Millcreek Manor
Millcreek Manor in ERIE, PA — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a resident was free from significant medication errors for one of seven residents reviewed (Resident R1).
Findings include: Review of a current facility policy entitled Management of Hypoglycemia revealed that nursing staff must notify the physician if the resident has signs of hypoglycemia [low blood sugar] that are not resolved by following the facility protocol for hypoglycemia management.
Resident R1's clinical record revealed an admission date of 12/07/21, with diagnoses that included diabetes (condition of improper blood sugar/insulin levels), pancreatectomy (removal of the pancreas), and Hodgkin's lymphoma (cancer of the immune system).
Resident R1's clinical record revealed a physician's order dated 8/22/25, for Lispro (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq injected into the tissue between the skin and muscle) three times daily (9:00 a.m. 1:00 p.m. and 6:00 p.m.) for diabetes.
Hold if BS (blood sugar) is below 270 [milligrams/deciliter (mg/dL)].
Resident R1's October 2025, Medication Administration Record (MAR) revealed that Resident R1 had a BS of 257 mg/dL on 10/6/25 at 1:00 p.m. and BS of 157 mg/dl on 10/6/25 at 6:00 p.m. and staff administered the Lispro 3 units, which should have been held according to physician's orders.
Lispro insulin was administered and not in accordance with physician's orders when Resident R1 was administered 3 units of Lispro when his/her BS was below 270 mg/dL on the above date and times and should have been held.
During an interview on 10/13/25, at approximately 11:55 a.m. the Director of Nursing confirmed that Resident R1's Lispro insulin was administered on 10/6/25 at 1:00 p.m. and on 10/6/25 at 6:00 p.m. when it was ordered to be held. 28 Pa.
Code 211.12(d)(1)(5) Nursing services 28 Pa.
Code 211.10(c) Resident care policies
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.