Health inspection·January 8, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of five units observed (South Wing).Findings include: Review of facility policy entitled Cleaning and Disinfecting Residents' Rooms dated 10/30/25, indicated Clean curtains. when they are visibly soiled or dusty. Observations on 1/5/26, at 2:00 p.m., of the South Wing in room [ROOM NUMBER] revealed a privacy curtain pulled between the residents' beds. On the privacy curtain were several areas of a dark brown substance which appeared to be feces. Observations on 1/6/26, at 9:00 a.m. and again at 1:11 p.m. of room [ROOM NUMBER]'s privacy curtain revealed the dark brown substance remained on the curtain. During an interview on 1/6/26, at 1:15 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the privacy curtain in resident room [ROOM NUMBER] had several areas of a dark brown substance on it. LPN Employee E6 also confirmed that the privacy curtain should have been cleaned. 28 Pa. Code 201.14 (a) Responsibility of licensee Page 1 of 10 395404 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R11). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 10/30/25, revealed non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Review of Resident R11's clinical record revealed an admission date of 11/4/25, with diagnoses that included depression, anxiety, and dysphagia (difficulty swallowing). The clinical record revealed that on 12/26/25, Resident R11's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.25 milliliters (ml) every 2 hours PRN for anxiety. Review of Resident R11's January 2026 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used on 1/1/26, 1/2/26, 1/3/26, and 1/5/26. Resident R11's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in January 2026. During an interview on 1/7/26, at 1:02 p.m. the Director of Nursing confirmed that Resident R11's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395404 Page 2 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of facility policy, 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 seven of 28 residents reviewed (Residents R4, R8, R11, R28, R37, R62, and R126). Findings include: A facility policy entitled Care Plans - Baseline dated 10/30/25, revealed The resident and/or representative are provided a written summary of the baseline care plan. Resident R4's clinical record revealed an admission date of 9/08/25, with diagnoses that included muscle wasting and atrophy (loss of muscle often due to inactivity or aging), elevated white blood count (increased infection fighting cells in your body that fight an infection and/or inflammation or a disorder of the white blood cells), dysphagia (difficulty swallowing), and hyperlipidemia (high level of fats like cholesterol in the blood). Resident R4's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R4 and/or his/her representative. Resident R8's clinical record revealed an admission date of 11/16/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia. Resident R8's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R8 and/or his/her representative. Resident R11's clinical record revealed an admission date of 11/4/25, with diagnoses that included depression, anxiety, and dysphagia. Resident R11's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R11 and/or his/her representative. Resident R28's clinical record revealed an admission date of 9/24/25, with diagnoses that included dependence on supplemental oxygen (uses oxygen on routine bases due to breathing), hypertension (high blood pressure). Resident R28's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R28 and/or his/her representative. Resident R37's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes mellitus (where the body either doesn't produce enough insulin or doesn't use the insulin efficiently), long term drug therapy, agranulocytosis (low levels of granulocytes which are a type of white blood cell, infection fighting cell), and asthma (a chronic lung disease caused by inflammation of the airways). Resident R37's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R37 and/or his/her representative. Resident R62's clinical record revealed an admission date of 11/1/25, with diagnoses that included muscle wasting and atrophy, pain, and restless legs syndrome. Resident R62's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R62 and/or his/her representative. Resident R126's clinical record revealed an admission date of 5/16/25, with diagnoses that included end stage renal disease (final stage of kidney disease where the kidney function has failed), hyperlipidemia, muscle wasting and atrophy, and diabetes mellitus. Resident R126's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R126 and/or his/her representative. During an interview on 1/07/26, at approximately 2:12 p.m. the Regional Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R4, R8, R11, R28, R37, R62, and R126 and/or their representatives. 28 Pa. Code 211.10(c) Resident Care Plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services 395404 Page 3 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of facility policy and clinical records and resident and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 28 residents reviewed (Resident R37). Findings include: Review of a facility policy entitled Catheter Care, Urinary dated 10/30/25, revealed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow - Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Resident R37's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes mellitus (where the body either doesn't produce enough insulin or doesn't use the insulin efficiently), long term drug therapy, agranulocytosis (low levels of granulocytes which are a type of white blood cell, infection fighting cell), and asthma (a chronic lung disease caused by inflammation of the airways). Resident R37's Treatment Administration Record (TAR) revealed a physician order dated 12/12/25, Irrigate Supra pubic cath (SP - catheter placed through a small incision in lower abdomen into the bladder to drain urine) daily with 60 cc [cubic centimeters] of normal saline - Instill and pull back everyday shift for maintenance care of SP cath. Resident R37's TAR lacked evidence that Resident R37's catheter was flushed daily between 12/01/25, and 12/31/25, 1/02/26, and 1/06/26. An interview with Resident R37 on 1/06/26, at 11:15 a.m. revealed that his/her SP catheter was not flushed daily per physician order. An interview with the Regional Director of Nursing on 1/07/26, at 3:00 p.m. confirmed that Resident R37's clinical record lacked evidence of his/her SP catheter being flushed daily per the physician order, and the facility failed to provide appropriate treatment and services regarding Resident R37's catheter. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395404 Page 4 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of six residents reviewed (Residents R28 and R68).Findings include: Review of facility policy dated 10/30/25, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order. for oxygen administration. Review of facility policy dated 10/30/25, entitled Departmental (Respiratory Therapy) - Prevention of Infection indicated Wash filters from oxygen concentrators every seven days with soap and water. Review of Resident R28's clinical record revealed an admission date of 9/24/25, with diagnoses that included dependence on supplemental oxygen (uses oxygen on routine bases due to breathing), and hypertension (high blood pressure). Review of Resident R28's care plan revealed a care plan for altered respiratory status with an intervention for oxygen at 3L/min (liters per minute) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) continuously. Review of Resident R28's physician orders revealed an order dated 9/24/25, for oxygen at 3L/min via nasal cannula continuous. Observations on 1/5/26, at 2:00 p.m. and again on 1/6/26, at 8:53 a.m. revealed Resident R28 sitting in his/her wheelchair with supplemental oxygen in place and running. Observation of the concentrator filters to bilateral sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering bilateral filters. Review of Resident R68's clinical record revealed an admission date of 9/11/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), shortness of breath, and hypertension. Review of Resident R68's care plan revealed a care plan for respiratory distress requiring oxygen use with interventions for oxygen at 2L/min via nasal cannula as needed, and oxygen concentrator filter cleaning weekly. Review of Resident R68's physician orders revealed orders dated 8/15/25, for oxygen at 2L/min inhalation as needed, and oxygen concentrator filter cleaning weekly. Observations on 1/5/26, at 1:54 p.m., and again on 1/6/26, at 8:52 a.m. revealed Resident R68 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set a 4L/min. Further observation of the concentrator filters to bilateral sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering bilateral filters. During an interview on 1/6/26, at 1:11 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that Resident R68's oxygen concentrator was on and set at 4L/min and was not in accordance with the physician's order dated 8/15/25, for oxygen at 2L/min. LPN Employee E6 also confirmed that the filters to the bilateral sides of the oxygen concentrators for Residents R28 and R68 were covered in a gray fluffy substance, and the filters should be clean per physician orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395404 Page 5 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policies, job descriptions, clinical records, resident council minutes and grievances, observations, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for 13 of 28 residents reviewed (Residents R1, R8, R31, R36, R37, R62, R77, R86, R92, R101, R106, R107 and R111). Findings include: Review of facility policy entitled Answering the Call Light dated 10/30/25, revealed The purpose of this procedure is to ensure timely responses to the resident's request and needs. and Answer the resident call system immediately. Review of facility policy entitled Activities of Daily Living (ADL), Supporting dated 10/30/25, revealed appropriate care and services are provided for residents who are unable to carry out ADLs. including appropriate support and assistance with: bathing, dressing, grooming, transfer, ambulation, toileting, dining, and eating. Review of facility job descriptions for a Nursing Assistant (NA) revealed, The C.N.A. - Certified Nurse Aide provides resident centered care in accordance with policy and procedures. and addressing resident needs and concerns., Responds to call bells promptly., Assist residents with the activities of daily living including but not limited to; bathing, dressing, dining, transportation; Must show respect for residents., Must respect all resident rights. Interviews during the Resident Council meeting on 1/6/25, between 11:00 a.m. and 12:00 p.m., revealed five out of five alert and oriented residents R37, R77, R92, R101, and R106, in attendance all five stated that their call bells are not being answered in a timely manner, between 30 minutes to one and a half hours to be answered. All five residents stated when they request a snack they have waited hours to receive a snack if they get one at all. All five residents stated that their beds do not get made even after they have requested that their beds be made. All five stated that their meals being delivered are always late. All five residents stated that what they receive on their meal tray does not match their meal ticket. Review of Resident Council minutes over three months from October, November and December of 2025, revealed the following: October 2025 Resident Council minutes revealed nine residents in attendance stated that snacks are not being passed, and ice water is not being passed. November 2025 Resident Council minutes revealed seven residents in attendance stated that they are not receiving showers and snacks are not being passed. December 2025 Resident Council minutes revealed six residents in attendance stated that showers are not being given as scheduled. Review of the grievance logs from October, November, and December of 2025, revealed grievances related to care, call bell response, not receiving showers, meals choices/concerns, getting out of bed, and receiving snacks. Interview with Resident R86 on 1/5/26, had concerns with not receiving what he/she had ordered on their meal tray and when Resident R86 asked to get what they had ordered it would take 30 to 45 minutes if he/she got it at all. Interview with Resident R107 on 1/5/26, had concerns with wanting to get up early in the morning. Resident R107 stated that the staff would tell him/her that they could not get them up. Resident R107 also had concerns with their call bell being answered timely. He/she stated that it can take between 30 to 45 minutes to be answered. Interview with Resident R31 on 1/5/26, had concerns with getting their shower on the scheduled day. Resident R31 stated that he/she had to wait until another day because staff would tell him/her they did not have time or a shower chair. Interview with Resident R8 on 1/5/26, had concerns with their call bell being answered timely. Resident R8 stated that he/she was on a bed pan for 40 minutes waiting for their call bell to be answered. Interview with Resident R1 on 1/5/26, had concerns with their call bell being answered timely. Resident R1 stated that it can take between one to two hours to be answered. Resident R1 also stated that when he/she receives their meal tray that the food is cold. Interview with Resident 395404 Page 6 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R62 on 1/5/26, had concerns with their call bell being answered timely. Resident R62 stated that it can take between one to two hours to be answered. He/she also stated that when they receive their meal tray that the food is cold. Interview with Resident R111 on 1/5/26, had concerns with his/her call bell being answered timely. Resident R111 stated that it can take between one to two hours to be answered. Interview with Resident R77 on 1/05/26, at 1:30 p.m. revealed concerns with their bed not made daily per his/her desire. Resident R77 at the time of interview was observed out of bed in their wheelchair and the bed without linen on the mattress. Further observations on 1/05/26, at 2:45 p.m. and 3:30 p.m. and 1/06/26, at 2:15 p.m. revealed no linen on Resident R77's mattress. Assistant Director of Nursing Employee E7 on 1/06/26, at 2:30 p.m. confirmed that Resident R77's bed was not made for two days, and the facility failed to provide sufficient services for the resident's physical and mental well-being. Interview with Resident R36 on 1/05/26, at 1:35 p.m. revealed concerns with call bell response times, receiving ice, water, and snacks daily, and having his/her bed made per their desire. Resident R36 was observed out of bed in his/her wheelchair awaiting the bed to be made on 1/05/26, at 1:35 p.m.; the bed was observed with no linen on the mattress. Resident R36 indicated that he/she had been waiting all day to get the bed made and just wanted to lay down. Resident R36 further indicated that at times, he/she waits over two hours to get assistance for incontinence care. Resident R36 also indicated that he/she requested to have ice water a few days earlier, and staff told him/her that the ice machine was broken, and there was no ice. Later that day, Resident R36 further indicated that a nurse gave him/her ice and said that the ice machine was never broken. Resident R36 also had concerns with staff providing a snack per their desire. Resident R36 indicated that staff at times will just say there are no snacks available if they don't want to get one for him/her, the same as with the ice. During an interview on 1/08/26, at approximately 10:30 a.m. the Nursing Home Administrator (NHA) confirmed that residents have concerns related to call bells, receiving snacks, beds being made, getting out of bed, receiving showers, and receiving meals late that are cold and not what is on the resident's meal ticket. The NHA also confirmed that all resident concerns should be addressed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services 395404 Page 7 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened; failed to ensure expired medications were discarded in a timely manner; and failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator in two of three medication carts reviewed and one of two medication rooms reviewed (Northwest Medication Cart, Southwest Medication Cart, and North Medication Room).Findings include: A facility policy entitled, Medication Labeling and Storage dated 10/30/2025, revealed, Controlled medications and other drugs subject to abuse are separately locked in permanently affixed compartments .Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Aspart insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observation on 1/5/26, at 3:00 p.m. of the Northwest Medication Cart revealed three open injector pens of Lantus and two open injector pens of Aspart without an open date, this was witnessed and confirmed at that time by Licensed Practical Nurse (LPN) Employee E3. Observation on 1/5/26, at 3:11 p.m. of the Southwest Medication Cart revealed an opened Humalog vial, an opened injector pen of Humalog, an opened injector pen of Lantus, and an opened injector pen of Aspart without an open date. Additionally, there was an opened injector pen of Lantus with an open date of 9/20/25, therefore the medication was expired. This was all witnessed and confirmed at that time by LPN Employee E4. Observation on 1/5/26, at 3:17 p.m. of the North Medication Room refrigerator revealed the separately locked container for controlled scheduled II-V medications was attached to a removeable shelf, therefore it was not permanently affixed to the refrigerator. This was witnessed and confirmed at that time by the Registered Nurse Supervisor Employee E5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 395404 Page 8 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and facility records, observations, and resident and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature for one of one test trays completed. Findings include: A current facility policy entitled, Food And Nutritional Services revealed food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Resident Council and food committee minutes from 10/27/25, 11/20/25 and 12/18/25, all revealed that food was being served cold and frequently without the items that have been ordered by residents. Interviews conducted on 1/5/26, with Residents R1, R31, R62, and R111, revealed that the food is frequently served cold. Review of temperature logs completed by kitchen staff on 1/6/26, revealed the following lunch meal temperatures were obtained prior to the food leaving the kitchen: Pork 145 degrees Fahrenheit (F)Broccoli 169 degrees FNoodles 132 degrees F Observations on 1/6/26, at approximately 12:45 p.m. in the main kitchen revealed that the Northwest Hall Cart the kitchen was prepared with a test tray prepared last and placed on the cart. The Dietary Manager escorted the cart to the Northwest Hall. All the items including pork, broccoli, noodles, and milk were tasted from the test tray upon delivery to the Northwest Hall. The milk on the tray was warm to taste, the broccoli was a mushy texture, the noodles were dry and had crusty sections on them, and the pork had some hard pieces within the meat that did not have an appetizing feel to the texture. All food items at the time of the test tray were not palatable due to cool temperatures. Dietary Manager Employee E1 was present during the test tray and the results including the unacceptable temperatures and poor palatability at the time of the tray testing were discussed with the employee. 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Some 395404 Page 9 of 10 395404 01/08/2026 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding care for a foley catheter (a medical device that drains urine from the bladder) for one of two residents reviewed with foley catheters (Resident R111).Findings include: Review of a facility policy entitled Charting and Documentation dated 10/30/25, revealed, All services provided to the resident , progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Treatment or services performed. Resident R111's clinical record revealed an admission date of 5/23/25, with diagnoses that included paraplegia (paralysis affecting the lower half of the body), pain, and muscle wasting and atrophy. Review of Resident R111's physician's orders dated 11/29/25, revealed an order for foley catheter care every shift. Resident R111's Treatment Administration Record for December 2025, revealed the entire month 12/1/25, through 12/31/25, lacked documentation indicating the foley catheter care was completed per physician orders. During an interview on 1/7/26, at 2:18 p.m. the Regional Director of Nursing confirmed that Resident R111's treatment records did not have complete documentation regarding foley catheter care. 28 Pa. Code 211.5(f)(xiii)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395404 Page 10 of 10