to provide enough nursing staff and services to meet resident needs, with multiple residents reporting delayed call light response, missed or late showers, late or incorrect meals, and delays in receiving snacks, ice water, and help getting out of bed. Residents described call bells going unanswered for 30 minutes to 2 hours, one resident waited 40 minutes on a bedpan, and staff were observed leaving a resident's bed unmade for 2 days. The DON/ADON and NHA confirmed resident concerns about call bells, meals, showers, snacks, and bed making.
Opened insulin vials and pens were found in medication carts without open dates, and one opened Lantus pen was past the 28-day discard timeframe. In addition, the separately locked compartment for controlled Schedule II-V meds in the medication refrigerator was attached to a removable shelf instead of being permanently affixed.
Food Served Cold and Unpalatable A test tray was delivered with food that was not palatable and was served at an unappetizing temperature. Residents reported that meals were frequently served cold, and food committee minutes documented complaints that items were often missing from orders. During tray testing, the milk was warm, the broccoli was mushy, the noodles were dry, and the pork had hard pieces, with kitchen logs showing lunch items leaving the kitchen at varying temperatures.
A privacy curtain between two residents' beds had several areas of a dark brown substance that appeared to be feces and remained soiled on repeated observations. An LPN confirmed the curtain was dirty and should have been cleaned, despite facility policy requiring visibly soiled curtains to be cleaned.
A resident with depression, anxiety, and dysphagia received PRN lorazepam for anxiety on multiple occasions, but the clinical record lacked evidence that non-pharmacological interventions were attempted before each administration. The DON confirmed the missing documentation and stated that non-pharmacological interventions should be attempted and documented before giving a PRN psychotropic medication.
Failure to Provide Ordered Suprapubic Catheter Care: A resident with DM, agranulocytosis, asthma, and long term drug therapy had a physician order for daily suprapubic catheter irrigation with NS for maintenance care. The TAR lacked evidence that the catheter was flushed daily on multiple dates, and the resident stated the SP cath was not flushed as ordered. The DON confirmed the record lacked evidence of the ordered catheter care.
Oxygen orders were not followed for two residents, and respiratory equipment was not kept clean. One resident with dependence on supplemental O2 was observed with a concentrator running while the filters on both sides were covered in gray fluffy substance. Another resident with SOB was observed with O2 in place, but the concentrator was set at 4L/min instead of the ordered 2L/min, and the filters were also covered in gray fluffy substance. An LPN confirmed the incorrect flow setting and the dirty filters.
A resident with a foley catheter had no TAR documentation for ordered catheter care every shift for an entire month. The facility policy required treatment/services performed to be documented in the medical record, and the RDN confirmed the records were incomplete.
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 Provide Baseline Care Plan and Order Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for seven of 28 residents reviewed. The residents identified were R4, R8, R11, R28, R37, R62, and R126. Facility policy titled "Care Plans - Baseline" dated 10/30/25 stated that the resident and/or representative are provided a written summary of the baseline care plan. Clinical records for each of the seven residents lacked evidence that this written summary and order summary were provided. The affected residents had multiple diagnoses documented in their records. R4 was admitted with muscle wasting and atrophy, elevated white blood count, dysphagia, and hyperlipidemia. R8 had anxiety and hyperlipidemia. R11 had depression, anxiety, and dysphagia. R28 had dependence on supplemental oxygen and hypertension. R37 had diabetes mellitus, long term drug therapy, agranulocytosis, and asthma. R62 had muscle wasting and atrophy, pain, and restless legs syndrome. R126 had end stage renal disease, hyperlipidemia, muscle wasting and atrophy, and diabetes mellitus. During interview, the Regional Director of Nursing confirmed there was no evidence that the written summary of the baseline care plan and order summary were provided to these residents and/or their representatives.
Insufficient Nursing Services and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of 13 of 28 residents reviewed, including residents who reported delayed call light responses, late or missing meals, missed or delayed showers, and unmet requests for snacks, ice water, bed making, and assistance getting out of bed. Facility policies required timely response to call lights and appropriate assistance with activities of daily living, and the CNA job description stated that call bells should be answered promptly and resident needs addressed. During the Resident Council meeting, five alert and oriented residents stated that call bells were not answered in a timely manner, with waits reported from 30 minutes to one and a half hours. Those same residents stated that snacks were delayed or not provided, beds were not being made, meals were late, and meal trays did not match the meal tickets. Resident Council minutes from October through December also documented concerns that snacks and ice water were not being passed, showers were not being given as scheduled, and snacks were not being passed. Individual interviews and observations supported these concerns. One resident reported waiting 40 minutes on a bedpan for call bell response, while others reported waiting one to two hours for call bells to be answered, cold meal trays, and delays in receiving ordered food items. One resident stated showers were missed because staff said they did not have time or a shower chair. Another resident was observed in a wheelchair while the bed remained unmade with no linen on the mattress for two days, and the ADON confirmed the bed had not been made. The NHA confirmed resident concerns related to call bells, snacks, beds being made, getting out of bed, showers, and late or incorrect meals.
Improper Medication Dating and Controlled Drug Storage
Penalty
Summary
Medications and biologicals were not properly labeled and stored in accordance with facility policy and manufacturer guidance. The facility policy stated that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise, and that controlled medications and other drugs subject to abuse must be separately locked in permanently affixed compartments. Manufacturer guidance for Humalog, Aspart, and Lantus insulin stated that opened vials and pre-filled pens must be discarded after 28 days. On observation, the Northwest Medication Cart contained three open Lantus injector pens and two open Aspart injector pens without open dates, and the Southwest Medication Cart contained an opened Humalog vial, an opened Humalog injector pen, an opened Lantus injector pen, and an opened Aspart injector pen without open dates. The Southwest Medication Cart also had an opened Lantus injector pen with an open date of 9/20/25, making it expired. In the North Medication Room refrigerator, the separately locked container for controlled Schedule II-V medications was attached to a removable shelf rather than being permanently affixed to the refrigerator.
Food Served at Unappetizing Temperature and Poor Quality
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature for one test tray. The facility policy for Food and Nutritional Services stated that staff were to inspect trays to ensure the correct meal was provided, the food appeared palatable and attractive, and it was served at a safe and appetizing temperature. Resident Council and food committee minutes from 10/27/25, 11/20/25, and 12/18/25 documented complaints that food was being served cold and frequently without items residents had ordered. During interviews on 1/5/26, Residents R1, R31, R62, and R111 stated that food was frequently served cold. Review of kitchen temperature logs on 1/6/26 showed lunch items were 145 degrees F for pork, 169 degrees F for broccoli, and 132 degrees F for noodles before leaving the kitchen. During an observation on 1/6/26 at about 12:45 p.m., the Northwest Hall cart was prepared with a test tray placed last and delivered by the Dietary Manager. When the tray was tested on arrival, the milk was warm to taste, the broccoli was mushy, the noodles were dry with crusty sections, and the pork had hard pieces and did not have an appetizing texture. The food items were not palatable due to cool temperatures, and Dietary Manager Employee E1 was present when the unacceptable temperatures and poor palatability were discussed.
Soiled privacy curtain left uncleaned in resident room
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain a clean environment on the South Wing. Facility policy titled Cleaning and Disinfecting Residents' Rooms dated 10/30/25 stated that curtains are to be cleaned when visibly soiled or dusty. On 1/5/26 at 2:00 p.m., observation of the South Wing room [ROOM NUMBER] showed a privacy curtain between two residents' beds with several areas of a dark brown substance that appeared to be feces. The same dark brown substance remained on the privacy curtain during observations on 1/6/26 at 9:00 a.m. and again at 1:11 p.m. During interview on 1/6/26 at 1:15 p.m., an LPN confirmed the privacy curtain had several areas of a dark brown substance on it and stated that the curtain should have been cleaned.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted before administering PRN psychotropic medication to one resident, R11. R11 was admitted with diagnoses including depression, anxiety, and dysphagia, and on 12/26/25 the physician ordered lorazepam 0.25 ml every 2 hours PRN for anxiety. Review of the January 2026 MAR showed the PRN lorazepam was administered on 1/1/26, 1/2/26, 1/3/26, and 1/5/26, but the clinical record lacked documentation that non-pharmacological interventions were attempted before each of those four administrations. During interview on 1/7/26 at 1:02 p.m., the DON confirmed the record lacked evidence of attempted non-pharmacological interventions for those dates and stated such interventions should be attempted and documented.
Failure to Provide Ordered Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services regarding catheter care for Resident R37. The resident was admitted on 4/30/25 and had diagnoses including diabetes mellitus, long term drug therapy, agranulocytosis, and asthma. A facility policy dated 10/30/25 stated that catheter care is intended to prevent catheter-associated complications, including urinary tract infections, and that catheter irrigation may be ordered to maintain unobstructed urine flow for residents at risk for obstruction. Resident R37’s TAR included a physician order dated 12/12/25 to irrigate the suprapubic catheter daily with 60 cc of normal saline, instilling and pulling back every day shift for maintenance care. The TAR lacked evidence that the catheter was flushed daily on multiple dates in December and January. During an interview on 1/06/26, the resident stated the suprapubic catheter was not flushed daily per the physician order. The Regional Director of Nursing confirmed on 1/07/26 that the clinical record lacked evidence of daily flushing per the order and that the facility failed to provide appropriate treatment and services regarding the resident’s catheter.
Oxygen Orders Not Followed and Respiratory Equipment Filters Left Dirty
Penalty
Summary
Failure to provide respiratory care according to physician orders was identified for two residents. Resident R28 had diagnoses including dependence on supplemental oxygen and hypertension, and the care plan and physician order dated 9/24/25 directed oxygen at 3L/min via nasal cannula continuously. On 1/5/26 at 2:00 p.m. and again on 1/6/26 at 8:53 a.m., R28 was observed sitting in a wheelchair with supplemental oxygen in place and running, and the oxygen concentrator filters on both sides were covered with a large amount of gray fluffy substance. Resident R68 had diagnoses including anxiety, shortness of breath, and hypertension, with a care plan and physician orders dated 8/15/25 for oxygen at 2L/min via nasal cannula as needed and weekly concentrator filter cleaning. On 1/5/26 at 1:54 p.m. and again on 1/6/26 at 8:52 a.m., R68 was observed lying in bed with supplemental oxygen in place, but the oxygen concentrator was set at 4L/min. The concentrator filters on both sides were also covered with a large amount of gray fluffy substance. During interview on 1/6/26 at 1:11 p.m., an LPN confirmed that R68's concentrator was set at 4L/min and not in accordance with the physician's order, and confirmed that the filters for both residents were covered in gray fluffy substance and should be clean per physician orders.
Incomplete Documentation for Foley Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation for foley catheter care for one of two residents reviewed with foley catheters, Resident R111. The facility policy required that all services provided to the resident, including treatment or services performed, be documented in the medical record. Resident R111 was admitted with diagnoses including paraplegia, pain, and muscle wasting and atrophy, and had a physician order for foley catheter care every shift. Review of the Treatment Administration Record for December 2025 showed no documentation for the entire month indicating that the ordered foley catheter care was completed. During interview, the Regional Director of Nursing confirmed that the treatment records did not have complete documentation regarding foley catheter care.
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.
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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) |
|---|---|---|---|---|
| Walnut Creek Nursing And Rehab | 0.9 mi | ★★★★★ | 14 | 0 |
| Millcreek Manor | 1.1 mi | ★★★★★ | 5 | 0 |
| Greenfield Healthcare And Rehabilitation Center | 1.3 mi | ★★★★★ | 25 | 0 |
| Lecom At Elmwood Gardens, Llc | 1.4 mi | ★★★★★ | 1 | 0 |
| Forestview | 1.6 mi | ★★★★★ | 3 | 0 |
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