LECOM at Presque Isle: Tube Feeding Error Found - PA
The finding came from a complaint inspection at LECOM at Presque Isle, a nursing facility on Schaper Avenue in Erie, completed March 31, 2026. Inspectors reviewed clinical records, observed the resident directly, and interviewed staff. What they found was straightforward: the pump settings did not match the doctor's orders, and nobody had corrected them.
The resident, identified in the inspection report as Resident R1, was admitted to the facility in August 2024. The diagnoses listed in the clinical record included cerebral palsy, chronic respiratory failure, and a gastrostomy, the surgical opening through the abdomen used to place a feeding tube directly into the stomach. For a resident who cannot eat or drink by mouth, the tube is the only route for nutrition and hydration. Getting the rate right is not a detail. It is the care.
A physician's order dated December 31, 2025, directed staff to run Peptamen AF, a specialized feeding solution used for patients at risk of malnutrition, at 55 cubic centimeters per hour. A second order from the same date called for a hydration flush at 70 cubic centimeters per hour, running continuously around the clock.
Inspectors observed the resident lying in bed with the feeding tube running at 10:30 in the morning on March 23, 2026. The pump was set to 50 cubic centimeters per hour for the feeding, and 80 cubic centimeters per hour for the hydration flush. Neither number matched the orders. The feeding was running five cubic centimeters per hour too slow. The hydration flush was running ten cubic centimeters per hour too fast.
Inspectors returned at 12:30 in the afternoon. The settings had not changed. They returned again at 1:25 in the afternoon. Still unchanged.
At 1:30 p.m., inspectors interviewed the registered nurse on duty, identified in the report as Employee E1. The nurse confirmed the feeding was set at 50 cubic centimeters per hour and the hydration flush at 80. The nurse confirmed those numbers were not what the physician had ordered. The nurse confirmed they should have matched the orders.
The facility's own policy on enteral tube feeding, dated October 30, 2025, directed staff to check the enteral nutrition label against the physician's order before administration, including the rate of administration. The check did not happen, or it happened and the discrepancy went uncorrected.
CMS rated the level of harm as minimal harm or potential for actual harm. The violation affected few residents. In the language of federal inspection reports, that places this finding at the lower end of the severity scale. But the scale measures what inspectors could document, not what the resident experienced across those hours.
Peptamen AF is a formula designed for patients with compromised metabolic function. Running it slower than ordered means the resident received less nutrition per hour than the physician determined was necessary. Running the hydration flush faster than ordered means the resident received more water than directed, continuously, for the duration of the error. For a resident with chronic respiratory failure, a condition in which the lungs already struggle to manage fluid and gas exchange, the balance of hydration is not incidental.
The inspection report does not say how long the pump had been running at the wrong settings before inspectors arrived at 10:30 that morning. It does not say whether anyone checked the pump during the night shift. It does not say when the settings were finally corrected.
What it says is that inspectors looked three times over the course of nearly three hours, and the numbers on the pump never changed.
Resident R1 was still lying in that bed when the nurse sat down with inspectors and confirmed, out loud, that the care being delivered at that moment was not the care the doctor had ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lecom At Presque Isle, Inc from 2026-03-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
LECOM AT PRESQUE ISLE, INC in ERIE, PA was cited for violations during a health inspection on March 31, 2026.
The finding came from a complaint inspection at LECOM at Presque Isle, a nursing facility on Schaper Avenue in Erie, completed March 31, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at LECOM AT PRESQUE ISLE, INC?
- The finding came from a complaint inspection at LECOM at Presque Isle, a nursing facility on Schaper Avenue in Erie, completed March 31, 2026.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ERIE, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from LECOM AT PRESQUE ISLE, INC or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395404.
- Has this facility had violations before?
- To check LECOM AT PRESQUE ISLE, INC's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.