Pennsylvania Department of Health
LECOM AT ELMWOOD GARDENS, LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LECOM AT ELMWOOD GARDENS, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on February 6, 2025, at Lecom at Elmwood Gardens, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #680202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 6, 2025, it was determined that Lecom at Elmwood Gardens was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type III (200), unprotected, ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain construction type and height regulations for all building areas.

Findings include:

Observation on Feburary 6, 2025, at 10:30 a.m., revealed the facility exceeded the height requirement for a Type III (200) building.

Interview with the director of facilities on Feburary 6, 2025, at 10:30 a.m., confirmed the facility exceeded the height requirements for the listed construction type.

Plan of Correction - To be completed: 03/14/2025

The facility will submit a Time Limited Waiver to the Division of Safety Inspection

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain cooking facilities for two of two kitchens.
Findings include:
Observation on February 6, 2025, at 10:50 a.m., revealed the facility lacked documentation that the semi-annual kitchen suppression testing/maintenance was completed for the Melrose kitchen. The last-documented test occurred January 25, 2024.
Interview with the maintenance supervisor on February 6, 2025, at 10:50 a.m., confirmed the kitchen suppression system documentation was not on-site during the time of the survey.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, the facility failed to maintain the sprinkler system for one of one laundry room.

Findings Include:

Observation on February 6, 2025, at 12:56 p.m., revealed sprinkler heads were covered with a layer of dust/lint in the laundry room. A build-up of material can insulate the sprinkler thermal element, impacting the temperature activation/response time of the sprinkler and/or can cause inadequate spray coverage.

Interview with the maintenance supervisor on February 6, 2025, at 12:56 p.m., confirmed the sprinkler head deficiency.

Plan of Correction - To be completed: 03/14/2025

Air dusters were purchased, and all heads were sprayed clean on 02/07/2025.

The maintenance director or designee will audit once a month for 3 months.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguishers in two of two building components.

Findings include:

Document review and observation on February 6, 2025, at 10:25 a.m., revealed the facility failed to produce documentation for the annual fire extinguisher maintenance as well as the service technician certification at the time of the survey.

Interview with the maintenance supervisor on February 6, 2025, at 10:25 a.m., confirmed the fire extinguisher deficiencies.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, for one of over fifty receptacles.

Finding include:

Observation on February 6, 2025, at 12:10 p.m., revealed the near east wing nurse station had a water cooler that was plugged into an outlet not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor on February 6, 2025, at 12:10 p.m., confirmed the receptacle deficiency.

Plan of Correction - To be completed: 03/14/2025

Maintenance director replaced the outlet with a proper GFCI immediately following discovery and purchasing of proper supplies.
A full in-house audit was completed by maintenance director on 02/10/2025.
Maintenance director or designee will complete inspections every 6 months for one year to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on the document review and interview, the facility failed to meet electrical system requirements for one of one generator.

Findings include:

Document review on February 6, 2025, at 10:40 a.m., revealed the facility was unable to provide annual generator documentation for the following:
A. 90-minute load bank test;
B. Fuel quality test.

Interview with the maintenance supervisor on February 6, 2025, at 10:40 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 03/14/2025

The maintenance director provided supporting documentation to the inspector on 02/10/2025.

The maintenance director contacted Cleveland Brothers and obtained copies of the documentation for the fuel quality testing completed.

Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #680202
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on February 6, 2025, it was determined that Lecom at Elmwood Gardens was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V, unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous area enclosures in one of over five hazardous areas.

Findings include:

Observation on February 6, 2025, at 11:53 a.m., revealed the east wing lift storage room lacked a self-closing device on the door to meet the requirements for a hazardous room enclosure.

Interview with the maintenance supervisor on February 6, 2025, at 11:53 a.m., confirmed the deficient closing device.

Plan of Correction - To be completed: 03/14/2025

The maintenance Director installed a self-closing device on 02/20/2025.

The maintenance Director and team will monitor daily for 2 weeks and weekly for 3 months.

Education was provided to staff and proper signage posted on door.

NFPA 101 STANDARD Cooking Facilities:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0324

Based on observation and interview, the facility failed to maintain cooking facilities for one of the two kitchens.

Findings include:

Observation and interview on February 6, 2025, between 10:50 a.m. and 1:14 p.m., revealed the following kitchen deficiencies:
A. (10:50 a.m.) The facility lacked documentation that the semi-annual kitchen suppression testing/maintenance was completed for the Elmwood kitchen. The last-documented test occurred on January 25, 2024;
B. (12:44 p.m.) The kitchen staff members in the Elmwood kitchen were unaware of the location of the manual pull activation for the kitchen hood suppression system.

Interview with the maintenance supervisor on February 6, 2025, at 12:44 p.m., confirmed the deficiencies on the day of the survey.

Plan of Correction - To be completed: 03/14/2025

The maintenance director provided supporting documentation to the inspector on 02/10/2025.
Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.

All dietary staff were reeducated on the Ansul system on 02/06/2025

Ansul system education will be included in the new hire building orientation for dietary department employees.

Verbal drills will be conducted by dietary manager or designee weekly for 1 month.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, the facility failed to maintain the sprinkler system for one of over thirty sprinkler heads.

Findings Include:

Observation on February 6, 2025, at 12:13 p.m., revealed a sprinkler head was covered with a layer of dust/lint in the skilled hall near the nurse station. A build-up of material can insulate the sprinkler thermal element, impacting the temperature activation/response time of the sprinkler and/or can cause inadequate spray coverage.

Interview with the maintenance supervisor on February 6, 2025, at 12:13 p.m., confirmed the sprinkler head deficiency.

NFPA 101 STANDARD Portable Fire Extinguishers:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguisher requirements in two of two building components.

Findings include:

Document review and observation on February 6, 2025, at 10:25 a.m., revealed the facility failed to produce documentation for the annual fire extinguisher maintenance as well as the service technician certification at the time of the survey.

Interview with the maintenance supervisor on February 6, 2025, at 10:25 a.m., confirmed the deficiencies.

NFPA 101 STANDARD Subdivision of Building Spaces - Accumulation:

Subdivision of Building Spaces - Accumulation Space
Space shall be provided on each side of smoke barriers to adequately accommodate the total number of occupants in adjoining compartments.
18.3.7.5.1, 18.3.7.5.2, 19.3.7.5.1, 19.3.7.5.2

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0373

Based on observation and interview, the facility failed to maintain the smoke barrier for one of over ten rooms.

Findings include:

Observation on February 6, 2025, at 12:01 p.m., revealed the east wing staff lounge had loose, misaligned, broken, and non-fitting ceiling tiles, allowing smoke passage.

Interview with the maintenance supervisor on February 6, 2025, at 12:01 p.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 03/14/2025

The maintenance director immediately corrected the loose-fitting ceiling tiles upon discovery by inspector.
The maintenance director or designee will complete routine checks of ceiling tiles to ensure proper fit and compliance. This will be completed weekly for 3 months during environmental rounds completed by maintenance director or designee.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, for one of over fifty receptacles.

Finding include:

Observation on February 6, 2025, at 12:49 p.m., revealed that near the north hall nurse station, a water cooler was plugged into an outlet not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor on February 6, 2025, at 12:49 p.m., confirmed the receptacle deficiency.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on the document review and interview, the facility failed to meet electrical system requirements for one of one generator.

Findings include:

Document review on February 6, 2025, at 10:40 a.m., revealed the facility was unable to provide annual generator documentation for the following:
A. 90-minute load bank test;
B. Fuel quality test.

Interview with the maintenance supervisor on February 6, 2025, at 10:40 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 03/14/2025

The maintenance director provided supporting documentation to the inspector on 02/10/2025.
The maintenance director contacted Cleveland Brothers and obtained copies of the documentation for the fuel quality testing completed.
Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0923

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of two storage areas.

Findings include:

Observation on February 6, 2025, at 11:49 a.m., revealed the skilled hall corridor oxygen storage room had oxygen cylinders that were unseparated or labeled as full or empty.

Interview with the maintenance supervisor on February 6, 2025, at 11:49 a.m., confirmed the oxygen cylinder deficiencies.

Plan of Correction - To be completed: 03/14/2025

The maintenance director provided education to staff immediately regarding proper storage of the oxygen tanks.

Additional signage was posted in the oxygen storage room designating the proper storage of the full and empty oxygen tanks. Red tape was also put on the floor to provide a visual line/designation for full and empty oxygen tanks.

The maintenance director or designee will complete weekly audits for 3 months to ensure compliance and proper storage.

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