Millcreek Manor
Erie, Erie County, Pennsylvania · CCN 396072 · Non-profit (Corporation) · part of Lecom Senior Living (5 facilities, chain average 4.2 stars)
CMS rates Millcreek Manor 4 of 5 overall as of August 2026. 144 certified beds, 139 residents a day on average. 29 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $100,240.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 5 / 2 of 5 |
Staffing
| Total nurse staffing | 4.07359 hours per resident per day |
|---|---|
| Registered nurses | 0.92643 hours per resident per day |
| Weekend total | 3.5599 hours per resident per day |
| Nursing staff turnover | 40% (registered nurses 19.4%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-03-29 complaint survey |
Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-16 |
| 2026-03-29 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-16 |
| 2026-01-23 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-16 |
| 2026-01-23 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-16 |
| 2025-11-18 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-05 |
| 2025-07-30 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-25 |
| 2025-07-30 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-08-25 |
| 2025-03-27 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-22 |
| 2025-01-24 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-21 |
| 2025-01-24 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-21 |
| 2025-01-24 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-21 |
| 2024-09-05 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-07 |
| 2024-07-24 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-16 |
| 2024-02-23 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · tag F0637 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-23 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · tag F0835 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2024-02-02 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-04 |
| 2024-02-02 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-04 |
| 2024-02-02 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-04 |
| 2023-10-16 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-17 |
| 2023-10-16 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-17 |
| 2023-10-16 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-17 |
| 2023-10-16 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-17 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-02-02 | Fine | $100,240 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Millcreek Health System Organization | 5% or greater direct ownership interest | 100% | 2003-11-08 |
| Millcreek Health System Organization | adp of the snf | — | 2003-11-08 |
| Beerbower, Joshua Individual | adp of the snf | — | 2023-11-03 |
| Lin, James Individual | adp of the snf | — | 2025-04-28 |
| Inman, Steven Individual | corporate director | — | 2023-09-01 |
| Lin, James Individual | corporate director | — | 2024-07-01 |
| Babiak, Jaime Individual | operational/managerial control | — | 2022-11-21 |
| Beerbower, Joshua Individual | operational/managerial control | — | 2023-11-03 |
| Lin, James Individual | trustee of the snf | — | 2024-07-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Millcreek Manor.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Erie County.