01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-23 | 5 | 2026-01-23 | 0 |
| Cycle 2 | 2025-01-24 | 7 | 2025-01-24 | 3 |
| Cycle 3 | 2024-02-23 | 17 | 2024-02-23 | 5 |
CMS CCN 3960722026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Millcreek Manor
5535 Peach Street · Erie, PA 16509 · Erie County
Certified beds144CMS provider file
Recent citation rows37current 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
37 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-29 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-05-16 · complaint2026-03-29 · 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 · 2026-05-16 · complaint2026-01-23 · 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 · 2026-03-162026-01-23 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2026-03-162025-11-18 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2026-01-05 · complaint2025-07-30 · 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 · 2025-08-25 · complaint2025-07-30 · HEALTHF0842Severity B · pattern; potential for minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-25 · complaint2025-03-27 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2025-01-24 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2025-02-212025-01-24 · 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 · 2025-02-212025-01-24 · 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 · 2025-02-212025-01-24 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-03-062025-01-24 · FIREK0912Severity B · pattern; potential for minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Correction field: Deficient, Provider has date of correction · 2025-03-062025-01-24 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-03-062024-09-05 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-10-07 · complaint2024-07-24 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-08-16 · complaint2024-02-23 · FIREE0004Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2024-03-082024-02-23 · FIREE0036Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2024-03-082024-02-23 · HEALTHF0554Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-02-23 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2024-04-012024-02-23 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-02-23 · 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 · 2024-04-012024-02-23 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-02-23 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-04-0103 / 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 |
|---|---|---|---|
| 2024-02-02 | Fine | $100,240 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MILLCREEK HEALTH SYSTEMOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/08/2003
- INMAN, STEVENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2023
- LIN, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- BABIAK, JAIMEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/21/2022
- BEERBOWER, JOSHUAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/03/2023
- LIN, JAMESIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2024
- MILLCREEK HEALTH SYSTEMOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/08/2003
- BEERBOWER, JOSHUAIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- LIN, JAMESIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/28/2025
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 hours4.07per resident day
RN hours0.93per resident day
Weekend nurse hours3.56per resident day
Staff turnover40.0%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 Village Square, Llc110 beds · CMS overall 4/524 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 rows