Pine Creek Manor Skilled Nursing & Rehab Center

34330 Van Born Rd, Wayne, MI 48184 (734) 721-0740
For profit - Limited Liability company 49 Beds PIONEER HEALTHCARE MANAGEMENT Data: November 2025
Trust Grade
75/100
#164 of 422 in MI
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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Pine Creek Manor Skilled Nursing & Rehab Center has received a Trust Grade of B, indicating it is a good choice for families looking for care, though it's not the top option available. It ranks #164 out of 422 facilities in Michigan, placing it in the top half, and #19 out of 63 in Wayne County, meaning there are only 18 local facilities that perform better. The facility is trending positively, having reduced its issues from 7 in 2024 to 5 in 2025. Staffing is a weakness, with a low rating of 2 out of 5 stars and a turnover rate of 53%, which is higher than the state average. However, the center has not incurred any fines, suggesting compliance with regulations. There have been some concerning incidents noted during inspections, such as dirty pans being stored with clean ones, improper food storage practices that could lead to foodborne illness, and maintenance issues like cracked ice machine doors and broken exhaust fans in the shower rooms. While these findings highlight areas for improvement, the absence of critical or serious violations is a positive sign. Overall, families should weigh both the strengths and weaknesses when considering this facility for their loved ones.

Trust Score
B
75/100
In Michigan
#164/422
Top 38%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
7 → 5 violations
Staff Stability
⚠ Watch
53% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Michigan facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
19 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 5 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

Staff Turnover: 53%

Near Michigan avg (46%)

Higher turnover may affect care consistency

Chain: PIONEER HEALTHCARE MANAGEMENT

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 19 deficiencies on record

Mar 2025 5 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a urinary catheter drainage bag was maintained ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R97) of two residents reviewed for urinary catheters and dignity covers, resulting in the potential for embarrassment. Findings include: On 03/10/25 at 09:15 AM, an observation of R97's foley catheter bag was observed outside of the room, visible from the hallway. The foley catheter drainage bag had dark amber urine. The urinary drainage bag was without a dignity cover (a bag used to cover a urine drainage/collection bag, so urine is not visible). R97 was observed in bed laying on their back, wearing pants and no shirt. R97 was asked how long they've been at the facility. R97 said, Not long, I'm here for therapy because my legs don't work. R97 was asked about care at the facility and their foley catheter bag not covered. R97 said, It is what it is .I can't do anything about that. On 03/10/25 at 10:30 AM, Nurse D was interviewed and asked why R97 did not have a dignity bag cover. Nurse D was unable to explain why R97 did not have a dignity cover on at the time of the observation. A review of R97's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Retention of Urine, Emphysema, Psychoactive Substance use, Morbid Obesity and UTI. A review of R97's BIMS (Brief Interview for Mental Status) dated 03/04/2025, revealed a score 15 out of 15 (cognitively Intact). A review of R97's care plan dated 02/26/2025 noted the following: Problem: I have a self-care deficit r/t [related to]: Decreased Mobility, Morbid Obesity, Weakness of Musculoskeletal System, Emphysema and Retention of Urine. Bladder Function: Indwelling Foley Cath. Problem: Indwelling Catheter .Resident requires an indwelling urinary catheter r/t: Retention of urine. Approach Start Date 02/26/2025 .Store collection bag inside a protective dignity pouch. Further review of the progress notes and care plan revealed no evidence of the R97 removing the catheter dignity bag. On 03/13/25 at 10:49 AM, Unit Manager A was interviewed and queried about R97's foley catheter bag being without a dignity cover. Unit Manager A said, [R97] takes the bag cover off. On 03/13/25 at 12:10 PM, The Director of Nursing (DON) was interviewed and asked about R97's foley catheter bag being without a dignity cover. The DON stated that the resident (R97) should have a dignity bag cover. A review of the facility's policy Catheter Care dated 11/1/2022 revealed the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for on...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident (R37) of two residents reviewed for catheter care with the potential to cause irritation and/or trauma. Findings include: On 3/11/25 at 1:28 PM, R37's foley catheter was observed with Licensed Practical Nurse (LPN) E. R37 was observed with no leg strap attached to the catheter. When LPN E was queried regarding the leg strap LPN E said the leg bag should have been attached with a strap. On 3/11/2025 at 2:25 PM, the Nursing Home Administrator (NHA) was interviewed and said residents should have leg straps when they have a catheter. The NHA explained leg straps are used to secure the catheter to prevent the catheter from being pulled out. Record review of R37 Electronic Medical Record (EMR) revealed R37 was admitted on [DATE] with diagnoses of Acute pyelonephritis, Dementia, Pressure ulcer of right heel, Pressure ulcer of left heel, Pressure ulcer of sacral region stage 4, Urinary tract infection, and schizoaffective disorder bipolar type. Review of R37's admission assessment dated [DATE] for Minimum Data Set for Brief Interview for Mental Status was severely impaired. Review of the facility policy titled, Catheter Caredated: 11/1/2022 revealed the following: It is the policy of the facility to ensure that residents with indwelling catheter receive appropriate catheter care. In accordance with the policy, it is noted leg bags will be attached to resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure professional standards of practice for oxygen administration for one (R7) of one resident reviewed for oxygen administra...

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Based on observation, interview and record review the facility failed to ensure professional standards of practice for oxygen administration for one (R7) of one resident reviewed for oxygen administration resulting in a R7 receiving supplemental oxygen therapy without a healthcare provider order. Findings include: On 03/10/25 at 10:45 AM, R7 was observed in bed on their back wearing a gown. Their left arm was bent at the elbow toward their chest. R7 was soft spoken and was able to answer basic questions. R7 was wearing supplemental oxygen via nasal canula (a device that delivers extra oxygen through a tube and into the nose). R7's oxygen was at three liters per minute. The oxygen tubing was not labeled with a date. On 03/10/25 at 01:28 PM, R7 was observed wearing oxygen via nasal canula with oxygen at three liters per minute. The oxygen tubing was not labeled with a date. On 03/11/25 at 08:38 AM, R7 was observed in bed with his eyes closed wearing a gown. R7 was observed wearing supplemental oxygen via nasal canula at 3.5 liters. The oxygen tubing was not labeled with a date. A review of R7's electronic medical record revealed an initial admission of 04/25/2024 and the diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Schizoaffective Dementia, Depression, Contracture of muscle, multiple sites, Seizure, Stroke, Traumatic Brain Injury, and Heart Failure. A review of R7's BIMS (Brief Interview for Mental Status) dated 02/01/2025, revealed a score 9 out of 15 (Moderately Impaired). A review of R7's care plan revealed the following: Problem Start Date: 04/25/2024: COPD: Approach: Monitor oxygen saturation via pulse oximetry as ordered. A review of R7's care plan did not address supplemental oxygen therapy. A review of R7's electronic medical record physician orders did not reveal an order for oxygen therapy. On 03/11/25 at 11:04 AM, Unit Manager A was interviewed and queried about R7 receiving oxygen therapy at 3-3.5 liters and not finding an order in the electronic medical record for oxygen therapy. Unit Manager A said, I forgot to enter the oxygen order. On 03/13/25 at 12:08 PM, The Director of Nursing (DON) was interviewed and queried regarding R7 receiving oxygen therapy without a physician order. The DON said that they should have a physician order to receive oxygen. A review of the facility's policy Consulting Physician/Practitioner Orders dated 11/01/2022 revealed the following: Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned before stacking; 2. Properly date-label and store food in the kitchen; and 3. properly store lad...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned before stacking; 2. Properly date-label and store food in the kitchen; and 3. properly store ladles. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 3/10/25 at 8:45 AM an initial tour of the kitchen was performed with Dietary Manager (DM) F, the following was observed: 1. Five sheet trays were heavily soiled and stored with clean pans in the clean pot/pan storage area. DM F agreed the sheet trays were heavily soiled and said they should not be used and stated, We need new ones. 2. Six large soup ladles were observed hanging from the side bracket of the hood vent. DM F said the ladles should not be hanging from the vent. In the dry food storage room: 1. One opened frosting can not dated. 2. One family sized bag of potato chips opened not dated. 3. One box of instant mashed potatoes box opened not dated. DM F agreed all opened items should be dated and stored properly. On 3/13/25 at 8:51 AM the Nursing Home Administrator was interviewed and said the expectation is for food to be stored correctly and for heavily soiled uncleanable kitchen items to be discarded and replaced. A review of the facility policy titled Date Marking for Food Safety date implemented 11/1/2022 and revealed in part; The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. A review of the facility policy titled Food Safety Requirements date implemented 10/26/22 revealed in part; All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. Clean dishes shall be kept separate from dirty dishes. c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. d. Staff shall adhere to safe hygienic practices to prevent contamination of foods.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

Based on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in three resident rooms resulting in the potential interference with care provide...

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Based on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in three resident rooms resulting in the potential interference with care provided and resident dissatisfaction with their living environment. Findings include: On 3/10/25 at 11:30 AM, the following rooms were observed and review of facility census count sheet dated 3/10/25 revealed the following resident rooms did not provide 80 square feet of floor space per resident. RM# SQ. FT. BEDS Residents 103 210 3 3 109 213 3 3 117 213 3 3 On 3/13/25 at 11:00 AM, the Nursing Home Administrator was interviewed, and they acknowledged they had rooms that did not meet the square footage regulations.
Jan 2024 7 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to provide intact linen for three residents (R13, R28, and R9) of 10 residents reviewed for bed linen, resulting in a less than o...

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Based on observation, interview, and record review the facility failed to provide intact linen for three residents (R13, R28, and R9) of 10 residents reviewed for bed linen, resulting in a less than optimal homelike environment. Findings include: R13 On 1/7/24 at 10:34 AM, R13 was observed lying in the bed. The bed linen was observed to have holes. The holes measured approximately the size of a quarter to the size of a baseball. The linen had threadbare areas that were frayed and revealed the color of the mattress underneath. R28 On 1/7/24 at 10:37 AM, R28 was observed lying in the bed. The bed linen was observed to have threadbare patches. The patches were thin and revealed the mattress. There were surrounding holes which were approximately the size of a quarter. R9 On 1/7/24 at 12:15 PM, R9 was observed lying on a bariatric bed. The bed linen was observed with threadbare areas. One area measured approximately the size of a basketball. Other areas measured approximately the size of a dime and a quarter. The fitted sheet was threadbare and the mattress was visible through the fabric. The fabric was frayed. On 1/7/24 at 10:40 AM, during an interview with Maintenance Director (MD) A, who was present during the observation, inspected the sheets and said they needed to be replaced. MD A said the worn sheets needed to be disposed of. On 1/8/2024 at 10:00 A.M. during an observation with MD A concerning the worn linen, R9 gestured and pointed to the worn areas in the fitted (bottom) sheet on his bed. Also, MD A observed R13 and R28s' linen with worn areas in their fitted sheets. MD A stated, linen had been brought out for the nursing staff to change the resident's bed on 1/7/24, but he did not know why the sheets were not changed. A subsequent observation of the back up linen was conducted with MD A and Laundry Aide B. During the observation, there appeared to be insufficient bariatric (extra large) bed linen. MD A stated, the bottom of the regular sheets were stretched and used on the bariatric beds in the facility. When asked how much linen the facility had available, and when the last time the facility ordered linen for the bariatric beds, MD A was not sure but would check with the NHA/DON. On 1/8/2024 at 10:30 A.M., MD A said the facility was previously informed about the linen and would try to find a requisition. On 1/8/2024 at 10:32 A.M. during an interviw, the NHA/DON had no knowledge of when the last time linen was ordered for the facility. On 1/8/2024 at 11:00 A.M. a requisition was presented dated 10/18/23 from a local vender, but the requisition did not identify linen was ordered. On 1/8/2024 at 11:40 A.M. the NHA/DON was interviewed regarding the ordering of linen for the facility. The NHA/ DON had not ordered any linen since working at the facility, and said the corporate office would have the information. Prior to exiting the facility on 1/9/2024 at 5:30 P.M., no additional information was provided concerning when the facility ordered linen for the resident's beds.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to revise/update a care plan for one resident (R6) out of two residents reviewed for skin conditions, resulting in the potential for lack of s...

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Based on interview and record review, the facility failed to revise/update a care plan for one resident (R6) out of two residents reviewed for skin conditions, resulting in the potential for lack of skin treatment. Findings include: A review of R6's EMR (Electronic Medical Record) revealed R6 was admitted to the facility 6/10/21. R6 had the following medical diagnoses: Psoriasis, Dementia, and Paranoid Schizophrenia. A review of R6's Quarterly MDS (Minimum Data Set) dated 12/24/23 revealed R6 was unable to complete the Brief Interview of Mental Status (BIMS). According to the MDS, R6 was receiving ointments for her skin. A review of R6's care plan dated 9/26/23 revealed, Resident has rash (Psoriasis) related to dry skin on right side of face / right ear .Resident's rash(es) will heal without complications .Treat rash per Physician order: Silvadene Cream each shift. A review of a nursing progress note dated 9/13/23 revealed, Recurrent rash on resident's right side of face, near the temple, is exacerbated. Physician ordered silvadene cream twice daily until resolved. A review of a nursing progress note dated 11/10/23 revealed, Writer notified Physician that resident Psoriasis was not resolving with silvadene so new orders were received to apply Betamethazone cream twice a day. New orders placed in EMAR. According to the care plan which was initiated 9/26/23, Silvadene was documented as the treatment for R6's Psoriasis, but there was no update to the care plan to reflect the new order placed (start date of 11/10/23). On 1/9/24 at 1:26 PM during an interview, the Nursing Home Administrator (NHA)/ Director of Nursing (DON) said when there is an update to the resident's care, there should be an update made to the order and care plan. A review of the facility's policy titled, Comprehensive Care Plans with a date of 10/26/22 revealed, The comprehensive care plan will include measurable objectives and timeframes to meet the resident ' s needs as identified in the resident ' s comprehensive assessment. The objectives will be utilized to monitor the resident ' s progress. Alternative interventions will be documented, as needed.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure an appropriate outlet extender for durable medical equipment (oxygen concentrator) was used for one resident (R31) of f...

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Based on observation, interview, and record review the facility failed to ensure an appropriate outlet extender for durable medical equipment (oxygen concentrator) was used for one resident (R31) of five residents reviewed for accidents, resulting in the potential for nonfunctioning medical equipment and an unsafe electrical connection. Findings include: On 1/7/24 at 12:14 PM during an observation, R31 was observed in bed wearing oxygen by nasal cannula (NC). The nasal cannula was attached to an oxygen concentrator delivering oxygen at 1.5 liters per minute. On 1/7/24 at 12:15 PM during an interview with R9 (R31's roommate), R9 reported that an outlet extender device had been loaned to R31 by R9's son. On 1/7/24 at 12:40 PM during an observation of R31's room, an outlet extender with three ports was observed plugged into the wall electrical outlet. The oxygen concentrator was plugged into the outlet extender. On 1/7/24 at approximately 1:30 PM during observation and interview, Maintenance Director (MD) A pointed to the label UL (Universal Laboratories) stamp on the outlet extender and explained that UL indicated the outlet extender is safe to use. On 1/8/24 at approximately 10:00 AM, MD A was interviewed and reported being unaware of the specific numbers for outlet extenders required for durable medical equipment. On 1/8/24 at 4:00 PM, MD A confirmed the device did not have the specific code that indicated it was safe for the use of durable medical equipment. MD A stated, the device was illegal. On 01/09/24 4:03 PM the NHA/DON and Registered Nurse (RN) E were interviewed and acknowledged that an outlet extender should not be used for durable medical equipment. Review of the facility's policy titled Electrical Safety dated October 1, 2022, documented the following: Power strips used in a patient care vicinity: I. Must not be used for patient-care equipment (i.e. beds, air mattress, concentrators, or other medical equipment). II. Must be UL approved in accordance with NFPA (National Fire Protection Association) 99 (2012) edition. III. Must be tested by the maintenance department prior to use.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to consistently post nurse staffing information that was readily accessible for all 40 residents as well as visitors and vendors ...

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Based on observation, interview and record review, the facility failed to consistently post nurse staffing information that was readily accessible for all 40 residents as well as visitors and vendors in the facility, resulting in necessary staffing information not being available to residents and visitors. Findings include: On 1/7/2024 at 8:30 A.M., upon entering the facility a document titled Daily Staff Report was observed dated 1/6/2024 was posted in the front lobby above the sign in area of the facility. At 5:15 P.M. the same dated (1/6/2024) Nursing Staffing Report was posted. On 1/8/2024 at 12:30 P.M. during an observation, and upon leaving the facility at 5:30 P.M. the Nurse Staffing Report remained dated 1/6/2024 and had not been updated or changed. On 1/9/2024 at 10:49 A.M. during an interview with Activities/Scheduler D concerning who was responsible for posting the Nurse Staffing information. Activities/Scheduler D confirmed it was the responsibility of the Activities/Scheduler. Activities/Scheduler D explained the posting information on 1/7/24 was not posted because at the time there was assistance needed to pass the meal trays. Activities/Scheduler D confirmed the daily schedule posting was forgotten until the surveyor was observed attempting to review the area where the daily schedule posting normally hung.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coord...

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Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs that could cause negative outcomes, affecting all 40 residents who resided in the facility. Findings include: On 1/9/2024 at 10:40 A.M. review of the staffing schedule with Activities/Scheduler D for the following dates revealed there was no scheduled RN coverage or replacement: September 2nd, 3rd, 14th, 19th, and 20th. (2023) October 6th, 10th, 12th, 22nd, and 28th. (2023) November 1st, 3rd, 6th, 11th, 13th, and 17th. (2023) December 1st. (2023) On 1/9/2024 at 12:00 P.M. the NHA/DON said during an interview the facility currently had a total of three Registered Nurses (RN) working and one of the RN's was on leave of absence (LOA). The NHA/DON said the facility did not utilize pool or Agency staff, providing consistent RN coverage was difficult, and NHA/DON periodically came in and worked as RN. When asked why the facility had not hired anyone the NHA/DON indicated RNs were hired but quit. No evidence of that information was provided or presented during the survey. On 1/9/2024 at 4:00 P.M. a review of the Facility Assessment updated 8/2023, revealed, Staffing: the facility required a minimum of two Licensed nurses per shift to meet the needs of the residents. On 1/9/2024 at 4:05 P.M. the NHA/DON acknowledged there was a problem with staffing and the facility expected some concerns.
CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 40 residents and its staff resulting in an increased chance of harm. Findings include: On 1/9/24 between 11:30 AM and 1:23 PM, during an environmental tour of the facility the following observations were made: The ice machine's door was observed cracked, glued, and separated in several areas. The exterior service entry doors were observed with a 1 inch gap on the vertical center seal allowing daylight to shine through the opening. The toilet and sink surround in resident room [ROOM NUMBER] was observed cracked and in poor condition. The radiator's protective grates in resident room [ROOM NUMBER] were observed damaged and with portions missing. Additionally, in this room drawer handles were observed missing on the furniture. The south shower room exhaust fan was observed not functioning. The north shower room exhaust fan was observed not functioning. Additionally, in this room an unprotected toilet plunger was observed stored on the floor, and the wall mounted nurse call device's pull cord was observed hanging 28 inches above the floors surface. In the soiled utility room the hopper and two compartment sink were observed soiled, and the tile flooring was observed cracked, damaged and with several sections missing. On 1/9/24 at 12:24 PM, the surveyor inquired with the Maintenance Director, staff A, on how the facility communicates its maintenance requests to the maintenance department to which they replied, we have book at the nurse's station that I check throughout the week. On 1/9/24 at 12:38 PM, upon record review by the surveyor and staff A of this book titled, Maintenance requisition/call light/ repair log revealed the last documented maintenance request was made on 10/17/23. At this time the surveyor inquired with staff A on if they thought this book was being consistently utilized to communicate maintenance requests to the maintenance department to which they replied, Not really, and I'm the only one in maintenance. Most people just tell me things and I go and do them, or I try to get the parts ordered for them if it's something I don't already have. On 1/9/24 between 1:37 PM and 2:03 PM, during a tour of the laundry room and its support spaces the following observations were made: An accumulation of dust and debris was observed on top of both washing machines, underneath and behind both dryers, and on the radiator grates. A portion of the exposed ceiling near the clean linen folding table was observed actively leaking into the laundry room. On 1/9/24 at 1:44 PM, the surveyor inquired with the Maintenance Director, staff A, on if they were aware of the current state of the roof leak to which they replied, No. It must have just started. It looks like the seal around the vent needs to be redone. On 1/9/24 at 1:57 PM, three fitted bed sheets were observed with dark colored stains in the clean linen room. At this time the surveyor inquired with staff A on if these items met the facility's cleanliness expectations prior to providing them to residents to which they replied, they have been washed, but we need to order some new sheets. This is as clean as we can make them.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

Based on observation and record review, the facility failed to provide 80 square feet of space per resident in 10 of 15 multiple resident rooms resulting in potential interference with care provided a...

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Based on observation and record review, the facility failed to provide 80 square feet of space per resident in 10 of 15 multiple resident rooms resulting in potential interference with care provided and resident dissatisfaction with their living environment. Findings include: On 01/9/24 at 11:10 AM, observations of the following rooms and review of the facility bed count sheet, most recent dated 8/2/21 revealed the following resident rooms did not provide 80 square feet of floor space per resident. MEDICARE/MEDICAID ROOMS: RM # SQ. FT. BEDS 102 215 3 103 210 3 107 220 3 109 213 3 110 217 3 111 217 3 112 210 3 113 212 3 116 224 3 117 213 3 The health and safety of the residents were not affected by the room size. Interviews of the residents revealed no problems with their rooms.
Aug 2023 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure Pneumococcal immunizations were received for one residents (R603) out of five reviewed for immunizations, resulting in placing an imm...

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Based on interview and record review the facility failed to ensure Pneumococcal immunizations were received for one residents (R603) out of five reviewed for immunizations, resulting in placing an immune compromised resident at risk for pneumonia. Findings include: Resident #603 Review of an admission record revealed, Resident #603(R603) admitted to the facility 9/15/21 with pertinent diagnoses which included Dementia and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/4/23 revealed R603 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of Flu and Pneumonia Vaccine Consent form revealed R603 guardian consented for the pneumonia vaccine on 9/21/22. Review of R603's Physician orders and MAR for September 2022 revealed there was no order or documentation of administration of Pneumococcal vaccine. In an interview on 8/24/23 at 1:43 p.m., the Director of Nursing (DON) reported R603 did not receive the pneumonia vaccine. In an interview on 8/24/23 at 1:48 p.m., the Nursing Home Administrator (NHA) reported R603 did not receive the pneumonia vaccine. The NHA reported they reviewed the records and MDS and there is no documentation that R603 received the pneumonia vaccine. Review of a Pneumococcal Vaccination policy with a implemented date of 11/1/22 revealed, It is our policy to offer our residents, staff, ad volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . 12. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal .
Oct 2022 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertain to Intake number MI00128767. Based on observation, interview, and record review, the facility failed to fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertain to Intake number MI00128767. Based on observation, interview, and record review, the facility failed to follow the proper procedure for the withdrawal of personal funds for one (R28) of one resident reviewed for personal funds resulting in the inability for R28 to manage their own money and in the resident expressing anger and frustration. Findings include: In a complaint called into the State Agency documented, The activities staff are keeping my money and cigarettes from me (R28). In an observation and interview on 10/19/22 at 9:05 AM, R28 was in a wheelchair, eating breakfast. When asked about his ability to access and manage his money, R28 confirmed not being able to withdraw money from a trust account. R28 said, I never get to have my money. (Activity Directors name) takes it out and I never see it. She buys snacks with my money. Review of the clinical medical record revealed R28 was admitted into the facility on 9/15/21 with diagnoses which included, dementia, Paranoid Schizophrenia (mental health disorder), and bipolar disease (mental health disorder). The Annual Minimum Data Set Assessment (MDS) dated [DATE] indicated the R28's cognition was intact and was independent with all activities of daily living (ADL's). R28's face sheet indicated the resident had a Legal Guardian (LG). During a review of R28's Resident Trust Account ledger dated 1/6/22 to 10/18/22 revealed that R28 had cash withdrawn from the Trust Account 31 times. The cash drawer withdrawal receipts/vouchers were signed out by 2 staff members who included; Medical Records staff (MR) A, Activities Director (AD) B, previous Administrator, and/or Unit Manager, Licensed Practical Nurse (LPN) C. In an interview on 10/19/22 at 1:45 PM with employees MR A and AD B they explained the trust fund cash withdrawal process. AD B said when a resident expresses wanting money out of they're trust account for requested items (e.g. cigarettes, snacks, pop, etc .), the money is first taken from facility's petty cash. After purchasing requested items, the money is then debited out of the residents account and put back into the facility's petty cash. MR A staff reported the receipt/voucher for purchased items is then co-signed by another staff member. MR A, reported that the co-signer is usually AD B, who shares the same office. MR A confirmed that the resident does not sign the voucher or get a receipt of the transaction. Review of R28's Trust Fund Agreement signed by the resident's LG on 6/8/22 documented, Residents may withdraw funds from their account when available; they will sign a withdrawal voucher and will receive a receipt for each withdrawal. The Business Office Manager or designee will also countersign this withdrawal voucher .Withdrawals can only be made by the resident or responsible party. There are no exceptions. In an interview with the Nursing Home Administrator (NHA) on 10/20/22 at 9:44 AM it was reported that staff would be in-serviced on the proper procedure for trust fund. Review of the policy titled, Residents Rights dated 3/11/22 documented, The Right . to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0608 (Tag F0608)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of resident (R16) inappropriately touching resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of resident (R16) inappropriately touching resident (R10) to local law enforcement, affecting one resident (R10) out of 13 residents reviewed for abuse, resulting in R10's right to have an allegation of sexual abuse investigated by local law enforcement and the potential for feelings of helplessness. Findings Include: Record review of facility's documents titled Investigation of (R10) and (R16) dated 10/10/22 and Unusual Occurrence Report dated 10/10/22 revealed an allegation of R16 touching R10's penis and no documentation of local law enforcement being called and made aware of the sexual abuse allegation. During interview on 10/19/22 at 2:34 PM with Nursing Home Administrator (NHA), when asked if local law enforcement was notified when the allegation of sexual abuse was reported by R10, NHA said, No. When asked the reason that local law enforcement was not called, NHA said, I did not think the alleged sexual abuse occurred after I completed my investigation. Record review of R10's face sheet revealed admission into the facility on 2/7/22 with diagnoses of hypertension (high blood pressure) and depression. According to the Minimum Data Set (MDS) dated [DATE], R10 had intact cognition. R10 had intact cognition and received supervised assistance with all activities of daily living (ADL's). Record review of R16's face sheet revealed admission into the facility on 5/25/21 with diagnosis of unspecified dementia (a group of thinking or social symptoms that interferes with daily living). According to the MDS dated [DATE], R16 had intact cognition and received supervised assistance with all activities of daily living (ADL's). Record review of Abuse/Neglect policy last revised on 3/9/22 documented the following: Incidents involving alleged, suspected or actual abuse (including misappropriation or exploitation) or resulting in serious bodily injury to the patient (including injuries of unknown origin), shall be reported to the state immediately, but not more than 2 hours after forming the suspicion. If the incident or suspected incident did not involve abuse or result in serious bodily injury it shall be reported not longer than 24 hours after the incident In addition to the State survey agency, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: a. The local/State Ombudsman. b. The Resident's Representative of Record. c. Law enforcement officials. d. The resident's Attending Physician. e. The facility Medical Director .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medication (Nicoderm transdermal-smoking c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medication (Nicoderm transdermal-smoking cessation patch) according to standards of clinical practice for one resident (R28) of one resident reviewed for standards of care, resulting in the potential for medication errors. Findings Include: In an observation and interview on 10/19/22 at 9:05 AM, R28 was in a wheelchair, eating breakfast. When asked about smoking, R28 confirmed wearing a nicotine patch and no longer smoking cigarettes. Review of the clinical medical record revealed R28 was admitted into the facility on 9/15/21 with diagnoses which included, dementia, Paranoid Schizophrenia (mental health disorder), and bipolar disease (mental health disorder). The Annual Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident's cognition was intact and was independent with all activities of daily living (ADLs). Review of the current physician's orders from 10/1/22 to 10/20/22, revealed no order for Nicoderm Transdermal Patch. In an observation and record review with Licensed Practical Nurse (LPN) D on 10/19/22 at 11:29 AM, the current physician's orders were reviewed. It was confirmed that R28 did not have an order for Nicoderm Patch. Along with LPN D, R28 was observed to have a Nicoderm Transdermal Patch on the left back shoulder area. The Nicoderm patch was dated 10/18/22 (the previous day) and initialed AR. At 12:04 PM, review of the North Hall medication cart with LPN D, revealed a plastic bag with approximately 7-8 Nicoderm Transdermal Patches. The bag was labeled Nicoderm Transdermal Patch 21 milligram (mg) one patch every day, dated 7/22/22, with R28's name. LPN D could not explain why R28 had Nicoderm patches, but no physician's order for their use. In an interview on 10/19/22 at 12:24 PM with Unit Manager (UM) LPN C, it was reported that R28 sometimes wants the patch and sometimes does not. UM C reported the physician had discontinued the (Nicoderm) patch because the resident was non-complaint with use. Review of the facility's policy titled Administrating Medications; Protocols and Standards dated 3/16/22 documented, 3. Medications must be administered in accordance with the orders, including any required time frame.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop person-centered interventions and approaches for dementia c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop person-centered interventions and approaches for dementia care for one resident (R35) of 13 reviewed for comprehensive care plans, resulting in the potential for the inability of all staff to appropriately care for a resident with dementia. Findings include: Record review face sheet revealed R35 was admitted into the facility on 4/5/22 with a diagnosis of Schizophrenia (mental health disorder) and dementia (a group of thinking and social symptoms that interferes with daily functioning). According to the Minimum Daily Set (MDS) dated [DATE], R35 had impaired cognition and required supervision to extensive assist with Activities of Daily Living (ADLS). Record review of R35's electronic medical records revealed no dementia care plan. During an interview on 10/20/22 at 10:00 AM with Nursing Home Administrator (NHA) and Corporate Social Worker (CSW) I, it was confirmed by both that R35 did not have a dementia care plan. When NHA was queried if all residents with dementia should have a care plan and interventions, NHA said, Yes. Record review of policy Care Plans- Comprehensive last revised 8/1/2016 documented the following: . 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the resident's strengths. d. Reflect the resident's expressed wishes regarding care and treatment goals. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a comfortable environment in 15 (Room numbers ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a comfortable environment in 15 (Room numbers 101, 102, 103, 104, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, and 117) of 16 resident rooms and common area, resulting in potential for resident dissatisfaction with living conditions. Findings Include; In an environmental tour on 10/21/22 at 9:32 AM with Maintenance Director (MD) G the following was observed: room [ROOM NUMBER] food stains on walls; room [ROOM NUMBER] chipped paint on door jams, chipped tiles, items on top of light fixtures (heart device), wax build up around toilet; room [ROOM NUMBER] chipped paint on walls; room [ROOM NUMBER] antenna on top of light fixture, missing closet door; room [ROOM NUMBER] chipped wall paint, cracked mirror, missing cove base, fly strip hanging in the bathroom (loaded with pests); room [ROOM NUMBER] blackened buildup on floor between floor and base boards, hole below shower access door covered with gray adhesive tape; room [ROOM NUMBER] food debris on walls, missing plaster on floor boards, missing bathroom tiles; room [ROOM NUMBER] chipped paint on walls; room [ROOM NUMBER] chipped paint on door jams, door guard on bathroom door peeling, food debris on walls, broken slats on blinds; room [ROOM NUMBER] chipped paint on door; room [ROOM NUMBER] chipped paint on walls, items stored on overbed light, dull floors; Room114 missing floor tiles x 2, items observed on over bed lights, chipped paint on door jam, wax worn off floors; room [ROOM NUMBER] no cover on overbed light, loose door protector; room [ROOM NUMBER] scrapes on bathroom door, no light bulb in overbed light for bed 2; room [ROOM NUMBER] wax floor worn, no closet door; Employee access double doors, chipped paint; Carpet at entry way and down hallways noted with black stains and spills. Carpet observed to have blackened adhesive tape residue throughout. MD G reported that staff should be entering items that need repairing in the Maintenance log book. MD G reported partially painting the walls, but was unable to complete the job, due to other demands on his time. In an interview with the Administrator on 10/21/22 at 11:22 AM, it was reported that flooring replacement was being discussed, but has not been approved. Review of the policy titled, Residents Rights dated 3/11/22 documented, The Right . to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to maintain backflow protection at the kitchen three compartment sink, resulting in the potential for cross-contamination. This d...

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Based on observation, interview, and record review the facility failed to maintain backflow protection at the kitchen three compartment sink, resulting in the potential for cross-contamination. This deficient practice has the potential to affect all 46 residents who reside in the facility. Findings Include: On 10/18/22 at 11:30 AM during an observation in the kitchen, the main drain line of the three compartment sink was observed to be directly connected to the floor drain leading to the sewage system, and not provided with an air gap to prevent the potential backflow of solid, liquid, or gas contaminants. During an interview on 10/19/22 at 1:10 PM with Corporate Director of Maintenance (CDM) H, when asked if the drain lines should have an air gap he said, Yes. Record review of the 2013 Michigan Modified FDA (Food Drug Administration) Food Code Section 5-402.11 Backflow Protection.a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment or utensils are placed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Michigan facilities.
Concerns
  • • 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Pine Creek Manor Skilled Nursing & Rehab Center's CMS Rating?

CMS assigns Pine Creek Manor Skilled Nursing & Rehab Center an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Michigan, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Pine Creek Manor Skilled Nursing & Rehab Center Staffed?

CMS rates Pine Creek Manor Skilled Nursing & Rehab Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 53%, compared to the Michigan average of 46%.

What Have Inspectors Found at Pine Creek Manor Skilled Nursing & Rehab Center?

State health inspectors documented 19 deficiencies at Pine Creek Manor Skilled Nursing & Rehab Center during 2022 to 2025. These included: 17 with potential for harm and 2 minor or isolated issues.

Who Owns and Operates Pine Creek Manor Skilled Nursing & Rehab Center?

Pine Creek Manor Skilled Nursing & Rehab Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PIONEER HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 49 certified beds and approximately 43 residents (about 88% occupancy), it is a smaller facility located in Wayne, Michigan.

How Does Pine Creek Manor Skilled Nursing & Rehab Center Compare to Other Michigan Nursing Homes?

Compared to the 100 nursing homes in Michigan, Pine Creek Manor Skilled Nursing & Rehab Center's overall rating (4 stars) is above the state average of 3.1, staff turnover (53%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Pine Creek Manor Skilled Nursing & Rehab Center?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Pine Creek Manor Skilled Nursing & Rehab Center Safe?

Based on CMS inspection data, Pine Creek Manor Skilled Nursing & Rehab Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Pine Creek Manor Skilled Nursing & Rehab Center Stick Around?

Pine Creek Manor Skilled Nursing & Rehab Center has a staff turnover rate of 53%, which is 7 percentage points above the Michigan average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pine Creek Manor Skilled Nursing & Rehab Center Ever Fined?

Pine Creek Manor Skilled Nursing & Rehab Center has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Pine Creek Manor Skilled Nursing & Rehab Center on Any Federal Watch List?

Pine Creek Manor Skilled Nursing & Rehab Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Pine Creek Manor Skilled Nursing & Rehab Center

34330 Van Born Rd, Wayne, MI 48184 | (734) 721-0740

B
Trust Grade (75/100)
4.0
CMS Rating
19
Deficiencies

Strengths

  • Licensed facility

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025