Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A-
Grade
62
Score
CMS Ratings
16.7/22
Staffing Quality
13.7/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
2.0/10

Current Availability Estimate

Occupancy Rate96.5%
144
Total Beds
139
Occupied
5
Available

Basic Information

Address:

5535 PEACH STREET

ERIE, PA 16509

Number of Beds:

144

Estimated Occupancy:

97% (~5 available)

Chain:

LECOM SENIOR LIVING

Quality Ratings

Overall Rating:4/5 Stars
Health Inspection:3/5 Stars
Staffing Rating:5/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

396072

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

0.93

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

4.07

hours

National Avg

3.89

hours

Breakdown:

RN: 0.93hLPN: 0.99hAide: 2.16h

Staff Turnover Rate

Annual nursing staff turnover

Below Average

This Facility

40.0%

National Avg

46.6%

RN Turnover: 19.4%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 2 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

58

Inspections

9

Critical

2

Mar 27, 2025 - Health Survey

2 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Apr 22, 2025From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Apr 22, 2025From Complaint

Jan 24, 2025 - Health Survey

6 deficiencies cited

Medium - PatternTag F0758

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.

Corrected: Feb 21, 2025
Medium - PatternTag F0761

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.

Corrected: Feb 21, 2025
Medium - PatternTag F0578

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.

Corrected: Feb 21, 2025
Medium - PatternTag F0758

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.

Corrected: Feb 21, 2025
Medium - PatternTag F0761

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.

Corrected: Feb 21, 2025
Medium - PatternTag F0578

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.

Corrected: Feb 21, 2025

Sep 5, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Oct 7, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Oct 7, 2024From Complaint

Jul 24, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Aug 16, 2024From Complaint
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Aug 16, 2024From Complaint

Feb 23, 2024 - Health Survey

18 deficiencies cited

Medium - PatternTag F0637

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Corrected: Apr 1, 2024
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Apr 1, 2024
Medium - PatternTag F0637

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Corrected: Apr 1, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Apr 1, 2024
Medium - PatternTag F0655

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

Corrected: Apr 1, 2024
Medium - PatternTag F0656

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.

Corrected: Apr 1, 2024
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 1, 2024
Medium - PatternTag F0758

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.

Corrected: Apr 1, 2024
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 1, 2024
Medium - PatternTag F0842

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.

Corrected: Apr 1, 2024
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Apr 1, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Apr 1, 2024
Medium - PatternTag F0655

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

Corrected: Apr 1, 2024
Medium - PatternTag F0656

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.

Corrected: Apr 1, 2024
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 1, 2024
Medium - PatternTag F0758

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.

Corrected: Apr 1, 2024
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 1, 2024
Medium - PatternTag F0842

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.

Corrected: Apr 1, 2024

Feb 2, 2024 - Health Survey

6 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

From Complaint
Medium - PatternTag F0842

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.

From Complaint
Medium - PatternTag F0842

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.

From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

From Complaint

Oct 16, 2023 - Health Survey

8 deficiencies cited

Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

From Complaint
Medium - PatternTag F0842

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.

From Complaint
Medium - PatternTag F0842

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.

From Complaint

Mar 24, 2023 - Health Survey

12 deficiencies cited

Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: May 14, 2023
Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: May 14, 2023
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 14, 2023
Medium - PatternTag F0758

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.

Corrected: May 14, 2023
Medium - PatternTag F0656

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.

Corrected: May 14, 2023
Low - IsolatedTag F0625

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.

Corrected: May 14, 2023
Medium - PatternTag F0656

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.

Corrected: May 14, 2023
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 14, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: May 14, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: May 14, 2023
Medium - PatternTag F0758

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.

Corrected: May 14, 2023
Low - IsolatedTag F0625

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.

Corrected: May 14, 2023

Feb 6, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Mar 18, 2023From Complaint
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Mar 18, 2023From Complaint

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Total fines: $100,240

FineFebruary 2, 2024

$100,240

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

High CMS Rating
4 out of 5 stars from Medicare
👨‍⚕
Above Average RN Staffing
0.93 RN hours per resident/day (national avg: 0.64)
Low Staff Turnover
40.0% (national avg: 46.6%)
🏢
Part of Healthcare Chain
LECOM SENIOR LIVING

Frequently Asked Questions

What is the quality rating for Millcreek Manor?

Millcreek Manor has an overall CMS rating of 4 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

Millcreek Manor has 144 certified beds. The facility averages 139 residents per day, with an occupancy rate of approximately 97%.

What type of ownership does this facility have?

This facility is non profit - corporation owned. It is part of the LECOM SENIOR LIVING network.

How can I contact Millcreek Manor?

You can call Millcreek Manor at (814)868-7395. The facility is located at 5535 PEACH STREET, ERIE, PA 16509.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

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