Pine Creek Manor Skilled Nursing & Rehab Center
34330 Van Born Rd, Wayne, MI 48184 · For profit - Limited Liability company · 49 certified beds · (734) 721-0740 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.3% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 11.0% | 4.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.0% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 37.4% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 12.9% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.1% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.8% | 14.8% | 17.1% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.8% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 32.8% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.9% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.36 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.45 | 1.64 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 57% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.2–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 49 beds and averages 43.2 residents a day — about 88% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.48 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 2.88 on weekdays — 10% thinner on weekends. RN hours go from 0.54 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · Fcited before2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 8:50 AM an interview with Dietary Manager (DM) E regarding date marking found a receive date and open date should be marked on food items.On 04/28/2026 at 8:52 AM observed cut carrots wrapped in plastic with a facility marked date of 4/15 in the two-door refrigerator located in the dry storage room. Further observation found chopped carrots wrapped in plastic with a number four written on the outside. DM E discarded the items.On 04/28/2026 at 8:54 AM observed two containers of sliced tomatoes in plastic packages with no facility marked date. An interview at this time with DM E found they did not see a date and indicated they are supposed to be labeled. DM E discarded the items.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-30 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/28/2026 at 10:20 AM observed a hand sink with an inoperable hot water faucet in the laundry washing room. An interview with Laundry Aid (LA) H at this time found staff do not use the sink, and it has no warm water. On 04/28/2026 at 10:24 AM observed a utility sink located next to the hand sink in the laundry washing room with linens piled inside the basin. An interview with LA H at this time found the sink is not used, and the basin is used to store rags. Further observation found the sink had no drain line, and water was observed discharging directly onto the floor when turned on.On 04/28/2026 at 11:04 AM observed a shallow pool of cloudy water in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-30 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/28/2026 at 9:44 AM observed a mop sink in the soiled linen room with the hot water faucet missing. When the cold water faucet was turned on, water was observed leaking from the vacuum breaker.On 04/28/2026 at 9:49 AM observed the two-compartment utility sink in the soiled linen room with a chemical pre-dispensing system in place and the faucet left on. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism.On 04/28/2026 at 10:00 AM observed the outdoor waste receptacle in an enclosure with debris scattered around the unit, including matted cardboard and leaves accumulated behind it. The side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to formulate an Advance Medical Directive (AMD- the written instruction relating to the provision of health care) for one (R7) of five residents reviewed for Advance Directives. Findings include: On 04/28/2026 at 12:22 P.M., a record review of the Electronic Health Record (EHR) revealed R7 had a code status of Full Code with an admit date of 06/03/2025 and a diagnosis of Acute Cystitis without Hematuria, Schizophrenia, Diabetes and Peripheral Vascular Disease, Unspecified. Record review also revealed that R7 had a legal guardian. On 04/29/2026 at 11:20 A.M., Social Worker (SW) A was interviewed to discuss the formulation of a written Advanced Directive for R7. SW A was queried as to the expectations of Advance Directives for long term care residents within the facility. SW A stated, All residents should have documentation of an Advance Directive being offered. I should have documentation of an Advanced Directive for R7 but I don't. I do not have written documentation from R7's guardian.On 04/29/2026 at 2:15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan that includes and supports the dementia care needs for one (R7) of one resident reviewed for care planning resulting in the potential to limit R7's highest practicable physical, mental, and psychosocial well-being.Findings include: On 04/28/2026 at 12:22 P.M., a record review of the Electronic Health Record (EHR) revealed R7 was admitted to this facility on 06/03/2025 with a diagnosis of Acute Cystitis without Hematuria, Schizophrenia, Diabetes and Peripheral Vascular Disease, Unspecified.Record review of the (EHR) revealed a care plan dated: 2/26/26 without a Dementia diagnosis, goal, focus or interventions for this diagnosis within the care plan. Record review of R7's Care Plan dated 02/26/2026 revealed Focus: I HAVE DIAGNOSIS OF SCHIZOPHRENIA; MAY EXHIBIT SYMPTOMS OF DELUSIONS, DISORGANIZED THINKING, FLAT AFFECT, HALLUCINATIONS, SOCIAL WITHDRAWL, DEPRESSION, ABNORMAL MOTOR BEHAVIORS,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-09 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · E2024-01-09 · tag F0727 — failed to provide required RN coverage — patternHave 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.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2026-04-30 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in 10 (102, 103, 107, 109, 110, 111, 112, 113, 116, and 117) resident Medicare or Medicaid rooms. Findings include:On 4/30/2026 at 10:15 AM, a review of the facility's room documentation and measurements determined the following residents' rooms were undersized, providing the following square feet of floor space per resident:RM# SQ. FT. ROOM # OF BEDS # OF Residents102 215 3 2 103 210 3 2107 220 3 3109 213 3 3110 217 3 2111 217 3 2112 210 3 3113 212 3 2116 224 3 2117 213 3 2On 04/28/26, during the recertification survey, observations of resident rooms were made. There were no complaints verbalized by residents regarding room size.On 4/30/2026 at 2:19 PM, the Nursing Home Administrator (NHA) was interviewed, and acknowledged they had rooms that did not meet the square footage regulations.
- No harm found · Bcited before2025-03-13 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
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.
- No harm found · Bcited before2024-01-09 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PIONEER HEALTHCARE MANAGEMENT — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.3 | +0.7 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 8 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UDDIN, FAHIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/23/2018 |
| HENDERSON, DARYL | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2018 |
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $441K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235559. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.