C+
65/100Millcreek Manor Inspection Report, Violations & Safety Grade (ERIE, Pennsylvania)
5535 PEACH STREET, ERIE, Pennsylvania 16509
Phone: 8148687395
CMS Overall:3/5
Overview & Bed Count
Certified Beds
144
Avg Residents/Day
136.5
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Erie
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health3/5
Staffing4/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Pennsylvania Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.84 | 0.78 | +0.06 |
| Total Nurse Hours per Resident per Day | 4.22 | 3.90 | +0.33 |
| CMS Staffing Rating | 4/5 | 3.1/5 | - |
| Nursing Staff Turnover | 42.9% | 44.6% | - |
Health Citation History
29 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-29 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2026-03-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-01-23 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E – Moderate Harm Potential |
| 2026-01-23 | 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. | D – Moderate Harm Potential |
| 2025-11-18 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2025-07-30 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-07-30 | 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. | B – Minimal Harm Potential |
| 2025-03-27 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2024-09-05 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-07-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2024-02-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-02-23 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | E – Moderate Harm Potential |
| 2024-02-23 | 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 | E – Moderate Harm Potential |
| 2024-02-23 | 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. | E – Moderate Harm Potential |
| 2024-02-23 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2024-02-23 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-02-23 | 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. | D – Moderate Harm Potential |
| 2024-02-23 | 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. | D – Moderate Harm Potential |
| 2024-02-23 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D – Moderate Harm Potential |
| 2024-02-02 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-02-02 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-02-02 | 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. | D – Moderate Harm Potential |
| 2023-10-16 | 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. | E – Moderate Harm Potential |
| 2023-10-16 | 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. | E – Moderate Harm Potential |
| 2023-10-16 | 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. | D – Moderate Harm Potential |
| 2023-10-16 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | B – Minimal Harm Potential |
| 2024-02-23 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-02-23 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | C – Minimal Harm Potential |
| 2024-02-23 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | C – Minimal Harm Potential |
| 2024-02-23 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | C – Minimal Harm Potential |
| 2024-02-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | C – Minimal Harm Potential |
Total Penalties & Fines
$100,240
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-02-02 | Fine | $100,240 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the ERIE area at no cost.
Find Safe, Vetted Facilities Near ERIE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.