LECOM At Village Square, Llc
149 West 22nd Street, Erie, PA 16502 · Non profit - Corporation · 110 certified beds · (814) 452-3271 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $10,033 in federal fines (most recent 2024-11-19)
- nursing-staff turnover (59%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 improved from 3 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.9% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.3% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.7% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.0% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 79.3% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.1% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 25.6% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.6% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.6% | 9.5% | 12.0% | worse |
§ 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.
46.7% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 82.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.7%CMS range 31.5–59.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 7.6–16.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 82.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 78.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 74.4% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 2.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 110 beds and averages 97.3 residents a day — about 88% occupied, or roughly 13 beds typically open. It runs fairly full. 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.33 hrs/resident/day on weekends vs 3.87 on weekdays — 14% thinner on weekends. RN hours go from 0.73 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above 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
Deficiencies are fewer than at the previous inspection — improving. 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.
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 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2024-11-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 facility policies and documentation and clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed regarding transfers (Resident R72) was free of neglect during care which resulted in actual harm of an anterior dislocation of left shoulder (when the shoulder slides forward out of the socket). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Abuse and Neglect Definitions dated 10/14/24, indicated Neglect: The failure to provide the goods and services necessary to avoid physical harm . Review of facility policy entitled Abuse and Neglect dated 10/14/24, indicated It is the policy .to have zero tolerance for incidents of abuse and/or neglect. Review of facility policy entitled Safe Lifting and Movement of Residents dated 10/14/24, revealed that Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding…
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.
- Potential for harm · E2025-12-18 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for five of 20 residents reviewed (Residents R1, R4, R14, R43 and R100).Findings include: Review of facility policy entitled Transfer or Discharge, Facility-Initiated dated 10/1/25, indicated Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The basis for the transfer., Contact information., Resident representative information., Advance directive information., All special instructions or precautions., Comprehensive care plan goals., All other information necessary to meet the residents' needs. Resident R1's clinical record revealed an admission date of 9/18/25, with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in…
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.
- Potential for harm · D2025-12-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise comprehensive care plans to reflect the current care and services for one of 20 residents reviewed (Resident R11).Findings include: Review of facility policy entitled Care Plans, Comprehensive Person Centered dated 10/1/25, indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R11's clinical record revealed an admission date of 9/19/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R11's progress notes revealed a note dated 11/21/25, at 6:56 p.m. indicating that his/her urinary catheter was removed. Review of Resident R11's Care Plan for altered genitourinary status dated 9/19/25, revealed…
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.
- Potential for harm · Dcited before2025-12-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, manufacturer's guidelines, observations, and staff interview, it was determined that the facility failed to ensure an expired medication was discarded in a timely manner in one of two medication carts reviewed (East Wing Cart). Findings include: Review of a facility policy entitled Medication Labeling and Storage dated [DATE], revealed that, 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 guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observation on [DATE], at 3:22 p.m. of the East Wing medication cart revealed an open injector pen of Humalog insulin with an open date of [DATE], therefore the medication was expired. During an interview at that time Licensed Practical Nurse Employee E1…
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.
- Potential for harm · E2025-03-30 · tag F0675 — failed to support quality of life — patternHonor each resident's preferences, choices, values and beliefs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documents and resident and staff interviews, it was determined that the facility failed to meet the needs of residents in a timely manner for nine of 11 residents interviewed (Residents R1, R4 through R9, R11 and R12). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m. during random resident interviews, the following residents complained of poor call bell response time: Resident R1 expressed frustration related to that often after activating the call bell for assistance, the staff would not respond for an hour or longer. Resident R4 indicated that they were worried that in the event of an emergency staff would not respond and often wait for response to their call light for over an hour. Resident R5 stated that staff would not respond to call bells, and were frequently observed ignoring the call lights while looking at their cell phones. Residents R6 and R7 also complained that call bell response was extremely slow and they often had to up to an hour or longer for assistance. Resident R9 indicated that he/she…
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.
- Potential for harm · E2025-03-30 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 documents and resident and staff interviews, it was determined that the facility failed to serve food that was at a palatable temperature for nine of 11 residents interviewed (Residents R1, R4 through R9, and R11). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m., during random resident interviews, the following alert and oriented residents complained of consistently of receiving cold food. Residents R1, R4 through R9, and R11 all expressed frustration that their meals were not palatable because the food was usually cold when delivered by staff, partly due to the trays sitting in the hall for long periods of time until they are delivered. A review of Resident Council meeting concerns for January 2025, February 2025, and March 2025, documented multiple resident complaints of being served cold food. During an interview on 3/29/25, at approximately 11:00 a.m. the Nursing Home Administrator confirmed awareness of the issue of facility food being served cold to the residents. 28 Pa. Code 201.14(a) Responsibility of…
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.
- Potential for harm · Ecited before2024-11-19 · tag F0655 — patternCreate 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 and 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 four of 19 residents reviewed (Residents R71, R49, R28, and R7) and failed to ensure that a baseline care plan for an indwelling foley catheter (a medical device that helps drain urine from the bladder) was developed and implemented for one of 19 residents reviewed (Resident R178 ). Findings include: A facility policy entitled, Care Plans - Baseline dated 10/14/24, revealed The baseline care plan included instructions needed to provide effective, person-centered care of the resident to meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident .The resident and/or representative are provided a written summary of the baseline care plan in a language that the resident/representative can understand that includes, but is not limited to the following: a. The stated goals and…
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.
- Potential for harm · D2024-11-19 · tag F0625 — isolatedNotify 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within 24 hours of transfer for two of 19 residents reviewed (Residents R41 and R7). Findings include: Review of facility policy entitled, Admission, Transfer, and Discharge Rights dated 10/14/24, revealed, In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with a written notification within 24 hours of the transfer. Review of Resident R41's clinical record revealed an initial admission date of 9/8/23, with diagnoses that included intellectual disabilities (certain limitations in cognitive functioning), dysphagia (difficulty swallowing), and hypertension (high blood pressure). A progress note dated 6/27/24, revealed that Resident R41 was transferred to the hospital. The clinical record…
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.
- Potential for harm · Dcited before2024-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to transcribe a physician's order for an anxiety medication for one of 19 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication and Treatment Orders dated 10/14/24, indicated Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Review of Resident R1's clinical record revealed an admission date of 10/31/24, with diagnosis that include Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), Diabetes (a health condition that caused by the body's inability to produce enough insulin), and Hypertension (high blood pressure). Review of Resident R1's clinical record revealed a physician's progress note dated 11/12/24, that indicated to add Hydroxyzine (an antianxiety medication) 25 milligrams (mg) every six hours as needed for anxiety. Further review of Resident R1's clinical record revealed his/her physician's orders lacked evidence…
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.
- Potential for harm · D2024-11-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 clinical records and staff interview, it was determined that the facility failed to ensure adequate physician orders were in place for an indwelling urinary catheter (a medical device that helps drain urine from the bladder) for one resident reviewed for catheters (R178). Findings include: Resident R178's clinical record revealed an admission date of 11/6/24, with diagnoses that included benign prostatic hyperplasia (enlarged prostate gland), heart failure, and dysphagia (difficulty swallowing). Resident R178's admission documentation revealed an indwelling foley catheter was present upon his/her entry into the facility. Review of R178's order summary lacked evidence of that physician orders were in place for a urinary catheter, which would include but not limited to foley catheter and balloon size, foley catheter scheduled changes, foley catheter as needed changes due to soiling or dislodgement, draining the foley catheter collection bag, foley catheter collection bag changes, and foley catheter hygiene care. During an interview on 11/18/24, at 12:15 p.m. Charge…
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.
- Potential for harm · D2024-11-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and 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 two of six residents reviewed regarding psychotropic medications (Residents R12 and R67). Findings include: A facility policy entitled Antipsychotic Medication Use dated 10/14/24, revealed The need to continue PRN orders of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Resident R12's clinical record…
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.
Show the remaining 6 citations
- Potential for harm · Dcited before2024-11-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (two east medication cart) and one of two medication rooms reviewed (first floor medication room). Findings include: Review of a facility policy entitled Expiration and Disposal of Medication dated [DATE], revealed Refrigerated items will be received from pharmacy with date opened sticker, nursing to write appropriate date once item is opened and/or removed from fridge. Nursing staff will inventory medications to assure medications are discarded when expired. And Guidelines: Medication Insulin Expiration after opening 28 days Medication PPD/TB [solution to test for tuberculosis] Expiration after opening 30 days. Review of manufacturer's guidelines revealed that an open pen of Aspart Insulin (medication to treat diabetes) must be used within 28 days after opening or be discarded.…
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.
- Potential for harm · E2023-12-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the manufacturer guidelines for the Modular Crescent Cuber (ice machine), dated 10/10/17, stated Be sure there is sufficient extra water supply line and drain line for the appliance to be pulled out for service. Separate piping to approved drain. Leave a 2-inch (5 cm) vertical air gap between the end of each pipe and the drain. Observations in the kitchen on 12/04/23, at approximately 11:15 a.m. revealed the ice machine drainage pipe resting on the floor drain and lacked a two-inch vertical air gap between the end of the pipe and drain. The drain and surrounding floor were observed unclean and black in color. Interview with the Dietary Manager on 12/04/23, at approximately 11:15 a.m. confirmed the ice machine's drainage pipe and floor drain lacked a two-inch air gap allowing the pipe to rest on the unclean drain creating unsafe storage for ice. 28…
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.
- Potential for harm · D2023-12-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain resident dignity during medication administration for one of 18 residents reviewed (Resident R49). Findings include: Review of facility policy entitled Resident Rights with a policy review date of 11/7/2023, revealed, the resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care for the necessary personal and social needs. Review of Resident R49's clinical record revealed an admission date of 10/18/2023, with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness), depression, and anxiety. Observation of Resident R49 on 12/5/23, at 9:20 a.m. during medication administration revealed that he/she was administered insulin subcutaneously (SQ-Injection between…
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.
- Potential for harm · Dcited before2023-12-07 · tag F0655 — isolatedCreate 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 clinical record review and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of 18 residents reviewed (Residents R172 and R173). Findings include: Review of a facility policy entitled, 24/48 Hour Care Conference dated 11/07/23, indicated that a care conference was to be completed within 24-48 business hours to discuss short- and long-term goals, dietary concerns, physical limitations, interests and hobbies, medical diagnoses, physical therapy goals/concerns, billing, and care plan preferences. Review of Resident R172's clinical record revealed an admission date of 11/28/23, with diagnoses that included Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), osteomyelitis (infection of the bone), amputation of right toes, inflammatory spondylopathy of the neck (inflammatory arthritis affecting the spine), and unstable angina (chest discomfort or pain caused by an insufficient flow of blood and oxygen to the heart). Review of Resident R172's clinical record revealed two…
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.
- Potential for harm · Dcited before2023-12-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical record and facility policy, observation, and staff interview, it was determined that the facility failed to follow a physician's order for the administration of insulin for one of 18 residents reviewed (Resident R49). Findings include: Review of a facility policy entitled Medication Dispensed According to Prescribers Orders with a policy review date of 11/7/2023, revealed Verbal, written, and/or electronic orders are dispensed according to the prescriber's orders and are tailored to the resident's needs. Review of Resident R49's clinical record revealed an admission date of 10/18/2023, with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness),depression, and anxiety. Review of Resident R49's physician's orders revealed that there was an order for NovoLog (type of insulin) injection solution to inject subcutaneously (between the skin and…
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.
- Potential for harm · D2023-12-07 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined the facility failed to implement part or all of the Antibiotic Stewardship Program for one of 18 residents reviewed (Resident R39). Findings include: Review of facility policy entitled Antibiotic Stewardship dated 11/07/23, revealed Antimicrobial prescribing protocols: assessment tools and management algorithms derived for and evidenced based clinical guidelines that are intended to be used as a resource for diagnosis and treatment of infections. Antimicrobial stewardship interventions and efforts to improve antimicrobial use will be regularly and will be implemented by a clinical leader. Review of Resident R39's clinical record revealed an admission date of 9/19/23, with diagnoses that included malignant neoplasm of prostate (a disease in which cancer cells form in the tissue of the prostate), secondary…
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.
“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.
- 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.
Fines & penalties
$10,033 in federal fines across 1 penalty.
- $10,033 — penalty dated 2024-11-19
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.2 | -0.2 vs chain |
| Health inspection | 4 of 5 | 4.0 | ≈ chain avg |
| Staffing | 3 of 5 | 3.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 3.4 | -0.4 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MILLCREEK MANOR | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/03/2019 |
| MILLCREEK HEALTH SYSTEM | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 05/03/2019 |
| DIIANNI, LUIGI | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 03/18/2025 |
| ECKERT, MARY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/03/2019 |
| FERRETTI, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/03/2019 |
| FERRETTI, SILVIA | Individual | CORPORATE DIRECTOR | — | since 05/03/2019 |
| FIERRO, VINCENT | Individual | CORPORATE DIRECTOR | — | since 05/03/2019 |
| FUCCI, ESTHER | Individual | CORPORATE DIRECTOR | — | since 05/03/2019 |
| KELLY, JOSEPH | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| LIN, JAMES | Individual | CORPORATE DIRECTOR | — | since 02/01/2016 |
| SAVOCCHIO, JOYCE | Individual | CORPORATE DIRECTOR | — | since 05/03/2019 |
| INMAN, STEVEN | Individual | CORPORATE OFFICER | — | since 05/03/2019 |
| BABIAK, JAIME | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/21/2022 |
| BEERBOWER, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/03/2023 |
CMS files one row per role, so the 20 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners 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.
About 86% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 395672. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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.