LECOM At Village Square, Llc

In the surveyor’s words

From the most serious findings on record at LECOM At Village Square, Llc, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 19, 2024

  Based on review of facility policies and documentation and clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed regarding transfers (Resident R72) was free of neglect during care which resulted in actual harm of an anterior dislocation of left shoulder (when the shoulder slides forward out of the socket). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Abuse and Neglect Definitions dated 10/14/24, indicated Neglect: The failure to provide the goods and services necessary to avoid physical harm . […]

• No harm, potential for more than minimal, patternF628Dec 18, 2025

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for five of 20 residents reviewed (Residents R1, R4, R14, R43 and R100).Findings include: Review of facility policy entitled Transfer or Discharge, Facility-Initiated dated 10/1/25, indicated Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The basis for the transfer., Contact information., Resident representative information., Advance directive information., All special instructions or precautions., Comprehensive care plan goals., All other… […]

• No harm, potential for more than minimal, patternF675Mar 30, 2025

  Based on review of facility documents and resident and staff interviews, it was determined that the facility failed to meet the needs of residents in a timely manner for nine of 11 residents interviewed (Residents R1, R4 through R9, R11 and R12). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m. during random resident interviews, the following residents complained of poor call bell response time: Resident R1 expressed frustration related to that often after activating the call bell for assistance, the staff would not respond for an hour or longer. Resident R4 indicated that they were worried that in the event of an emergency staff would not respond and often wait for response to their call light for over an hour. […]

• No harm, potential for more than minimal, patternF804Mar 30, 2025

  Based on review of facility documents and resident and staff interviews, it was determined that the facility failed to serve food that was at a palatable temperature for nine of 11 residents interviewed (Residents R1, R4 through R9, and R11). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m., during random resident interviews, the following alert and oriented residents complained of consistently of receiving cold food. Residents R1, R4 through R9, and R11 all expressed frustration that their meals were not palatable because the food was usually cold when delivered by staff, partly due to the trays sitting in the hall for long periods of time until they are delivered. […]

• No harm, potential for more than minimal, patternF655Nov 19, 2024

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 19 residents reviewed (Residents R71, R49, R28, and R7) and failed to ensure that a baseline care plan for an indwelling foley catheter (a medical device that helps drain urine from the bladder) was developed and implemented for one of 19 residents reviewed (Resident R178 ). […]