Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Creek Manor Skilled Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to ensure proper cleaning and storage practices in the kitchen, affecting all residents consuming food. Observations revealed heavily soiled sheet trays stored with clean pans, improperly stored soup ladles, and undated opened food items. The Dietary Manager and Nursing Home Administrator acknowledged these issues, which violated the facility's policies on food safety and equipment handling.
A resident's urinary catheter drainage bag was observed without a dignity cover, visible from the hallway, which could lead to embarrassment. The resident, who was cognitively intact, had a care plan requiring a dignity pouch, but it was not in use. Staff interviews revealed no clear explanation for the oversight, despite facility policy mandating covered catheter bags.
A resident with an indwelling foley catheter was observed without a leg strap, contrary to facility policy. An LPN confirmed the absence of the strap, and the Nursing Home Administrator stated that leg straps are necessary to prevent catheter dislodgement. The resident's medical history includes acute pyelonephritis, dementia, pressure ulcers, a urinary tract infection, and schizoaffective disorder. Facility policy requires leg bags to be secured to minimize pressure and tension.
A resident with COPD received supplemental oxygen therapy without a physician order, as observed on multiple occasions with oxygen administered via nasal cannula at 3 to 3.5 liters per minute. The resident's care plan did not address supplemental oxygen therapy, and the Unit Manager admitted to forgetting to enter the order. The facility's policy requires physician authentication for care orders, which was not adhered to in this instance.
The facility did not provide the required 80 square feet of space per resident in three rooms, potentially affecting care and resident satisfaction. Rooms 103, 109, and 117 housed three residents each but only offered 210 to 213 square feet of space. The Nursing Home Administrator acknowledged this deficiency.
Improper Cleaning and Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper cleaning and storage practices in the kitchen, which could potentially affect all residents consuming food from the kitchen. During an initial tour of the kitchen, it was observed that five sheet trays were heavily soiled and stored with clean pans in the clean pot/pan storage area. The Dietary Manager acknowledged the issue, stating that the trays should not be used and needed replacement. Additionally, six large soup ladles were improperly stored, hanging from the side bracket of the hood vent, which was also acknowledged as incorrect by the Dietary Manager. In the dry food storage room, several items were found improperly stored and not date-labeled, including an opened frosting can, a family-sized bag of potato chips, and a box of instant mashed potatoes. The Dietary Manager agreed that all opened items should be dated and stored properly. The Nursing Home Administrator confirmed that the expectation is for food to be stored correctly and for heavily soiled, uncleanable kitchen items to be discarded and replaced. The facility's policies on date marking for food safety and food safety requirements were reviewed, highlighting the need for proper cleaning, sanitization, and handling of food and equipment to prevent contamination.
Failure to Maintain Dignity with Catheter Care
Penalty
Summary
The facility failed to maintain a urinary catheter drainage bag in a dignified manner for a resident, identified as R97, which resulted in the potential for embarrassment. During an observation, R97's foley catheter bag was seen outside the room and visible from the hallway, containing dark amber urine and lacking a dignity cover. R97, who was cognitively intact with a BIMS score of 15 out of 15, expressed that they could not do anything about the situation. Nurse D was unable to explain why the dignity cover was not in place, and the facility's policy required catheter drainage bags to be covered at all times. R97's medical record indicated an admission with diagnoses including retention of urine, emphysema, psychoactive substance use, morbid obesity, and UTI. The care plan for R97, dated 02/26/2025, specified the use of a dignity pouch for the catheter bag. However, there was no evidence that R97 had removed the dignity cover. Interviews with Unit Manager A and the Director of Nursing confirmed that the dignity cover should have been used, but it was noted that R97 reportedly removed the cover themselves. The facility's catheter care policy, dated 11/1/2022, emphasized maintaining residents' dignity and privacy with indwelling catheters.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R37, who was observed without a leg strap securing their indwelling foley catheter. This observation was made by an LPN, who acknowledged that the leg bag should have been attached with a strap. The Nursing Home Administrator confirmed that residents with catheters should have leg straps to prevent the catheter from being pulled out. R37's medical history includes acute pyelonephritis, dementia, multiple pressure ulcers, a urinary tract infection, and schizoaffective disorder bipolar type. The facility's policy on catheter care, dated 11/1/2022, specifies that leg bags should be attached to the resident's thigh or calf with slack on the tubing to minimize pressure and tension.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to adhere to professional standards of practice for oxygen administration for a resident, resulting in the resident receiving supplemental oxygen therapy without a healthcare provider order. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD) among other medical conditions, was observed on multiple occasions receiving oxygen via nasal cannula at varying flow rates of 3 to 3.5 liters per minute. However, the oxygen tubing was not labeled with a date, and there was no physician order for the oxygen therapy in the resident's electronic medical record. The resident's care plan included monitoring oxygen saturation via pulse oximetry but did not address supplemental oxygen therapy. During interviews, the Unit Manager acknowledged forgetting to enter the oxygen order, and the Director of Nursing confirmed that a physician order should have been in place for the resident to receive oxygen. The facility's policy requires that the attending physician authenticate orders for resident care and treatment, which was not followed in this case.
Failure to Meet Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in three specific rooms, which could potentially interfere with the care provided and lead to resident dissatisfaction with their living environment. On March 10, 2025, observations and a review of the facility's census count sheet revealed that rooms 103, 109, and 117 did not meet the square footage regulations, as each room housed three residents but only provided 210 to 213 square feet of total space. This deficiency was acknowledged by the Nursing Home Administrator during an interview on March 13, 2025.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Wayne | 0.9 mi | ★★★★★ | 10 | 0 |
| Maple Manor Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Cherry Hill For Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 13 | 0 |
| Special Tree Neurocare Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Imperial, A Villa Center | 4 mi | ★★★★★ | 10 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.