Cycle 1
Health 2025-12-18 · Fire 2025-12-18
5 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Erie, PA
LECOM At Village Square, Llc
3-star overall rating with 3-star inspections with $20,373 in total fines with 5 recent health deficiencies
149 West 22nd Street, Erie, PA
(814) 452-3271
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
96
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,911
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.28
Baseline 44.62% · Performance 58.44% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Adjusted total nurse staffing
3.13
Baseline 3.34 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 2.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 18.75% · Lower 95% interval 7.59% |
| Discharge to community | 46.69% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 35.29% · Lower 95% interval 31.52% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.89% |
95.27%
3.4 pts worse
|
Numerator 34 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 63.33% |
53.69%
9.6 pts better
|
Numerator 19 · Denominator 30 |
| Discharge mobility score | 76.67% |
50.94%
25.7 pts better
|
Numerator 23 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 8.11% |
2.29%
5.8 pts worse
|
Numerator 3 · Denominator 37 · Adjusted rate 6.8% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 108 |
| Staff flu vaccination coverage | 7.69% |
42%
34.3 pts worse
|
Numerator 8 · Denominator 104 |
| Discharge function score | 83.33% |
56.45%
26.9 pts better
|
Numerator 25 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 6 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 48.2% |
86.9%
38.7 pts worse
|
93.4%
45.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 31.6% · Q3 57.0% · Q4 60.7% · 4Q avg 48.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.3% |
93.5%
14.2 pts worse
|
95.5%
16.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
6.5%
1.6 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.3% · Q3 2.6% · Q4 9.1% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.5%
1.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 11.1% · Q3 5.0% · Q4 8.6% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
19.9%
6.1 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 30.1% · Q3 26.2% · Q4 28.4% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
18.7%
5.2 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 25.0% · Q3 24.6% · Q4 22.4% · 4Q avg 23.9% · 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 | 5.3% |
19.6%
14.3 pts better
|
16.3%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 7.1% · Q3 2.5% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
18.3%
12.1 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 8.5% · Q3 0.0% · Q4 5.0% · 4Q avg 6.2% · 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 | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.3% · Q3 1.2% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
26.4%
4.4 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 23.1% · Q3 22.9% · Q4 24.6% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.3%
0.1 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.3% · Q3 9.1% · Q4 5.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 22.1% |
68.9%
46.8 pts worse
|
81.7%
59.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 25.8% · Q3 17.3% · Q4 8.6% · 4Q avg 22.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.8%
2.7 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.8% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.5%
2.2 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.6% · Q3 3.9% · Q4 2.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.6% |
68.7%
43.1 pts worse
|
79.7%
54.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
23.1%
2.7 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 25.6% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-19 · Fire 2024-11-19
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-12-07 · Fire 2023-12-07
5 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2024-11-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-15
C · Minimal harm
2023-12-07
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-01-31
C · Minimal harm
2023-12-07
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-01-31
C · Minimal harm
2023-12-07
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-01-31
C · Minimal harm
2023-12-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-31
C · Minimal harm
2023-12-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-01-31
C · Minimal harm
2023-12-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-01-23
E · Potential for more than minimal harm
2025-03-30
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-09
G · Actual harm
2024-11-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-11-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-19
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 2025-01-03
D · Potential for more than minimal harm
2024-11-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-03
E · Potential for more than minimal harm
2023-12-07
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 2024-02-02
D · Potential for more than minimal harm
2023-12-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-02
Penalties and ownership
What sits behind the stars
$15,435
2024-11-19
Fine
Fine · fine $15,435
Fine
$1,764
2023-08-07
Fine
Fine · fine $1,764
Fine
$3,174
2023-07-17
Fine
Fine · fine $3,174
Fine
Ownership
Millcreek Health System
5% Or Greater Indirect Ownership Interest · Organization
Millcreek Manor
5% Or Greater Direct Ownership Interest · Organization
Babiak, Jaime
Operational/Managerial Control · Individual
Beerbower, Joshua
Operational/Managerial Control · Individual
Diianni, Luigi
Corporate Director · Individual
Eckert, Mary
Corporate Director · Individual
Eckert, Mary
Corporate Officer · Individual
Ferretti, John
Corporate Director · Individual
Ferretti, John
Corporate Officer · Individual
Ferretti, Silvia
Corporate Director · Individual
Fierro, Vincent
Corporate Director · Individual
Fucci, Esther
Corporate Director · Individual
Inman, Steven
Corporate Officer · Individual
Kelly, Joseph
Corporate Director · Individual
Lin, James
Corporate Director · Individual
Savocchio, Joyce
Corporate Director · 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
Nightingale Nursing And Rehab Center
Erie, PA
3-star overall rating with 3-star inspections with $6,292 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lecom At Elmwood Gardens, LLC
Erie, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
Jump out