Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Food Service Sanitation and Food Handling Deficiencies: Staff failed to properly date mark ready-to-eat foods, and multiple food service sanitation issues were observed, including residue in a refrigerator, metal shavings on a can opener, debris in the ice scoop holder, a deteriorated spatula, cracked floor tiles near the dishwasher, and improper glove use by a staff member while plating food and handling other tasks.
Water Management Program Lacked Active Legionella Controls: The facility failed to maintain an active water management program to reduce the risk of Legionella and other OPPP. Surveyors observed an inoperable hot water faucet and a utility sink in the laundry room being used to store rags, with no drain line and water discharging onto the floor. In the soiled utility room, the hopper contained cloudy water and residue with the flush apparatus off, and a utility sink discharged brown water before running clear. MHS reported weekly flushing practices, no chlorine monitoring, and that legionella samples had not yet been sent in for the year; the written program did not identify Legionella growth areas or control limits.
Poor Sanitation and Disrepair in Utility, Laundry, Shower, and Waste Areas: Surveyors observed multiple cleanliness and maintenance issues, including a mop sink with a missing hot water faucet and leaking vacuum breaker, a utility sink with a chemical pre-dispensing system left on, an inoperable hand sink in the laundry room, and a utility sink being used to store rags and linens. They also found residue and pooled water in shower areas, a dirty hopper with missing floor tiles, peeling and missing bathroom tile in a resident room, and an outdoor waste enclosure with debris, an open door, and flies entering and exiting the receptacle.
A resident with a legal guardian and diagnoses including acute cystitis, schizophrenia, diabetes, and PVD had a Full Code status, but the facility had no written documentation that an Advance Directive was offered or completed. The SW and DON both acknowledged the missing documentation, and the record lacked evidence that the resident's legal representative was offered education or the opportunity to formulate an AMD.
Failure to Include Dementia in Care Plan and MDS: A resident with schizophrenia, diabetes, and PVD also had a PASARR dementia exemption and was later confirmed by the MD to have dementia, but the care plan and MDS did not identify the dementia diagnosis. The care plan focused on schizophrenia symptoms only, and the record lacked documentation of resident or legal rep involvement in setting dementia goals, outcomes, or dementia-related care parameters.
Undersized resident rooms were identified in multiple Medicare/Medicaid rooms, including rooms 102, 103, 107, 109, 110, 111, 112, 113, 116, and 117. Review of room documentation and measurements showed these rooms did not meet the required square footage per resident, and the NHA acknowledged that the rooms did not meet the square footage regulations.
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.
Food Service Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area, including date marking of ready-to-eat foods, cleanliness of food-contact surfaces, and proper handling of utensils and equipment. During observation and interview, cut carrots in the refrigerator were found with a facility-marked date of 4/15, chopped carrots were found with only a handwritten number 4 on the outside, and two containers of sliced tomatoes had no facility-marked date. The Dietary Manager acknowledged the missing or unclear date markings and discarded the items. The Dietary Manager also stated that refrigerators were cleaned at least weekly and that maintenance handled the ice machine and ice scoop holder. Additional observations found dried yellow residue in the bottom interior surface of a refrigerator, metal shavings accumulated next to the blade of the can opener, and an ice scoop holder containing a pool of water with brown debris floating at the bottom. A spatula stored in the utensil drawer had brown stained discoloration and deterioration with sections of rubber removed. Broken and cracked floor tiles were also observed near the floor drain adjacent to the dishwasher. In addition, a staff member was observed plating food with a gloved hand, opening a door and a reach-in refrigerator, then returning to the tray line and using the same gloves to break apart rolls and plate fries.
Water Management Program Lacked Active Legionella Controls
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During observation, a hand sink in the laundry washing room was found with an inoperable hot water faucet, and staff stated the sink was not used and had no warm water. A utility sink in the same room was observed with linens piled inside the basin; staff stated it was not used and was being used to store rags. The sink had no drain line, and water was observed discharging directly onto the floor when turned on. In the soiled utility room, a shallow pool of cloudy water was observed in the hopper bowl with black and gray residue on the interior and around the rim, and the flush apparatus was off. Brown water was observed discharging from the two-compartment utility sink for a few seconds before running clear. The Maintenance and Housekeeping Supervisor stated the team flushed toilets once a week, faucets twice a week, boilers once a week, and also flushed utility sinks and shower rooms, but later stated they had not yet sent legionella samples in for the year and did not monitor chlorine. The water management team was described as including the NHA, the previous DON, and Maintenance, with monthly meetings, while the NHA stated maintenance handled water management and that annual review was part of the emergency book reviewed in January. Record review showed the facility’s water management documents referenced identifying areas where biofilms and opportunistic pathogens may grow and spread, including stagnation areas, no residual disinfectant areas, and commodes and hoppers, but the program did not include identified areas where Legionella could grow and spread or a description of control limits for control measures.
Poor Sanitation and Disrepair in Utility, Laundry, Shower, and Waste Areas
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and to properly store clean and sanitary supplies. On 04/28/2026, surveyors observed a mop sink in the soiled linen room with the hot water faucet missing and water leaking from the vacuum breaker when the cold water faucet was turned on. They also observed a two-compartment utility sink in the soiled linen room with a chemical pre-dispensing system in place and the faucet left on, creating undue back pressure on the faucet's internal atmospheric vacuum breaker. In the laundry washing room, a hand sink had an inoperable hot water faucet, and Laundry Aid H stated staff do not use the sink and go outside of the room to wash their hands when needed. The same room also had a utility sink with linens piled inside the basin, which staff said was used to store rags, and water discharged directly onto the floor when turned on because there was no drain line from the basin. During the facility tour, surveyors observed multiple areas of poor sanitation and disrepair. In the north shower room, the shower bed had a sticky orange substance and black particulates beneath the mat, with yellow and brown discolored water pooled beneath the collection mat, and the shower room chair had brown dried residue on the back side within the netted material. In the soiled utility room, there was a shallow pool of cloudy water in the hopper bowl with black and gray residue on the interior and around the rim, several floor tiles were missing with mastic exposed between the hopper and mop sink, and the hopper flush apparatus was off at the fixture. In resident room [ROOM NUMBER], the bathroom door kick plate was peeling and a portion of tiles was missing along the perimeter at the floor wall junction above the floor molding. Outside, the waste receptacle enclosure had debris scattered around it, including matted cardboard and leaves behind the unit, the side sliding door was open, flies were observed entering and exiting the receptacle, and rolling chairs, plastic bags, and other debris were found outside the enclosure along the concrete wall.
Failure to Document Advance Directive Offer and Completion
Penalty
Summary
The facility failed to formulate an Advance Medical Directive for one resident, R7, who had a code status of Full Code, an admit date of 06/03/2025, and diagnoses including acute cystitis without hematuria, schizophrenia, diabetes, and peripheral vascular disease, unspecified. Record review also showed that R7 had a legal guardian, but there was no written documentation in the EHR showing that an Advance Directive had been offered or completed for the resident. During interview, the SW stated that all residents should have documentation showing that an Advance Directive was offered and acknowledged that documentation was missing for R7, including written documentation from the resident's guardian. The NHA/DON also stated that the facility did not have an Advance Directive for R7 and that there should be documentation of the offer for an Advance Directive for all residents. Further record review confirmed the absence of written documentation showing that R7's legal representative was offered education and the opportunity to formulate an Advance Directive.
Failure to Include Dementia in Care Plan and MDS
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed R7’s dementia care needs. R7 was admitted on 06/03/2025 with diagnoses including acute cystitis without hematuria, schizophrenia, diabetes, and peripheral vascular disease. A care plan dated 02/26/2026 included a focus for schizophrenia with symptoms such as delusions, disorganized thinking, hallucinations, social withdrawal, depression, abnormal motor behaviors, impulsivity, hyperverbal behavior, high energy, euphoria, sadness, hopelessness, and loss of interest, but it did not include a dementia diagnosis, goal, focus, or interventions. The MDS dated 03/12/2026 also did not identify dementia for R7. During record review and interviews, Social Worker D provided a PASARR Level II Dementia Exemption dated 09/10/2025, and Social Worker A stated there was no dementia diagnosis in the record. The NHA/DON stated they were checking with the Medical Director because they did not see a dementia diagnosis and confirmed that dementia should be included in a comprehensive care plan. The MDS Coordinator stated there was no dementia diagnosis in the system. The Medical Director later confirmed that R7 has dementia and stated R7 has multifactorial impaired mental status and dementia with no change in condition since admission. The record also lacked documentation showing R7 or the legal representative participated in establishing dementia care goals, outcomes, or the amount, frequency, and duration of dementia-related care.
Undersized Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet of space per resident in 10 Medicare or Medicaid resident rooms, including rooms 102, 103, 107, 109, 110, 111, 112, 113, 116, and 117. On 4/30/2026 at 10:15 AM, review of the facility's room documentation and measurements showed that these rooms were undersized, with floor space per resident ranging from 210 to 224 square feet per room while housing 2 or 3 residents in each room. During the 04/28/26 recertification survey, observations of resident rooms were made, and no complaints were verbalized by residents regarding room size. On 4/30/2026 at 2:19 PM, the NHA was interviewed and acknowledged that the facility had rooms that did not meet the square footage regulations.
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 | ★★★★★ | 12 | 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 August 2026) and official state health department websites.