Cycle 1
Health 2026-01-23 · Fire 2026-01-23
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Erie, PA
Millcreek Manor
4-star overall rating with 3-star inspections with $100,240 in total fines with 6 recent health deficiencies
5535 Peach Street, Erie, PA
(814) 868-7395
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
137
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-07-24
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
0.96
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.91
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
4.24
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,512
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.81
Baseline 17.07% · Performance 20.59% · Measure score 1.81 · Achievement 1.81 · Improvement 0
Healthcare-associated infections
5.10
Baseline 5.58% · Performance 6.31% · Measure score 5.10 · Achievement 5.10 · Improvement 0
Total nurse turnover
2.05
Baseline 57.58% · Performance 55.29% · Measure score 2.05 · Achievement 2.05 · Improvement 0.20
Adjusted total nurse staffing
5.42
Baseline 3.59 hours · Performance 4.62 hours · Measure score 5.42 · Achievement 5.42 · Improvement 4.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.95% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 158 · Observed rate 5.7% · Lower 95% interval 6.27% |
| Discharge to community | 47.74% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 155 · Observed rate 43.23% · Lower 95% interval 40.91% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 90 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 62.67% |
53.69%
9 pts better
|
Numerator 47 · Denominator 75 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 45 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 6 · Denominator 93 · Adjusted rate 7.13% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 4.4% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 0.38% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 265 |
| Staff flu vaccination coverage | 5.09% |
42%
36.9 pts worse
|
Numerator 11 · Denominator 216 |
| Discharge function score | 62.67% |
56.45%
6.2 pts better
|
Numerator 47 · Denominator 75 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 2.04% |
25.2%
23.2 pts worse
|
Numerator 1 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.9% |
86.9%
24 pts worse
|
93.4%
30.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 53.4% · Q3 79.7% · Q4 73.5% · 4Q avg 62.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 51.1% |
93.5%
42.4 pts worse
|
95.5%
44.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 51.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.4% · Q3 5.1% · Q4 3.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
6.5%
1.7 pts worse
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.6% · Q3 8.7% · Q4 0.9% · 4Q avg 8.2% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
6.5%
2.9 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.3% · Q3 7.3% · Q4 12.5% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
19.9%
0.5 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 18.0% · Q3 20.9% · Q4 19.3% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
18.7%
5.9 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 14.8% · Q3 9.4% · Q4 6.9% · 4Q avg 12.8% · 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 | 7.9% |
19.6%
11.7 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 14.1% · Q3 3.1% · Q4 5.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
18.3%
8.1 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 15.2% · Q3 4.6% · Q4 9.2% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 2.2% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 3.5% · Q4 0.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
26.4%
3.5 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 32.7% · Q3 29.1% · Q4 32.4% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.3%
0.3 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.6% · Q3 6.0% · Q4 5.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.2% |
68.9%
30.7 pts worse
|
81.7%
43.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 39.1% · Q3 47.1% · Q4 44.2% · 4Q avg 38.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
9.8%
0.5 pts worse
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 10.1% · Expected 11.0% · 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 0.0% · Q2 0.0% · Q3 0.9% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.5% |
68.7%
29.2 pts worse
|
79.7%
40.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 39.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
23.1%
2 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 24.6% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-24 · Fire 2025-01-24
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2024-02-23 · Fire 2024-02-23
16 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-01-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-06
B · Minimal harm
2025-01-24
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-02-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-08
C · Minimal harm
2024-02-23
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-03-08
C · Minimal harm
2024-02-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-08
C · Minimal harm
2024-02-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-08
C · Minimal harm
2024-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-23
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
D · Potential for more than minimal harm
2025-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-25
B · Minimal harm
2025-07-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-01-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2024-09-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-07-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-16
J · Immediate jeopardy
2024-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-23
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 2024-04-01
E · Potential for more than minimal harm
2024-02-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
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 2024-04-01
D · Potential for more than minimal harm
2024-02-23
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 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-04
E · Potential for more than minimal harm
2023-10-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
Penalties and ownership
What sits behind the stars
$100,240
2024-02-02
Fine
Fine · fine $100,240
Fine
Ownership
Millcreek Health System
5% Or Greater Direct Ownership Interest · Organization
Babiak, Jaime
Operational/Managerial Control · Individual
Beerbower, Joshua
Operational/Managerial Control · Individual
Inman, Steven
Corporate Director · Individual
Lin, James
Corporate Director · Individual
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