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Lecom At Presque Isle, INC

4114 Schaper Avenue, Erie, PA 16508 · Non profit - Corporation · 135 certified beds · (814) 868-0831 Medicare & Medicaid certified

Call the home — (814) 868-0831 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jan 2026
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3910 Schaper Ave · (814) 453-5072 · Call to confirm hours
Pharmacy
1910 W 26th St · (814) 455-5383 · Call to confirm hours
Grocery
BFA Mart0.9 mi
1511 W 38th St · (814) 315-1955 · Call to confirm hours
Park
W 32nd St &, Schaper Ave · Typically dawn to dusk
Place of worship
2205 W 38th St · (814) 790-5200

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.6%16.8%15.4%better
Long-stay residents who lose too much weight7.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection0.9%1.5%2.0%better
Long-stay residents with depressive symptoms4.8%10.8%6.5%better
Long-stay residents who were physically restrained0.6%0.2%0.1%worse
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened7.0%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.3%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine74.2%93.5%95.3%worse
Long-stay residents with pressure ulcers14.2%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control30.8%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%17.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.9%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine12.0%68.7%79.4%worse
Short-stay residents rehospitalized after admission29.1%22.5%22.6%worse
Short-stay residents with an outpatient ER visit9.8%9.5%12.0%better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.9%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.9%CMS range 31.3–61.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.0–15.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.141.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.73
RN hours/ resident / day
0.90
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.51
RN hoursweekends
53.5%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 135 beds and averages 113.6 residents a day — about 84% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.92 on weekdays — 16% thinner on weekends. RN hours go from 0.82 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-08)
1
at the previous standard inspection (2025-01-13)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · Ecited before2026-03-31 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding wound treatments and showers for five of five residents reviewed (Residents R1, R2, R3, R4, and R5). Findings include: Review of facility policy entitled Activities of Daily Living (ADL), Supporting dated 10/30/25, indicated Appropriate care and services are provided for residents who are unable to carry out ADLs independently. including appropriate support and assistance with: hygiene (bathing.). Review of facility policy entitled Charting and Documentation dated 10/30/25, indicated Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided. the signature and title of the individual documenting. Review of Resident R1's clinical record revealed an admission date of 8/30/24, with diagnoses that included cerebral palsy (a brain disorder that affects a person's movement and muscle coordination caused from abnormal development or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-31 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide enteral nutrition (a method for providing nutritional needs via tube feeding) and hydration in accordance with physician's orders for one of two residents reviewed (Resident R1).Findings include: Review of facility policy entitled Enteral Tube Feeding via Continuous Pump dated 10/30/25, indicated Check the enteral nutrition label against the order before administration. Check the following information: Rate of administration (mL/hour). Review of Resident R1's clinical record revealed an admission date of 8/30/24, with diagnoses that included cerebral palsy (a brain disorder that affects a person's movement and muscle coordination caused from abnormal development or damage to the brain), chronic respiratory failure (a condition where your lungs don't exchange air properly), and gastrostomy (a surgical opening in the abdomen into the stomach). Review of Resident R1's physician's orders revealed an order for Enteral Feed Order every shift for at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-05 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policy, review of facility and clinical records, and staff interviews, it was determined that the facility failed to provide a weekly bath/shower for four of six residents reviewed (Residents R1, R2, R3, and R4). Findings include: Review of a facility policy entitled, Resident Self determination and Participation, dated 10/30/25, revealed Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or his interests, values, assessments and plans of care, including: a daily routine, such as sleeping and waking, eating, exercise and bathing schedules. Resident Council minutes dated 12/16/25, revealed new business resident concerns as Showers are not being offered as scheduled. Resident's R1's clinical record revealed an admission date of 4/06/24, with diagnoses that included lumbar spina bifida without hydrocephalus (a condition that occurs when the spine and spinal cord don't form properly during early fetal development), diarrhea, diabetes mellitus (a chronic condition where blood sugar…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for seven of 28 residents reviewed (Residents R4, R8, R11, R28, R37, R62, and R126). Findings include: A facility policy entitled Care Plans - Baseline dated 10/30/25, revealed The resident and/or representative are provided a written summary of the baseline care plan. Resident R4's clinical record revealed an admission date of 9/08/25, with diagnoses that included muscle wasting and atrophy (loss of muscle often due to inactivity or aging), elevated white blood count (increased infection fighting cells in your body that fight an infection and/or inflammation or a disorder of the white blood cells), dysphagia (difficulty swallowing), and hyperlipidemia (high level of fats like cholesterol in the blood). Resident R4's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R4 and/or his/her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, job descriptions, clinical records, resident council minutes and grievances, observations, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for 13 of 28 residents reviewed (Residents R1, R8, R31, R36, R37, R62, R77, R86, R92, R101, R106, R107 and R111). Findings include: Review of facility policy entitled Answering the Call Light dated 10/30/25, revealed The purpose of this procedure is to ensure timely responses to the resident's request and needs. and Answer the resident call system immediately. Review of facility policy entitled Activities of Daily Living (ADL), Supporting dated 10/30/25, revealed appropriate care and services are provided for residents who are unable to carry out ADLs. including appropriate support and assistance with: bathing, dressing, grooming, transfer, ambulation, toileting, dining, and eating. Review of facility job descriptions for a Nursing Assistant (NA) revealed, The C.N.A.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-08 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened; failed to ensure expired medications were discarded in a timely manner; and failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator in two of three medication carts reviewed and one of two medication rooms reviewed (Northwest Medication Cart, Southwest Medication Cart, and North Medication Room).Findings include: A facility policy entitled, Medication Labeling and Storage dated 10/30/2025, revealed, Controlled medications and other drugs subject to abuse are separately locked in permanently affixed compartments .Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and facility records, observations, and resident and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature for one of one test trays completed. Findings include: A current facility policy entitled, Food And Nutritional Services revealed food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Resident Council and food committee minutes from 10/27/25, 11/20/25 and 12/18/25, all revealed that food was being served cold and frequently without the items that have been ordered by residents. Interviews conducted on 1/5/26, with Residents R1, R31, R62, and R111, revealed that the food is frequently served cold. Review of temperature logs completed by kitchen staff on 1/6/26, revealed the following lunch meal temperatures were obtained prior to the food leaving the kitchen: Pork 145 degrees Fahrenheit (F)Broccoli 169 degrees…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of five units observed (South Wing).Findings include: Review of facility policy entitled Cleaning and Disinfecting Residents' Rooms dated 10/30/25, indicated Clean curtains. when they are visibly soiled or dusty. Observations on 1/5/26, at 2:00 p.m., of the South Wing in room [ROOM NUMBER] revealed a privacy curtain pulled between the residents' beds. On the privacy curtain were several areas of a dark brown substance which appeared to be feces. Observations on 1/6/26, at 9:00 a.m. and again at 1:11 p.m. of room [ROOM NUMBER]'s privacy curtain revealed the dark brown substance remained on the curtain. During an interview on 1/6/26, at 1:15 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the privacy curtain in resident room [ROOM NUMBER] had several areas of a dark brown substance on it. LPN Employee E6…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R11). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 10/30/25, revealed non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Review of Resident R11's clinical record revealed an admission date of 11/4/25, with diagnoses that included depression, anxiety, and dysphagia (difficulty swallowing). The clinical record revealed that on 12/26/25, Resident R11's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.25 milliliters (ml) every 2 hours PRN for anxiety. Review of Resident R11's January 2026…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records and resident and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 28 residents reviewed (Resident R37). Findings include: Review of a facility policy entitled Catheter Care, Urinary dated 10/30/25, revealed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow - Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Resident R37's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes mellitus (where the body either doesn't produce enough insulin or doesn't use the insulin efficiently), long term drug therapy, agranulocytosis (low levels of granulocytes which are a type of white blood cell, infection fighting cell), and asthma (a chronic lung disease caused by inflammation of the airways). Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 7 citations
  • Potential for harm · Dcited before2026-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of six residents reviewed (Residents R28 and R68).Findings include: Review of facility policy dated 10/30/25, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order. for oxygen administration. Review of facility policy dated 10/30/25, entitled Departmental (Respiratory Therapy) - Prevention of Infection indicated Wash filters from oxygen concentrators every seven days with soap and water. Review of Resident R28's clinical record revealed an admission date of 9/24/25, with diagnoses that included dependence on supplemental oxygen (uses oxygen on routine bases due to breathing), and hypertension (high blood pressure). Review of Resident R28's care plan revealed a care plan for altered respiratory status with an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding care for a foley catheter (a medical device that drains urine from the bladder) for one of two residents reviewed with foley catheters (Resident R111).Findings include: Review of a facility policy entitled Charting and Documentation dated 10/30/25, revealed, All services provided to the resident , progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Treatment or services performed. Resident R111's clinical record revealed an admission date of 5/23/25, with diagnoses that included paraplegia (paralysis affecting the lower half of the body), pain, and muscle wasting and atrophy. Review of Resident R111's physician's orders dated 11/29/25, revealed an order for foley catheter care every shift. Resident R111's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and in accordance with physician's orders for five of 23 residents reviewed (Residents R4, R40, R75, R95 and R205). Findings include: A facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen to breathe) dated 10/28/24, revealed to not run concentrator with a dusty filter. A facility policy entitled, Oxygen Therapy dated 10/28/24, revealed that humidification (process that adds moisture to oxygen therapy to prevent a dry, irritated respiratory tract) for patient comfort may be provided at any flow rate and whenever specifically ordered by the physician. A facility policy entitled, Oxygen Therapy via Nasal Cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) dated 10/28/24, revealed to verify physician's order, attach the humidifying…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, review of facility policy, and staff interview it was determined that the facility failed to maintain a clean, homelike environment for two of 12 residents reviewed (Residents R1 and R2). Findings include: Review of a facility policy entitled Daily Resident Room and Bathroom Cleaning dated 10/10/23, indicated, Check privacy curtains and spot clean as needed. Observations of Resident R1's room on 8/8/24, at approximately 12:50 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. Observations of Resident R2's room on 8/8/24, at approximately 12:55 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. During an interview on 8/8/24, at 1:25 p.m. the Assistant Director of Nursing confirmed that the privacy curtains in Resident R1's and R2's rooms were heavily soiled with a brown colored substance and that the privacy curtains should have been cleaned or replaced. 28 Pa. Code 201.18 5(e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-16 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and facility documents, and staff and resident interviews, it was determined that the facility failed to ensure that the residents were offered snacks at bedtime daily for four of four nursing units. Findings include: Review of facility policy entitled Resident Nourishments, with a policy review date of 10/30/2023, revealed Nourishments will be provided in addition to regular meals in order to promote high levels of nutritional intake. These items are located in the pantries. At any time, residents can request food from the kitchen or direct care staff. When kitchen staff are not available, the direct care staff can access food if it is not in the pantry. Review of meal times revealed that breakfast is delivered to the first hallway at 7:35 a.m. and dinner delivered to the first hallway at 4:35 p.m., which is fifteen hours between meals. The facility must provide meals within 14 hours unless a nourishing snack is served. During a resident council meeting held on 2/14/2024, at 1:00 p.m. there were seven cognitively intact residents that regularly…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-16 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (North medication room) and one of five medication carts (South medication cart). Findings include: Observation on 2/14/2024, at 9:45 a.m. in the North medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded. At the time of the observation, the Registered Nurse Supervisor Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing (DON) confirmed on 2/15/2024, at 9:45 a.m. the PPD vial should have been identified with an open date to indicate after 30 days of use, the vial would be discarded. Observation on 2/14/2024, at 3:10 p.m. of the South medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-06-18 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) User's Manual (provides instructions and guidelines for completing required Minimum Data Set [MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care] assessments), dated October 2024, and clinical records, and staff interview, it was determined that the facility failed to make certain that MDS assessments were completed in the required time frame for four of sixteen residents reviewed (Resident R1, R2, R8, and R13). Findings include: Review of the Long-Term Care Facility RAI User's manual, revealed that for an admission MDS, the MDS completion date, and the Care Area Completion Date is to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days), and the Care Plan Decision Date is to be the Care Area Completion Date plus 7 calendar days. The RAI manual further revealed that for a quarterly MDS, the MDS completion date is the Assessment Reference Date (ARD) plus…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LECOM SENIOR LIVING — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.2-1.2 vs chain
Health inspection 3 of 54.0-1.0 vs chain
Staffing 2 of 53.6-1.6 vs chain
Quality measures 2 of 53.4-1.4 vs chain
The other 4 homes this chain runs (chain average 4.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MILLCREEK HEALTH SYSTEMOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2016
ECKERT, MARYIndividualCORPORATE DIRECTORsince 02/01/2016
FERRETTI, JOHNIndividualCORPORATE DIRECTORsince 02/01/2016
HANSEN, DANIELLEIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2023
INMAN, STEVENIndividualCORPORATE DIRECTORsince 01/01/2021
LIN, JAMESIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/01/2016
MOSCO, MARLENEIndividualCORPORATE DIRECTORsince 02/01/2016
TITZEL, MELANIEIndividualCORPORATE DIRECTORsince 02/01/2016
BABIAK, JAIMEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/21/2022
BEERBOWER, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/03/2023
MOYER, TONYAIndividualADP OF THE SNFsince 06/16/2025

CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.0M
Net patient revenuemost recent cost report
-1.6%
Operating marginrevenue minus expenses
$4
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 3%Other / private 12%

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4 paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$356per resident / day
operating cost
$10,823per month
≈ monthly operating cost
$351per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395404. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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