Lecom at Elmwood Gardens, LLC

In the surveyor’s words

From the most serious findings on record at Lecom at Elmwood Gardens, LLC, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 18, 2022

  Based on review of clinical records and facility documentation and staff and resident interviews, it was determined that the facility failed to identify the development of a pressure ulcer for one of four residents (Resident R1) reviewed resulting in the formation of an unstageable pressure injury. This deficiency is cited as past non-compliance. Findings include: Protocol for skin assessment in an interview with the Director of Nursing (DON) on 2/17/22, at 3:32 p.m. revealed that the Nurse Aides (NA) are to observe resident's skin while in the shower/bath/bed bath and if any skin issues are observed by the NA, the nurse is to be notified. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two resident refrigerators ([NAME] Unit and [NAME] Lane); failed to label food brought into the facility with the resident's name and use by date; and failed to maintain sanitary conditions in one of two resident refrigerators ([NAME] Unit). Findings include: Review of facility policy entitled, Food Brought by Family/Visitors, dated [DATE], revealed that perishable foods are to be stored in re-sealable containers with tightly fitting lids in a refrigerator. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2025

  Based on review of facility policy and infection control records, and staff interviews, it was determined that the facility failed to ensure measures were in place to monitor and prevent legionella in the facility water. Findings include: A facility policy, Infection Prevention and Control Plan FY2024, dated 11/14/24, revealed the infection control plan describes the process for the detection, prevention, and control of healthcare-associated infections (HAI), and disease transmission among residents, visitors, and healthcare personnel (HCP) (i.e., staff, providers, contractors/vendors, volunteers, and students). Water is tested at least quarterly for waterborne pathogens including Legionella. Response to positive test results is prescribed in the WMP (Water Management Plan). […]

• No harm, potential for more than minimal, isolatedF712Feb 13, 2026

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a physician completed the initial comprehensive visit for one of ten new admissions reviewed (Resident R17).Findings include: A facility policy entitled Physician Services dated 11/26/25, indicated that physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current regulations. Resident R17's clinical record revealed an admission date of 9/14/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and high blood… […]

• No harm, potential for more than minimal, isolatedF711Feb 13, 2025

  Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during each of his/her visits for four of 12 residents reviewed (Residents R26, R36, R37, and R42). Findings include: A facility policy entitled Physician Services dated 11/14/24, indicated that physician orders and progress notes are maintained with current regulations. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and endocarditis (inflammation of the inner lining of the heart chambers and valves usually caused by bacterial infection). […]