01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-18 | 3 | 2025-12-18 | 0 |
| Cycle 2 | 2024-11-19 | 9 | 2024-11-19 | 1 |
| Cycle 3 | 2023-12-07 | 5 | 2023-12-07 | 6 |
CMS CCN 3956722026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lecom At Village Square, Llc
149 West 22Nd Street · Erie, PA 16502 · Erie County
Certified beds110CMS provider file
Recent citation rows24current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
24 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-18 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-01-232025-12-18 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-01-232025-12-18 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2026-01-232025-03-30 · HEALTHF0675Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Honor each resident's preferences, choices, values and beliefs.
Correction field: Deficient, Provider has date of correction · 2025-05-09 · complaint2025-03-30 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-05-09 · complaint2024-11-19 · FIREE0039Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-01-152024-11-19 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2024-11-14 · complaint2024-11-19 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Notify 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.
Correction field: Deficient, Provider has date of correction · 2025-01-032024-11-19 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-01-032024-11-19 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-01-032024-11-19 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-01-032024-11-19 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2025-01-032024-11-19 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-01-032023-12-07 · FIREE0006Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · FIREE0007Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Address patient/client population and determine types of services needed.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · FIREE0022Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for sheltering.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · FIREE0023Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for medical documentation.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · FIREE0036Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · FIREE0041Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-01-312023-12-07 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-02-022023-12-07 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-02-022023-12-07 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-02-022023-12-07 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-02-022023-12-07 · HEALTHF0881Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2024-02-0203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-11-19 | Fine | $10,033 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MILLCREEK MANOROrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 05/03/2019
- MILLCREEK HEALTH SYSTEMOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 05/03/2019
- DIIANNI, LUIGIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/18/2025
- ECKERT, MARYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- FERRETTI, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- FERRETTI, SILVIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- FIERRO, VINCENTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- FUCCI, ESTHERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- KELLY, JOSEPHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- LIN, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2016
- SAVOCCHIO, JOYCEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2019
- ECKERT, MARYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/03/2019
- FERRETTI, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/03/2019
- INMAN, STEVENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/03/2019
- BABIAK, JAIMEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/21/2022
- BEERBOWER, JOSHUAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/03/2023
- DIIANNI, LUIGIIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 03/18/2025
- KELLY, JOSEPHIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.72per resident day
RN hours0.64per resident day
Weekend nurse hours3.33per resident day
Staff turnover58.7%CMS reported field
06 / LOCAL RECORDS
Open the Erie ledger →Other published facilities nearby
Ball Pavilion, The85 beds · CMS overall 5/522 citation rowsForestview80 beds · CMS overall 5/514 citation rowsGreenfield Healthcare And Rehabilitation Center133 beds · CMS overall 1/559 citation rowsLecom At Elmwood Gardens, Llc51 beds · CMS overall 5/57 citation rowsLecom At Presque Isle, Inc135 beds · CMS overall 3/539 citation rowsLecom At Asbury Ridge Dba Saint Mary'S Asbury Ridg80 beds · CMS overall 5/59 citation rowsManchester Commons Of Presbyterian Seniorcare78 beds · CMS overall 5/521 citation rowsMillcreek Manor144 beds · CMS overall 4/537 citation rows