Cycle 1
Health 2025-03-13 · Fire 2025-03-13
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wayne, MI
Pine Creek Manor Skilled Nursing & Rehab Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
34330 Van Born Rd, Wayne, MI
(734) 721-0740
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pioneer Healthcare Management
Operator or chain grouping
Approved since
1994-08-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.53
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
2.89
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,967
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.70
Baseline 61.29% · Performance 48.57% · Measure score 3.70 · Achievement 3.70 · Improvement 2.99
Adjusted total nurse staffing
0
Baseline 3.61 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 30 · Observed rate 16.67% · Lower 95% interval 7.25% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 44 |
| Staff flu vaccination coverage | 27.69% |
42%
14.3 pts worse
|
Numerator 18 · Denominator 65 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.7
1.2 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
95.0%
0.1 pts worse
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 91.4% · Q3 94.9% · Q4 95.7% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.1%
0.5 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 2.6% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
4.1%
8 pts worse
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 14.3% · Q3 20.6% · Q4 11.4% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.5%
4.8 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.0% |
19.6%
20.4 pts worse
|
19.6%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 36.4% · Q3 41.0% · Q4 43.2% · 4Q avg 40.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 43.5% |
16.5%
27 pts worse
|
16.7%
26.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 43.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.5% |
13.9%
8.4 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
11.7%
4.9 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.2% · Q3 7.9% · Q4 9.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 3.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 4.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.2% |
20.4%
14.2 pts better
|
19.8%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.7% · Q3 5.0% · Q4 10.8% · 4Q avg 6.2% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
5.6%
5.4 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.6% · Q3 9.2% · Q4 21.4% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
82.8%
6.7 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 79.3% · Q3 81.5% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
11.5%
5.6 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 22.2% · Expected 14.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.8% |
79.5%
3.3 pts better
|
79.7%
3.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
24.2%
About the same
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 25.9% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
7 health deficiencies
Top issue: Environmental (2 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
7 health deficiencies
Top issue: Environmental (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-01-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-19
F · Potential for more than minimal harm
2022-10-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-23
F · Potential for more than minimal harm
2022-10-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-23
F · Potential for more than minimal harm
2022-10-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-10-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-10-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-10-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-18
B · Minimal harm
2025-03-13
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Not marked corrected
F · Potential for more than minimal harm
2024-01-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-01-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-01-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-01-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-01-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-01-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-27
B · Minimal harm
2024-01-09
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-02-19
D · Potential for more than minimal harm
2023-08-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-28
F · Potential for more than minimal harm
2022-10-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-10-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-11-28
Penalties and ownership
What sits behind the stars
Ownership
Uddin, Fahim
5% Or Greater Direct Ownership Interest · Individual
Henderson, Daryl
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Orchards at Wayne
Wayne, MI
2-star overall rating with 3-star inspections with $8,991 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Maple Manor Rehab Center
Wayne, MI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cherry Hill for Nursing and Rehabilitation
Westland, MI
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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