Millcreek Manor

5535 PEACH STREET
ERIE, PA, 16509
8148687395
CCN: 396072
4
Overall
3
Health
5
Staffing
3
Quality
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
MILLCREEK HEALTH SYSTEM5% OR GREATER DIRECT OWNERSHIP INTEREST100%
INMAN, STEVENCORPORATE DIRECTORNOT APPLICABLE
LIN, JAMESCORPORATE DIRECTORNOT APPLICABLE
BABIAK, JAIMEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
BEERBOWER, JOSHUAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2024-02-02Fine$100K
Health Deficiencies (27)
2026-01-23 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
2025-11-18 · Health
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
2025-07-30 · Health
B
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-03-27 · Health
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
2025-01-24 · Health
D
F761 · Pharmacy Service Deficiencies
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.
D
F758 · Pharmacy Service Deficiencies
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.
D
F578 · Resident Rights Deficiencies
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.
2024-09-05 · Health
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
2024-07-24 · Health
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2024-02-23 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F835 · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
D
F758 · Pharmacy Service Deficiencies
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.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F637 · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
E
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
2024-02-02 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-10-16 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F584 · Resident Rights Deficiencies
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.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
4.24
3.68
RN Hrs/Resident/Day
0.96
0.54
LPN Hrs/Resident/Day
0.91
0.81
CNA Hrs/Resident/Day
2.37
2.33
PT Hrs/Resident/Day
0.10
0.12
Data as of 2026-03-01