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Millcreek Manor

5535 Peach Street, Erie, PA 16509 · Non profit - Corporation · 144 certified beds · (814) 868-7395 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Jul 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$100,240 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $100,240 in federal fines (most recent 2024-02-02)
  • its payroll-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5637 Peach St · (814) 864-0690 · Call to confirm hours
Pharmacy
Rite Aid0.1 mi
5430 Peach St · (814) 868-4624 · Call to confirm hours
Grocery
2067 Interchange Rd · (814) 866-1089 · Call to confirm hours
Park
Wander Park, 1723 Berry St · Typically dawn to dusk
Place of worship
2402 W Grandview Blvd · (814) 868-8685

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 5 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 2 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.

Overall rating4★
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 increased10.6%16.8%15.4%better
Long-stay residents who lose too much weight11.2%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.7%0.9%better
Long-stay residents with a urinary tract infection2.0%1.5%2.0%typical
Long-stay residents with depressive symptoms3.1%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.6%3.1%3.3%typical
Long-stay residents whose ability to walk worsened6.0%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.1%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine51.1%93.5%95.3%worse
Long-stay residents with pressure ulcers4.4%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control29.5%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.4%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine39.5%68.7%79.4%worse
Short-stay residents rehospitalized after admission27.6%22.5%22.6%worse
Short-stay residents with an outpatient ER visit15.5%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.611.621.67typical
Long-stay outpatient ER visits per 1,000 resident days0.921.181.80better

§ 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.

47.7% 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 155 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.7%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
58.2%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 58.2% 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 79 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.7%CMS range 40.9–54.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.3–12.710.7%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 discharge58.2%56.6%Oct 2024–Sep 2025CMS 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 discharge53.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.6%50.0%Oct 2024–Sep 2025CMS 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 identified94.1%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 setting65.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge90.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened5.9%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 hospitalization6.3%CMS range 3.7–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

0.93
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.16
Aide hours/ resident / day
4.07
Total nurse hours/ resident / day
0.72
RN hoursweekends
40.0%
Total nursing turnover
19.4%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 139.0 residents a day — about 97% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 4.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.56 hrs/resident/day on weekends vs 4.28 on weekdays — 17% thinner on weekends. RN hours go from 1.01 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

2
deficiencies at the latest standard inspection (2026-01-23)
3
at the previous standard inspection (2025-01-24)

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.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · J2024-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical and hospital records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide attempt by overdose, from appropriating a significant number of prescription medications that resulted in an overdose of the prescription medications that were provided during medication administration by the facility for one (Resident R234) of three residents reviewed with a history of suicide attempts, and resulted in an Immediate Jeopardy situation. Findings include: Review of a facility policy entitled Medication Administration dated 10/30/23, indicated that staff will remain at bedside with the resident until all medications are taken. Resident R234's clinical record revealed an admission date of 10/09/23, with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy. Resident R234's clinical record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-29 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and staff and resident interviews, it was determined that the facility failed to ensure resident's privacy rights by opening residents' mail/delivered packages without resident consent for one of one residents reviewed (Resident R1). Findings include: A facility policy entitled Mail/Package Screening revealed that delivered items would be opened by the facility upon written consent from the resident. The policy also made reference to residents' right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the resident, including those delivered through a means other than a postal service. During an interview on March 28, 2026, from approximately 10:00 am through 11:30 a.m. Resident R1 revealed that facility staff, at the direction of a previous administrative staff person, were opening packages delivered to the resident without his/her consent, and that the previous staff person explained that since the packages were not always delivered by the U.S. Postal Service he/she did not have the right to…

    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 · Dcited before2026-03-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 records, resident and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of one residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 5/19/25, with diagnoses that included bladder cancer, diabetes, pain, high blood pressure and muscle wasting. Resident R1's clinical record revealed physician's orders, dated 1/26/26, that the resident was scheduled for a colonoscopy on 3/18/26, and directed that the resident's Aspirin be held for five days prior to the procedure. During an interview on 3/28/26, from approximately 10:00 a.m., through 11:30 a.m. Resident R1 revealed that the colonoscopy procedure scheduled to be done on 3/18/26, had to be canceled because the facility nursing staff failed to hold the daily Aspirin and continued to administer the medication daily up to the day of the scheduled procedure. During interview on 3/28/26, at approximately 12:15 a.m., the Nursing Home Administrator confirmed that the physician's orders were not…

    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 · E2026-01-23 · tag F0628 — pattern
    Provide 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 four of eight residents reviewed for hospitalization (Residents R1, R56, R58, and Closed Record Resident CR149). Findings include: Review of a facility policy entitled Transfer or Discharge, Facility - Initiated, dated January 2026, indicated that should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: basis for the transfer or discharge, contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other information necessary to meet the resident's needs. Resident R1's clinical record revealed an admission date of 2/18/25, with diagnoses that included…

    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 · Dcited before2026-01-23 · 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 and clinical records, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation for one of 28 residents reviewed (Closed Record Resident CR149). Findings include: Review of a facility policy entitled Charting and Documentation dated January 2026 indicated All services provided to the resident, progress toward the care plan goals, or any change sin the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy further sated The following information is to be documented in the resident medical record: Objective observations, Medication administration, Treatment or services performed, Changes in the resident's condition, Events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals or objectives. Resident CR149's clinical record 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 ensure that a resident was free from significant medication errors for one of seven residents reviewed (Resident R1). Findings include: Review of a current facility policy entitled Management of Hypoglycemia revealed that nursing staff must notify the physician if the resident has signs of hypoglycemia [low blood sugar] that are not resolved by following the facility protocol for hypoglycemia management. Resident R1's clinical record revealed an admission date of 12/07/21, with diagnoses that included diabetes (condition of improper blood sugar/insulin levels), pancreatectomy (removal of the pancreas), and Hodgkin's lymphoma (cancer of the immune system). Resident R1's clinical record revealed a physician's order dated 8/22/25, for Lispro (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) three times daily (9:00 a.m. 1:00 p.m. and 6:00 p.m.) for diabetes. Hold if BS (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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 follow physician's orders regarding the administration of insulin for one of five residents reviewed (Resident R1). Findings include: A facility policy entitled Administering Medications dated 11/12/24, indicated that medications are administered in accordance with prescriber orders. Resident R1's clinical record revealed an admission date of 5/19/21, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), Hodgkin lymphoma (cancer of the immune system) and Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R1's clinical record revealed a physician's order dated 3/8/25, for Insulin Lispro (a hormone that works by lowering level of glucose [sugar] in the blood) inject 3 units subcutaneously (sq - between the skin and muscle) after meals. Hold for BG (blood glucose) below 270. Resident R1's June 2025 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 ensure that a resident was free from significant medication errors for one of ten residents reviewed (Resident R1). Findings include: Review of a current facility policy entitled Management of Hypoglycemia revealed that nursing staff must notify the physician if the resident has signs of hypoglycemia [low blood sugar] that are not resolved by following the facility protocol for hypoglycemia management. Resident R1's clinical record revealed an admission date of 12/07/21, with diagnoses that included diabetes (condition of improper blood sugar/insulin levels), pancreatectomy (removal of the pancreas), and Hodgkin's lymphoma (cancer of the immune system). Resident R1's clinical record revealed a physician's order dated 2/27/25, for Lispro (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the morning (9:00 a.m.) for diabetes. Hold if BS (blood sugar) is below 270…

    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 · D2025-01-24 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 26 residents reviewed (Resident R121). Findings include: A facility policy entitled Advance Directives dated [DATE], indicated The Director of Nursing services . of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care. and The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Resident R121's clinical record revealed an admission date of [DATE], with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time),…

    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 · Dcited before2025-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 R58). Findings include: Review of facility policy entitled Antipsychotic Medication Use dated 11/12/24, revealed Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Review of Resident R58's clinical record revealed an admission date of 3/14/24, with diagnoses that included anxiety, major depressive disorder, and cognitive communication deficit. The clinical record revealed that on 8/28/24, Resident R58's physician ordered Hydroxyzine (a medication ordered to treat anxiety) 10 milligrams (mg) every 24 hours PRN for anxiety. Review of Resident R58's December…

    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 · D2025-01-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store schedule II-V medications in a separately locked, permanently affixed compartment in one of four medication rooms reviewed (3 West) and the facility failed to appropriately discard outdated medications for one of four medication rooms reviewed (2 West). Findings include: Review of facility policy entitled Medication Labeling and Storage dated [DATE], indicated Controlled substances . and other drugs subject to abuse are separately locked in permanently affixed compartments . and Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days . Review of manufacturer's guidelines revealed that an open vial of Lispro Insulin (medication to treat diabetes and control blood sugar) must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on [DATE], at 1:15 p.m. of the 3 [NAME] medication room…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-09-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 ensure that it was free from significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of a facility policy entitled Person Centered Medication Administration dated 3/1/24, revealed that nursing staff must comply with person centered medication pass time ranges and Medication Administration Record (MAR) directions. Resident R1's clinical record revealed an admission date of 5/19/21, with diagnoses that included diabetes, pancreatectomy (removal of the pancreas), and Hodgkin lymphoma (cancer of the immune system). Resident R1's clinical record revealed physician's order dated 4/4/24, for Lantus (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the evening (6:00 p.m.) for diabetes. Hold if BS (blood sugar) is below 150 [milligrams/deciliter (mg/dL)]. Resident R1's August 2024 MAR revealed that Resident R1 had a BS of 226 mg/dL on…

    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 · D2024-07-24 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 interviews, it was determined that the facility failed to implement their established procedures for investigation and protection of residents in response to potential abuse for one of two residents reviewed (Resident R1). Findings include: Facility policy, Abuse and Neglect dated 1/10/24, revealed It is the policy to have zero tolerance for incidents of abuse and/or neglect. The purpose of the policy is to show that all allegations of abuse/neglect will be thoroughly investigated and reported to the appropriate County, State and Federal agencies pursuant to Federal regulations to include: screening, training, prevention, identification, investigation, protection, and reporting. Procedure: Identifying/Reporting/Investigating/Protection: Staff witnessing any incident of alleged abuse or neglect of Residents are required to report the incident to the supervisor immediately. The nursing supervisor will have the staff witnessing write a detailed account of the event, then sign and date. The supervisor will notify the…

    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 · E2024-02-23 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 25 residents reviewed (Resident R102). Findings include: Review of facility policy entitled Resident Self-Administration of Medication dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility. Resident R102's clinical record revealed an admission date of 1/19/23, with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression. Observation of medication administration on…

    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 · E2024-02-23 · 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 record review, 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 25 residents reviewed (Residents R10, R79, R124, and R117). Findings include: A facility policy entitled, Care Plans dated 10/30/2023, revealed that A copy of the care plan will be provided to the resident and/or family/responsible party. Resident R10's clinical record revealed an admission date of 9/25/2023, with diagnoses that included hypertension (high blood-pressure), hyperlipidemia (high cholesterol), and a femur fracture. R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative. Resident R79's clinical record revealed an admission date of 1/5/2024, with diagnoses that included hypertension, muscle weakness, and a femur fracture. R79's clinical record lacked evidence that a written summary of the baseline care plan and order…

    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 before2024-02-23 · 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 observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to medication administration for one of 25 residents reviewed (Resident R102). Findings include: Review of facility policy entitled Resident Self-Administration of Medication dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility. Resident R102's clinical record revealed an admission date of 1/19/23, with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression. Observation 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R89). Findings include: Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Resident R89's clinical record revealed an admission date of 9/23/23, with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), muscle wasting, neurogenic bowel (the loss of normal bowel function), and cognitive communication deficit (difficulty with thinking and how someone uses language). The clinical record revealed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 25 residents reviewed (Resident R67). Findings include: Resident R67's admission record revealed an admission date of 1/30/2023, with diagnoses that included dementia, depression, and pain. Resident R67's clinical record revealed that Hospice (end-life services) was ordered on 1/30/2023 and has continued throughout R67's stay at the facility. The Annual MDS dated [DATE], Section O110. Special Treatments, Procedures, and Programs category K1. Hospice was marked No indicating Resident R67 was not receiving Hospice services. During an interview on 2/22/2024, at 12:58 p.m. Licensed Nurse Assessment Coordinator Employee E2 confirmed that Section O110. Special Treatments, Procedures, and Programs category K1. Hospice for the…

    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 · D2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, it was determined that the facility failed to implement a person-centered care plan that included safety precautions for a resident with a history of suicide attempt by overdose, for one of 25 residents reviewed (Resident R234). Findings include: A facility policy entitled, Care Plans (Plans of Service) dated 10/30/23, indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs within 10 days of admission. Resident R234's clinical record revealed an admission date of 10/09/23, with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy. Resident R234's clinical record revealed a care plan related to major depressive disorder which lacked interventions to ensure resident safety related to previous suicide attempts with an overdose. Further review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 interviews, 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 for one of five residents reviewed (Resident R61). Findings include: A facility policy entitled PRN Psychotropic Medication Use, dated 10/30/23, indicated that all PRN non-antipsychotic psychotropic medications will be limited to an initial duration of 14 days or less, and Use may be extended beyond 14 days upon provider . documentation of rationale and expected duration. Review of Resident R61's clinical record revealed an admission date of 4/28/21, with diagnoses that included Generalized Anxiety Disorder (a disorder that causes a person to feel nervous), Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (a disease that causes obstructed airflow from the lungs). Review of Resident R61's medication orders revealed a physician order dated 2/8/24, to administer Vistaril (anti-anxiety medication) 25…

    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 · D2024-02-23 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure adequate resident safety and supervision. Findings include: Review of the job description for the NHA revealed that he/she is responsible for overall facility management, profitability, operations, and direction in all aspects. Accountable for but not limited to, census development, management of accounts receivable and collections, maximization of Net Operating Income, resident/patient care, state and federal survey compliance, positive employee relations, a positive return on investment, an effective business plan and implementation of core programs. Designated the representative in the facility and community. Follows all policies and procedures. Completes rounds of entire facility premises at least daily to ensure compliance with all policies, procedures, and regulations. Review of the job description for the DON revealed that he/she is responsible for maintaining a high standard…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to follow physician's orders for two of three residents reviewed (Residents R4 and R7). Findings include: Review of a facility policy entitled Person Centered Medication Administration dated 1/10/24, revealed that all nurses are to follow physician orders as written. Review of the facility hypoglycemic (low blood sugar) protocol entitled Standing Diabetic Orders dated 11/15/23, revealed that if blood sugar (BS) is less than 70 [milligrams/deciliter (mg/dL)] and resident is symptomatic and able to swallow, squeeze one entire tube [of oral glucose (form of sugar)] into mouth. Review of Resident R4's clinical record revealed an admission date of 6/29/22, with diagnoses that included diabetes, high blood pressure, and depression. Resident R4's clinical record revealed a physician's order dated 7/18/23, for Insulin Lispro sliding scale before meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m…

    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 before2024-02-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of three residents reviewed (Resident R7). Findings include: Review of a facility policy entitled Person Centered Medication Administration dated 1/10/24, revealed that all nurses are to follow physician orders as written. Resident R7's clinical record revealed an admission date of 5/19/21, with diagnoses that included diabetes, pancreatectomy (removal of the pancreas), and Hodgkin lymphoma (cancer of the immune system). Resident R7's clinical record revealed physician's order dated 12/28/23, for Novolog (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the morning (8:00 a.m.) for diabetes. Hold if BS (blood sugar) is below 270 [milligrams/deciliter (mg/dL)]. Resident R7's January 2024 Medication Administration Record (MAR) revealed that Resident R7 had a BS of 181 mg/dL on 1/5/24, 223 mg/dL on 1/6/24, and 144…

    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 · Dcited before2024-02-02 · 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 and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to refusal of medications for one of three residents reviewed (Resident R4). Findings include: Review of facility policy entitled Charting and Documentation dated 1/10/24, revealed that the residents medical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of resident's condition and it is a written support of care and services provided and serves as communication among caregivers who are providing services. Resident R4's clinical record revealed an admission date of 6/29/22, with diagnoses that included diabetes, high blood pressure, and depression. Resident R4's clinical record revealed a physician's order dated 12/7/23, for Insulin Lispro 10 units subcutaneous (sq - injected into the tissue between the skin and muscle) daily at 11:30 a.m. Resident R4's Medication Administration Record (MAR) revealed Resident R4's 11:30 a.m. insulin was held on 1/1/24, 1/6/24,…

    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 · E2023-10-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe homelike environment for three of seven residents (Residents R1, R5, and R6). Findings include: Observations on 10/11/23, at 11:43 a.m. revealed Resident R6's bed controller (a device attached to the bed that moves the position of the bed) had the outer rubber layer of the controller cord pulled away from the coated smaller wires that are contained inside the outer rubber layer, leaving the coated wires inside of the rubber outer layer exposed. Observations on 10/11/23, at 11:52 a.m. revealed Resident R5's bed controller had the outer rubber layer of the controller cord pulled away from the coated smaller wires that are contained inside the outer rubber layer, leaving the coated wires inside of the rubber outer layer exposed. Observations on 10/11/23, at 12:01 p.m. revealed Resident R1's bed controller had the outer rubber layer of the controller cord pulled away from the coated smaller wires that are contained inside the outer rubber layer, leaving the coated…

    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 · Ecited before2023-10-16 · 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 clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation in the treatment records regarding wound dressing changes for three of four residents reviewed with wounds (Residents R2, R3, and R4) Findings include: Review of Resident R2's clinical record revealed an admission date of 8/24/23, with diagnoses that included Stage Three (full thickness loss of skin) pressure ulcer, diabetes (condition of improper blood sugar control), hypotension (a condition where your blood pressure is too low), hyperlipidemia (high cholesterol), and sleep apnea (a condition where you stop breathing while you are sleeping). Review of Resident R2's August 2023 Treatment Administration Record (TAR) revealed 11 different wound dressings that lacked documentation indicating the treatment was completed per physician orders on 12 different occasions. Resident R2's September 2023 TAR revealed six different wound dressings that lacked documentation indicating the treatment was completed per physician orders on six different…

    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 · D2023-10-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to notify the resident's physician and emergency contact regarding a change in condition for one of ten residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Hypoglycemia & Hyperglycemia Protocol, dated 8/2023, indicated that after immediate action for a hypoglycemic episode (blood sugar less than 70 milligrams [mg] per decilliter [dL]) the physician should be notified and upon resolution of a hypoglycemic episode it should be documented that the medical team or house officer and family were notified. Review of Resident R1's clinical record revealed an admission date of 5/19/2021, with diagnoses that included Type 1 Diabetes (condition of improper blood sugar control) with hyperglycemia (high blood sugar), liver transplant, and anxiety disorder. Review of the clinical record revealed that on 10/01/2023, at 1:26 a.m. Resident R1 had a blood sugar reading of 58 mg/dL. The clinical record lacked evidence that the physician 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to obtain physician's orders and failed to implement interventions related to a hypoglycemic (low blood sugar) episode for one of ten residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Hypoglycemia & Hyperglycemia Protocol, dated 8/2023, indicated that in a suspected hypoglycemia situation obtain a STAT [immediate] finger stick: if blood glucose is less than 70 [milligrams (mg) per deciliter (dL)] and patient is unconscious or uncooperative or NPO (nothing by mouth) proceed to Appendix A: if blood glucose is less than 70 [mg/dL] and patient is symptomatic, conscious, cooperative, and able to swallow, proceed to Appendix B. Appendix A indicated for staff to remain with resident, administer glucagon [substance used to quickly increase blood sugar levels], and notify physician. Appendix B indicated to provide 15 grams of carbohydrates and notify physician.…

    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
  • No harm found · Bcited before2025-07-30 · 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 and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to physician notification for one of five residents reviewed (Resident R17).Findings include: Review of facility policy entitled Charting and Documentation dated 11/12/24, indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's conditions and response to care. The policy further stated that documentation of procedures and treatments will include care-specific details, including notification of family, physician, or other staff, if indicated. Resident R17's clinical record revealed an admission date of 10/9/24 with diagnoses that included Alzheimer's disease (a brain disorder that destroys memory and thinking skills), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R17's clinical record revealed a physician's order dated 11/20/24, for Insulin Lispro sliding scale before…

    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

“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

$100,240 in federal fines across 1 penalty.

  • $100,240 — penalty dated 2024-02-02

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 →

RatingThis homeChain avg
Overall 4 of 54.2-0.2 vs chain
Health inspection 3 of 54.0-1.0 vs chain
Staffing 5 of 53.6+1.4 vs chain
Quality measures 3 of 53.4-0.4 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 / managerTypeRoleShareSince
MILLCREEK HEALTH SYSTEMOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 11/08/2003
INMAN, STEVENIndividualCORPORATE DIRECTORsince 09/01/2023
LIN, JAMESIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNFsince 04/28/2025
BABIAK, JAIMEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/21/2022
BEERBOWER, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/03/2023

CMS files one row per role, so the 9 rows in the source record cover these 5 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.

$16.7M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$4
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 39%Medicare 6%Other / private 55%

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

$883per resident / day
operating cost
$26,842per month
≈ monthly operating cost
$336per 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 396072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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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