Cycle 1
Health 2025-02-13 · Fire 2025-02-13
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Erie, PA
Lecom At Elmwood Gardens, LLC
5-star overall rating with 4-star inspections with 4 recent health deficiencies
2628 Elmwood Avenue, Erie, PA
(814) 864-4802
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-07-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,634
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
1.40
Baseline 5.95% · Performance 7.41% · Measure score 1.40 · Achievement 1.40 · Improvement 0
Total nurse turnover
0
Baseline 63.01% · Performance 64.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.44
Baseline 3.67 hours · Performance 4.91 hours · Measure score 6.44 · Achievement 6.44 · Improvement 5.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.09% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 11.94% · Lower 95% interval 7.43% |
| Discharge to community | 57.63% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 53.73% · Lower 95% interval 47.8% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 25.81% |
95.27%
69.5 pts worse
|
Numerator 8 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 44% |
53.69%
9.7 pts worse
|
Numerator 11 · Denominator 25 |
| Discharge mobility score | 68% |
50.94%
17.1 pts better
|
Numerator 17 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 2.13% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 94 |
| Staff flu vaccination coverage | 19.57% |
42%
22.4 pts worse
|
Numerator 18 · Denominator 92 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 16 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
86.9%
9.1 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 84.2% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.8% |
93.5%
11.7 pts worse
|
95.5%
13.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.5%
4.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
19.9%
12.9 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.0% · Q3 6.9% · Q4 11.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
18.7%
12 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.7% · Q3 4.0% · Q4 4.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.1% |
19.6%
4.5 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
18.3%
9.6 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 9.4% · Q3 3.4% · Q4 2.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
26.4%
9.5 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 51.7% · Q3 32.6% · Q4 21.5% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.3%
0.2 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 6.7% · Q3 1.9% · Q4 1.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
68.9%
26.2 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 80.0% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
9.8%
5.1 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
68.7%
30.3 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
23.1%
7 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 13.0% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-03-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-18
D · Potential for more than minimal harm
2024-03-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-18
Penalties and ownership
What sits behind the stars
Ownership
Millcreek Manor
5% Or Greater Direct Ownership Interest · Organization
Babiak, Jaime
Operational/Managerial Control · Individual
Beerbower, Joshua
Operational/Managerial Control · Individual
Eckert, Mary
Corporate Officer · Individual
Ferretti, John
Corporate Officer · Individual
Ferretti, Silvia
Corporate Officer · Individual
Fierro, Vincent
Corporate Director · Individual
Fucci, Esther
Corporate Officer · Individual
Inman, Steven
Corporate Officer · Individual
Kelly, Joseph
Corporate Officer · Individual
Lin, James
Corporate Director · Individual
Savocchio, Joyce
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sarah Reed Senior Living
Erie, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
LECOM At Village Square, Llc
Erie, PA
3-star overall rating with 3-star inspections with $20,373 in total fines with 5 recent health deficiencies
#3
Lecom At Presque Isle, Inc
Erie, PA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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