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
- 27
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 17
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
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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