Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Village Square, Llc during CMS and state inspections, most recent first.
The facility failed to ensure that required clinical information was communicated to the receiving provider when five residents were transferred to the hospital. The affected residents had diagnoses including respiratory failure, COPD, HTN, renal dialysis dependence, diabetes, A-fib, anxiety, depression, and repeated falls, and the records lacked evidence that the needed transfer information was sent; the DON confirmed the missing documentation.
A resident with diabetes, anxiety, and HTN had an altered genitourinary care plan that still included indwelling urinary catheter interventions after the catheter was removed and discontinued. The current physician orders no longer included a catheter order, but the care plan was not reviewed or revised to match the resident's current care and services, and the NHA and DON confirmed this during interview.
An expired Humalog insulin injector pen was found in the East Wing med cart during survey observation. Facility policy required opened multi-dose medications to be dated and discarded within 28 days, and the manufacturer’s instructions for Humalog also required opened vials and pre-filled pens to be discarded after 28 days. An LPN confirmed the pen was expired and should have been discarded.
Multiple residents reported excessive delays in staff response to call bells, with some waiting an hour or more for assistance and others noting that staff ignored call lights or failed to return as promised. These concerns were also documented in Resident Council meeting minutes, and the facility administrator confirmed awareness of the issue.
Multiple residents reported consistently receiving cold meals, with complaints documented over several months and attributed to delays in tray delivery. The administrator confirmed awareness of the issue, and records showed ongoing resident dissatisfaction with food temperature.
A resident with dementia and other conditions required a mechanical lift with two staff for transfers. However, a nursing assistant attempted a transfer alone, leading to the resident's anterior shoulder dislocation. The facility's investigation confirmed the neglect due to non-compliance with the care plan.
The facility failed to provide a written summary of the baseline care plan and order summary to several residents and/or their representatives, including those with conditions such as dementia and heart failure. Additionally, a baseline care plan for an indwelling foley catheter was not developed for a resident admitted with this device, as confirmed by a charge nurse.
The facility failed to provide two residents or their representatives with written notification of the bed-hold policy within 24 hours of hospital transfer, as required by its policy. The clinical records for these residents lacked documentation of the notification, which was confirmed by the Corporate Nursing Home Administrator.
A facility failed to transcribe a physician's order for Hydroxyzine, an antianxiety medication, for a resident with anxiety, diabetes, and hypertension. The facility's policy mandates that such orders be recorded on the physician's order sheet. A review of the resident's clinical record showed the absence of the transcribed order, which was confirmed by the DON during an interview.
A facility failed to have adequate physician orders for a resident's indwelling urinary catheter, which was present upon admission. The orders should have included details on catheter size, scheduled changes, and hygiene care. This deficiency was confirmed by a charge nurse during an interview.
The facility failed to document a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not attempt non-pharmacological interventions before administering the medication for two residents. Both residents received Vistaril for anxiety without the required stop date or rationale for extended use, and there was no evidence of non-pharmacological interventions being attempted prior to administration. The DON confirmed these deficiencies.
The facility failed to discard outdated medications, including Tubersol vials without open dates, expired Glargine and Aspart Insulin pens, and a bottle of cholestacare tablets. Staff confirmed these items should have been discarded according to policy and guidelines.
Failure to Communicate Required Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when five residents were transferred to the hospital. Review of the facility’s Transfer or Discharge policy showed that, when a resident is transferred or discharged, information such as the basis for transfer, contact information, resident representative information, advance directive information, special instructions or precautions, comprehensive care plan goals, and other information needed to meet the resident’s needs is to be communicated to the receiving facility or provider. Clinical records showed that Resident R1, with diagnoses including acute and chronic respiratory failure, COPD, and hypertension, had hospital transfers documented in progress notes, but the record lacked evidence that necessary clinical information was sent. Resident R4, with hypertension, dependence on renal dialysis, and diabetes, also had hospital transfers documented without evidence of communication of necessary clinical information. Resident R14, with diabetes, atrial fibrillation, and chronic respiratory failure, had multiple hospital transfers documented, and the record lacked evidence that necessary clinical information was communicated. Resident R43, with hypertension, anxiety, and depression, and Resident R100, with atrial fibrillation, diabetes, and repeated falls, each had a documented hospital transfer with no evidence that necessary clinical information was provided to the receiving health care provider. During interview, the DON confirmed the records lacked evidence that the required clinical information had been provided upon transfer.
Care plan not updated after urinary catheter discontinuation
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident to reflect current care and services. Resident R11 was admitted with diagnoses including diabetes, anxiety, and hypertension, and had an altered genitourinary status care plan dated 9/19/25 that included interventions for an indwelling urinary catheter, such as monthly catheter changes, drainage bag changes, covering the drainage bag, flushing the catheter, and providing catheter care. A progress note dated 11/21/25 documented that the resident's urinary catheter was removed, and the November 2025 treatment record showed the catheter was discontinued on 11/22/25. Current physician orders contained no order for a urinary catheter, yet the care plan was not updated to reflect the change in the resident's condition and services. During interview, the Nursing Home Administrator and DON confirmed that the altered genitourinary status care plan was not reviewed or revised to reflect current resident care and services.
Expired Humalog Insulin Left in Medication Cart
Penalty
Summary
The facility failed to ensure an expired medication was discarded in a timely manner in one of two medication carts reviewed, the East Wing cart. A facility policy titled Medication Labeling and Storage stated that opened or accessed multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. Manufacturer guidelines for Humalog insulin stated that opened vials and pre-filled pens should be discarded after 28 days. During an observation of the East Wing medication cart, surveyors found an open injector pen of Humalog insulin with an open date that made it expired. During the observation, an LPN confirmed that the Humalog injector pen was expired and should have been discarded.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to meet the needs of residents in a timely manner, as evidenced by multiple resident complaints and documentation from a Resident Council meeting. During a facility tour and random resident interviews, nine out of eleven residents reported excessive delays in staff response to call bells, with several residents stating they often waited an hour or longer for assistance. Some residents expressed concerns about staff ignoring call lights, sometimes while using their cell phones, and others reported that after long waits, staff would promise to return but did not follow through. The issue of delayed call bell response was also documented in the Resident Council meeting minutes, and the Nursing Home Administrator acknowledged awareness of the problem and agreed that such delays were inappropriate.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable temperature to nine out of eleven residents interviewed, as evidenced by multiple complaints from alert and oriented residents who consistently received cold meals. During a facility tour, residents reported that their food was not palatable due to it being cold upon delivery, attributing this to meal trays sitting in the hallway for extended periods before being served. A review of Resident Council meeting records for three consecutive months also documented repeated complaints about cold food. The Nursing Home Administrator confirmed awareness of the ongoing issue during an interview.
Neglect During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a transfer, resulting in actual harm. The resident, who had a history of dementia, diabetes, and cognitive communication deficit, required dependent assistance for transfers, specifically needing a mechanical lift with the assistance of two staff members. However, during a transfer from a wheelchair to bed, a nursing assistant attempted to perform the transfer alone using a sit-to-stand lift, contrary to the resident's care plan and facility policy. During the transfer, the resident's knees gave way, causing them to start sliding down the lift. The nursing assistant then called for help from a fellow team member, but by that time, the resident had already sustained an injury. The resident complained of pain in the left shoulder, which was later diagnosed as an anterior dislocation at the emergency room. The incident was a result of the nursing assistant's failure to adhere to the care plan that required two staff members for the transfer. The facility's investigation confirmed that the nursing assistant did not have a second staff member present at the start of the transfer, which was a violation of the facility's policy on safe lifting and movement of residents. This neglect led to the resident's injury, highlighting a lapse in following established protocols for resident safety during transfers.
Removal Plan
- The facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers were performed per facility policy and resident care plans.
- Immediate suspension of NA Employee E10.
- Immediate education regarding resident mechanical lifts and checking transfer status before transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's, and was ongoing.
- Therapy Department conducted competencies of staff included in the education to ensure that they understood the education and could perform the task correctly.
- Interviews with LPN Employees E3 and E4, NA Employees E5, E6 and E7, and RN Employee E8 confirmed the facility initiated education and competencies, which included education on where to find transfer status for the resident and performing a return demonstration to ensure proper knowledge and technique while using mechanical lifts.
- Audits were conducted to ensure safe transfers for residents and remain ongoing.
- These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting post incident.
- The NHA also identified that review of resident transfers will continue to be reviewed at QAPI meeting and will continue until determined otherwise by the QAPI committee.
- The facility has demonstrated compliance with using correct transfer status for residents.
Failure to Provide Baseline Care Plans and Documentation
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to four residents and/or their representatives. These residents included individuals with various diagnoses such as dementia, dysphagia, malignant neoplasm of the lung, muscle wasting, hyperlipidemia, heart failure, hypertension, and hypothyroidism. The clinical records for these residents lacked evidence that the required documentation was provided, which is necessary to ensure effective, person-centered care and meet professional standards of quality care. Additionally, the facility did not develop and implement a baseline care plan for an indwelling foley catheter for one resident who was admitted with this medical device. This oversight was confirmed by a charge nurse during an interview. The absence of a baseline care plan for the foley catheter indicates a failure to address the specific medical needs of the resident upon admission, as required by the facility's policy.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives within 24 hours of a hospital transfer, as required by its own policy. This deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. Specifically, two residents, identified as R41 and R7, were transferred to the hospital, but their clinical records did not contain documentation that they or their representatives received the bed-hold policy notification. Resident R41, who has diagnoses including intellectual disabilities, dysphagia, and hypertension, was transferred to the hospital on a specific date, but there was no evidence of the required notification. Similarly, Resident R7, with diagnoses of hyperlipidemia, hypertension, and hypothyroidism, was transferred on two separate occasions, yet the clinical records also lacked the necessary documentation. The Corporate Nursing Home Administrator confirmed the absence of this documentation during an interview.
Failure to Transcribe Physician's Order for Anxiety Medication
Penalty
Summary
The facility failed to transcribe a physician's order for an anxiety medication for one resident. The facility's policy requires that drug and biological orders be recorded on the physician's order sheet in the resident's chart. A review of the clinical record for a resident with diagnoses including anxiety, diabetes, and hypertension revealed a physician's progress note indicating the addition of Hydroxyzine 25 mg every six hours as needed for anxiety. However, the physician's orders for this resident lacked evidence that the Hydroxyzine order was transcribed. During an interview, the Director of Nursing confirmed that the order was not transcribed as required.
Lack of Physician Orders for Urinary Catheter Care
Penalty
Summary
The facility failed to ensure adequate physician orders were in place for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including benign prostatic hyperplasia, heart failure, and dysphagia, had a foley catheter upon entry into the facility. However, the clinical record review revealed a lack of physician orders for the urinary catheter, which should have included details such as catheter and balloon size, scheduled changes, changes as needed due to soiling or dislodgement, draining of the collection bag, collection bag changes, and hygiene care. This deficiency was confirmed during an interview with a charge nurse, who acknowledged the absence of necessary physician orders for the resident's catheter care.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not document attempts of non-pharmacological interventions prior to administering the medication for two residents. Resident R12, diagnosed with anxiety, heart failure, and chronic pain, had a physician's order for Vistaril 50 mg as needed for anxiety, but the order lacked a required stop date within 14 days or a clinical rationale for continued use beyond this period. The medication was administered multiple times in October and November 2024 without evidence of non-pharmacological interventions being attempted beforehand. Similarly, Resident R67, with diagnoses of anxiety and dementia, had a physician's order for Vistaril 10 mg as needed for anxiety, also lacking the required stop date or clinical rationale for extended use. The medication was administered numerous times in October and November 2024 without documentation of non-pharmacological interventions being attempted prior to administration. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the lack of required documentation and intervention attempts.
Failure to Discard Outdated Medications
Penalty
Summary
The facility failed to appropriately discard outdated medications, as evidenced by observations and staff interviews. During a review of the first floor medication room, two open multi-dose vials of Tubersol were found without any indication of when they were opened, making it impossible for staff to determine the discard date. This was confirmed by a Registered Nurse, who acknowledged that the vials should have been discarded. Additionally, the facility's policy and manufacturer's guidelines specify that Tubersol should be discarded within 30 days of opening. Further observations of the two east medication cart revealed an opened Glargine Insulin pen and an opened Aspart Insulin pen, both of which were past their expiration dates. An open bottle of cholestacare tablets was also found with a best-by date that had passed. The Director of Nursing confirmed that these items were expired and should have been discarded. The facility's policy and manufacturer's guidelines require that insulin pens be discarded 28 days after opening, even if they still contain insulin.
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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 | 0.1 mi | ★★★★★ | 4 | 0 |
| Nightingale Nursing And Rehab Center | 0.9 mi | ★★★★★ | 9 | 0 |
| Lecom At Elmwood Gardens, Llc | 1.4 mi | ★★★★★ | 1 | 0 |
| Pennsylvania Soldiers And Sailors Home | 1.6 mi | ★★★★★ | 9 | 0 |
| Greenfield Healthcare And Rehabilitation Center | 2.7 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.